(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. Declan Murphy discussing that when a PSMA PET is negative for high risk disease, we can skip the extended pelvic lymph node dissection.
For context, this discussion was regarding a case presentation of a 51 year old with a screening PSA of 17 ng/mL, cT2 disease, with an mpMRI showing a PI-RADS 5 lesion. After prostate biopsy, he was diagnosed with cribriform and acinar adenocarcinoma Gleason 4+4 in 5/15 cores and subsequently had negative conventional imaging and PSMA PET/CT. For his organ-confined high-risk prostate cancer, his risk of lymph node involvement (updated Briganti nomogram) was 3.2%. He underwent a radical prostatectomy with extended pelvic lymph node dissection, with final pathology revealing Gleason 4+4, pT3a, pN0 (0 of 20 nodes). This patient ultimately had a lymphocele that required intervention, had a PSA persistence (0.34 ng/mL), and subsequently received salvage radiotherapy + 2 years of ADT.
Dr. Murphy notes that there has been a seismic shift in the EAU guidelines from 2023 to 2024. In 2023, based on a firm stance from the guidelines, this patient would have had an extended pelvic lymph node dissection given his predicted lymph node involvement of 23% based on the 2019 Briganti nomogram.1 However, in 2024, the guidelines have softened their view on extended pelvic lymph node dissection, suggesting that “in patients undergoing a lymph node dissection you should perform an extended pelvic lymph node dissection” based on the updated Briganti nomogram incorporating PSMA PET imaging suggesting a predicted lymph node involvement of 3.2%.2 Indeed, an extended pelvic lymph node dissection for this patient led to a Clavien 3b complication, with no oncologic benefit. As highlighted, Dr. Murphy emphasized the shift in the guidelines stance on extended pelvic lymph node dissection:
Dr. Murphy concluded his presentation discussing that when a PSMA PET is negative for high risk disease, we can skip the extended pelvic lymph node dissection by confirming that in 2024 the sun is setting on pelvic lymph node dissection. This is secondary to PSMA PET/CT being more strongly recommended, routine extended pelvic lymph node dissection for high-risk patients no longer recommended, and nomograms no longer being emphasized for intermediate risk patients.
Presented by: Professor Declan G. Murphy, MD, Peter MacCallum Cancer Centre, Melbourne, Australia
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
References:
- Gandaglia G, Ploussard G, Valerio M, et al. A novel nomogram to identify candidates for extended pelvic lymph node dissection among patients with clinically localized prostate cancer diagnosed with magnetic resonance imaging-targeted and systematic biopsy. Eur Urol 2019 Mar;75(3):506-514.
- Gandaglia G, Barletta F, Robesti D, et al. Identification of the Optimal Candidates for Nodal Staging with Extended Pelvic Lymph Node Dissection Among Prostate Cancer Patients who Underwent Preoperative Prostate-specific Membrane Antigen Positron Emission Tomography. External Validation of the Memorial Sloan Kettering Cancer Center and Briganti Nomograms and Development of a Novel Tool. Eur Urol Oncol. 2023 Dec;6(6):543-552.