The role of local therapies including radical prostatectomy (RP) in prostate cancer (PCa) patients with clinical lymphadenopathies on prostate-specific membrane antigen (PSMA) positron emission tomography/computerized tomography (PET/CT) has scarcely been explored. Limited data are available to identify men who would benefit from RP; on the contrary, those more likely to benefit already have systemic disease.
We aimed to assess the predictors of prostate-specific antigen (PSA) persistence in surgically managed PCa patients with lymphadenopathies on a PSMA PET/CT scan by integrating clinical, magnetic resonance imaging (MRI), and PSMA PET/CT parameters.
We identified 519 patients treated with RP and extended lymph node dissection, and who received preoperative PSMA PET between 2017 and 2022 in nine referral centers. Among them, we selected 88 patients with nodal uptake at preoperative PSMA PET (miTxN1M0).
The outcome was PSA persistence, defined as a PSA value of ≥0.1 ng/ml at the first measurement after surgery. Multivariable logistic regression models tested the predictors of PSA persistence. Covariates consisted of biopsy International Society of Urological Pathology (ISUP) grade group, clinical stage at MRI, and number of positive spots at a PET/CT scan. A regression tree analysis stratified patients into risk groups based on preoperative characteristics.
Overall, lymph node invasion (LNI) was detected in 63 patients (72%) and 32 (36%) experienced PSA persistence after RP. At multivariable analyses, having more than two lymph nodal positive findings at PSMA PET, seminal vesicle invasion (SVI) at MRI, and ISUP grade group >3 at biopsy were independent predictors of PSA persistence (all p < 0.05). At the regression tree analysis, patients were stratified in four risk groups according to biopsy ISUP grade, number of positive findings at PET/CT, and clinical stage at MRI. The model depicted good discrimination at internal validation (area under the curve 78%).
One out of three miN1M0 patients showed PSA persistence after surgery. Patients with ISUP grade 2-3, as well as patients with organ-confined disease at MRI and a single or two positive nodal findings at PET are those in whom RP may achieve the best oncological outcomes in the context of a multimodal approach. Conversely, patients with a high ISUP grade and extracapsular extension or SVI or more than two spots at PSMA PET should be considered as potentially affected by systemic disease upfront.
Our novel and straightforward risk classification integrates currently available preoperative risk tools and should, therefore, assist physician in preoperative counseling of men candidates for radical treatment for prostate cancer with positive lymph node uptake at prostate-specific membrane antigen positron emission tomography.
European urology oncology. 2023 Sep 07 [Epub ahead of print]
Elio Mazzone, Giorgio Gandaglia, Daniele Robesti, Pawel Rajwa, Juan Gomez Rivas, Laura Ibáñez, Timo F W Soeterik, Lorenzo Bianchi, Luca Afferi, Claudia Kesch, Christopher Darr, Hongqian Guo, Junlong Zhuang, Fabio Zattoni, Wolfgang P Fendler, Daniele Amparore, Nicolai A Huebner, Alexander Giesen, Steven Joniau, Riccardo Schiavina, Eugenio Brunocilla, Agostino Mattei, Fabrizio Dal Moro, Jesus Moreno Sierra, Francesco Porpiglia, Maria Picchio, Arturo Chiti, Roderick van den Bergh, Shahrokh F Shariat, Francesco Montorsi, Alberto Briganti
Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy. Electronic address: ., Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy., Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland., Department of Urology, Hospital Clinico San Carlos, Madrid, Spain., Department of Urology, St Antonius Hospital, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands., Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy., Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland., Department of Urology, West German Cancer Center, University of Duisburg, Essen, Germany; German Cancer Consortium, University Hospital Essen, Essen, Germany., Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, Jiangsu, China., Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padova, Padua, Italy., German Cancer Consortium, University Hospital Essen, Essen, Germany; Department of Nuclear Medicine, University of Duisburg, Essen, Germany., Department of Oncology, Division of Urology, San Luigi Gonzaga Hospital, Turin, Italy., Department of Urology, Medical University of Vienna, Vienna, Austria., Department of Urology, University Hospitals Leuven, Leuven, Belgium., Vita-Salute San Raffaele University, Milan, Italy; Department of Nuclear Medicine, IRCCS Ospedale San Raffaele, Milan, Italy., Department of Urology, St Antonius Hospital, Utrecht, The Netherlands., Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Division of Urology, Department of Special Surgery, The University of Jordan, Amman, Jordan.