Limitations of abdominopelvic CT and multiparametric MR imaging for detection of lymph node metastases prior to radical prostatectomy

The role and controversy of pelvic lymph node dissection in prostate cancer treatment: a focused review

Pelvic lymph node dissection (PLND) is commonly performed alongside radical prostatectomy. Its primary objective is to determine the lymphatic staging of prostate tumors by removing lymph nodes involved in lymphatic drainage. This aids in guiding subsequent treatment and removing metastatic foci, potentially offering significant therapeutic benefits. Despite varying recommendations from clinical practice guidelines across countries, the actual implementation of PLND is inconsistent, partly due to debates over its therapeutic value. While high-quality evidence supporting the superiority of PLND in oncological outcomes is lacking, its role in increasing surgical time and risk of complications is well-recognized. Despite these concerns, PLND remains the gold standard for lymph node staging in prostate cancer, providing invaluable staging information unattainable by other techniques. This article reviews PLND's scope, guideline perspectives, implementation status, oncologic and non-oncologic outcomes, alternatives, and future research needs.

Diagnostic capability of 18F-PSMA PET-MRI and pelvic MRI plus bone scan in treatment-naive prostate cancer: a single-center paired validating confirmatory study

BACKGROUND

Radical prostatectomy with pelvic lymph node dissection for the treatment of high-risk localized prostate cancer (PCa) results in long-term benefits in selected patients. But insufficient sensitivity of conventional examinations which are pelvic MRI and bone scan, limits the diagnosis of bone and lymph node metastasis of PCa. This affects the surgical management strategy of a large number of patients. The purpose of this study was to investigate whether 18F-prostate-specific membrane antigen (PSMA) PET-MRI could improve the clinical detection of PCa metastases compared with the conventional pelvic MRI plus bone scan.

MATERIALS AND METHODS

From April 2020 to April 2023, we prospectively enroled 472 patients with histologically proven PCa in our centre, and 120 patients underwent 18F-PSMA PET-MRI, multiparametric MRI, and bone scan before laparoscopic radical prostatectomy plus lymph node dissection. The accuracy of imaging results in detecting lymph node and bone metastatic lesions was compared between PSMA PET-MRI and MRI plus bone scan.

RESULTS

In diagnosing lymph node metastasis, PSMA PET-MRI had an area under the curve (AUC) of 0.844 (95% CI: 0.738-0.949, P < 0.001), sensitivity and specificity of 75% and 96%, which performed apparently better than MRI [AUC=0.615 (95% CI: 0.480-0.750, P =0.073)]. PSMA PET-MRI showed excellent expression in the diagnosis of bone metastases, with an AUC of 0.910 (95% CI: 0.840-0.981, P <0.001) compared to 0.700 (95% CI: 0.577-0.823, P =0.001) in bone scanning. PSMA PET-MRI also had higher sensitivity than bone scanning (90% vs. 43%), while lower specificity (92% vs. 97%).

CONCLUSION

PSMA PET-MRI is superior to conventional imaging at diagnosing metastases in lymph nodes and bones in PCa and can provide a more accurate stagement.

The survival benefit of different lymph node yields in radical prostatectomy for pN1M0 prostate cancer patients: Implications from a population-based study

Background and objectives

The extent and survival benefits of lymph node dissection (LND) in radical prostatectomy (RP) for pN1M0 prostate cancer (PCa) patients remained unclear and were controversial. This study aimed to determine the survival benefit of different lymph node yields in RP for pN1M0 PCa patients.

Methods

pN1M0 PCa patients who received RP and LND were identified in Surveillance Epidemiology and End Results (SEER) (2010–2015). Patients were divided into two groups in SEER based on the removal of one to three regional lymph nodes (LND1 group) or four or more regional lymph nodes (LND4 group). Kaplan–Meier methods were used to calculate cancer-specific survival (CSS) and overall survival (OS).

Results

In total, 2,200 patients were identified; 264 patients received LND1 and 1,936 patients received LND4. CSS had no significant difference between the LND4 and LND1 groups (101mon vs. 98mon, p = 0.064), and OS was higher in LND4 patients compared with LND1 patients (97mon vs. 93mon, p = 0.024); for patients with Gleason score = 9 or 10 and T3b or T4, 5-year OS was higher in patients undergoing LND4 (80.9%; 95% CI, 79.0–82.8) compared with those undergoing LND1 (67.5%; 95% CI, 60.8–74.2) (p = 0.009).

Conclusion

More lymph node yield provided better survival for patients with Gleason score = 9 or 10 and T3b or T4, but not for other pN1M0 PCa patients. The extent of LND would be determined after a comprehensive evaluation including Gleason score, tumor stage, and the general condition of the patient.