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EAU 2024

EAU 2024: Negative Staging PSMA in High-Risk Disease: Can We Skip Extended PLND? the Guidelines' View

(UroToday.com) The 2024 European Association of Urology (EAU) annual meeting featured a plenary session on personalized approaches in high-risk and metastatic prostate cancer, and a presentation by Dr. Johan Stranne discussing what the guidelines say when a PSMA PET is negative for high risk disease. Dr. Stranne started his discussion by highlighting the rationale for extended pelvic lymph node dissection. The 2024 EAU guidelines regarding pelvic lymph node dissection include a systematic review that demonstrated that performing extended pelvic lymph node dissection during radical prostatectomy failed to improve oncological outcomes, including survival. Additionally, there are two RCTs that have failed to show the benefit of an extended approach versus a limited pelvic lymph node dissection on early oncologic outcomes. With an extended pelvic lymph node dissection, the majority of patients are correctly staged and as such, extended pelvic lymph node dissection provides accurate information for staging and prognosis. Thus, Dr. Stranne concluded that extended pelvic lymph node dissection is for staging.



Second, Dr. Stranne discussed extended pelvic lymph node dissection and morbidity. Overall, complication rates of 19.8% versus 8.2% are noted for extended pelvic lymph node dissection versus limited pelvic lymph node dissection, respectively. Moreover, the relative risk of DVT and PE associated with a pelvic lymph node dissection is 7.8% and 6.3%, respectively. Thus, Dr. Stranne concluded extended pelvic lymph node dissection causes morbidity.

Third, Dr. Stranne discussed PSMA PET/CT as an alternative to extended pelvic lymph node dissection. The guidelines state that for patients undergoing a radical prostatectomy, extended pelvic lymph node dissection may miss lymph node metastasis. Preoperative PSMA PET/CT is more accurate than conventional imaging for staging in general, but can also miss smaller lymph nodes (especially those < 5 mm). Thus, Dr. Stranne concluded PSMA PET/CT may be an alternative to extended pelvic lymph node dissection.

Dr. Stranne concluded his presentation by discussing what the guidelines say when a PSMA PET is negative for high risk disease with the following conclusions:

  • For high risk localized disease/locally advanced disease, the guidelines state that we should perform metastatic screening using PSMA PET/CT if available and at least cross-sectional imaging and a bone scan (strength rating: strong)
  • For high risk localized disease/locally advanced disease, risks and benefits of pelvic lymph node dissection versus PSMA PET/CT should be discussed with the patient preoperatively
  • For local salvage treatment, a negative PET/CT scan should not delay salvage radiotherapy if otherwise indicated (strength rating: strong)
  • For local salvage treatment, high-level evidence for the oncological value of salvage lymph node dissection (including adjuvant radiotherapy of the lymph nodes) is still lacking

Presented by: Johan Stranne, MD, PhD, FEBU, Sahlgrenska University Hospital, Göteborg, Sweden

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2024 European Association of Urology (EAU) annual congress, Paris, France, April 5th – April 8th, 2024