The updated Briganti 2019 nomogram failed to identify the presence of lymph node involvement in patients with negative PSMA-PET in our limited high-risk cohort.

PSMA-PET is a valuable, yet imperfect, rule-out test for the presence of LN metastasis and there is an urgent need to develop risk stratification tools to identify the men who are most likely to benefit from ePLND in the PSMA-PET era.

The established clinicopathologic factors associated with lymph node involvement do not work well in high-risk patients with negative PSMA-PET.

Depending on the risk of LN metastasis ePLND at RP is recommended. As ePLND has potential side effects, and diagnostics have improved substantially, our objective was to evaluate the performance of the Briganti 2019 nomogram in a contemporary cohort with preoperative negative PSMA-PET.

Patients with intermediate- and high-risk prostate cancer (CaP), undergoing RP and ePND at our center with preoperative negative [68Ga]Ga-PSMA-11 PET were included. The Accuracy of the nomogram was assessed using ROC analysis. The association of clinical parameters with the presence of LN metastasis was assessed using logistic regression. Specimen of prostate and LNs in patients with false negative PSMA-PET were additionally stained for AR and PSMA expression and assessed by IHC.

The study included 108 patients, 28% intermediate- and 72% high-risk. Twelve patients harbored occult LN metastasis. Accuracy of the nomogram was 0.62. [68Ga]Ga-PSMA-11 PET showed a NPV of 89%. IHC showed expression of PSMA and AR in the primary and LN metastasis in all patients. On logistic regression analysis only DRE (OR 2.72; 95%CI 1.01–7.35; P = 0.05) and percentage of cores with significant CaP (OR 1.29; 95%CI 1.05–1.60; P = 0.02) showed a significant association with LN metastasis.

The currently used nomogram is suboptimal in detecting patients with occult LNM. While the cut-off value to perform ePLND can be increased slightly following a negative PSMA-PET scan, more accurate methods of identifying these patients are needed. Whether ePLND can have a therapeutic benefit, as opposed to a diagnostic only, needs to be re-evaluated in the PSMA-PET era.

PSMA ligand

Prostate cancer

Lymphnode dissection

PSMA-PET

Lymphnode metastasis

© 2024 The Authors. Published by Elsevier Inc.