Can Negative Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Avoid the Need for Pelvic Lymph Node Dissection in Newly Diagnosed Prostate Cancer Patients? A Systematic Review and Meta-analysis with Backup Histology as Reference Standard

A Comprehensive Systematic Review and Meta-analysis of the Role of Prostate-specific Membrane Antigen Positron Emission Tomography for Prostate Cancer Diagnosis and Primary Staging before Definitive Treatment

BACKGROUND AND OBJECTIVE

Positron emission tomography (PET) with prostate-specific membrane antigen (PSMA) in the diagnosis and primary staging of patients with prostate cancer (PCa) has an established role, but recent summative evidence on its actual diagnostic and staging value is still missing. We aimed to collect and analyze published studies reporting the accuracy of PSMA PET for the diagnosis of clinically significant prostate cancer (csPCa) and detection of distant metastases at primary staging before definitive treatment.

METHODS

We performed a systematic review of the literature, by searching the PubMed/MEDLINE, Cochrane library's CENTRAL, EMBASE, and Scopus databases, from inception to April 2024. Two coprimary outcomes were assessed: first, to evaluate the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of PSMA PET in detecting intraprostatic csPCa on a per-patient level, and second, to assess the positivity rates of metastatic disease in the primary staging, prior to definitive therapy. As a secondary outcome, the diagnostic accuracy of PET PSMA for the detection of lymph nodal invasion (LNI) was tested in a per-patient-level analysis of studies where pelvic lymph node dissection (PLND) was available as the reference standard. Positivity and detection rates were pooled using random-effect models. Preplanned subgroup analyses tested the diagnostic accuracy of PET PSMA across different study cohorts. Variation in PPV and NPV over csPCa and LNI prevalence was evaluated.

KEY FINDINGS AND LIMITATIONS

In total, 12 and 99 studies, with a total of 1533 and 18 649 participants, respectively, were included in the quantitative synthesis for intraprostatic diagnosis and staging. For intraprostatic disease, the sensitivity, specificity, PPV, and NPV of PSMA PET for csPCa were 82% (95% confidence interval [CI] 73-90%), 67% (95% CI 46-85%), 77% (95% CI 63-88%), and 73% (95% CI 56-87%), respectively. At a bivariate analysis, the diagnostic accuracy of PSMA PET estimated through a summary receiver operating characteristic curve-derived area under the curve was 84%, increasing up to 88% when combined with magnetic resonance imaging (MRI). On staging level, PSMA PET results were positive outside the prostate in 23% of the patients, with substantial variation in positivity rates between high-risk (31%) and intermediate-risk (12%) subcohorts. When using PLND as the reference standard (51 studies, 7713 patients), the sensitivity, specificity, PPV, and NPV of PSMA PET were, respectively, 54%, 94%, 77%, and 86%. With higher csPCa and LNI prevalence, a similar increase in PPV and a decrease in NPV were observed.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The current updated systematic review and meta-analysis provides updated evidence on the diagnostic and staging accuracy of PSMA PET in PCa. We reported good accuracy of PSMA PET to discriminate csPCa, particularly when added to MRI, but NPV alone is insufficient to omit a biopsy. Regarding staging, PSMA PET cannot be used alone to determine the need for lymph node dissection (LND) and should be combined with additional clinical information within predictive tools. As such, further research should develop and validate models that incorporate PSMA PET to reliably inform biopsy or LND.

Impact of Pelvic Lymph Node Dissection on Early Oncological Outcomes in Intermediate-Risk Prostate Cancer Patients With Node-Negative PSMA PET

BACKGROUND

PSMA PET/CT has previously shown superior performance in nodal staging of prostate cancer (PCa) and may be used to reduce the number of unnecessary PLND procedures. This study aims to assess the performance of PSMA PET/CT in nodal staging of intermediate-risk prostate cancer and to evaluate the effect of PLND on oncological outcomes of intermediate-risk prostate cancer patients with a negative PSMA PET/CT.

METHODS

A total of 308 patients with intermediate-risk PCa who underwent PSMA PET/CT for nodal staging between January 2014 and July 2024 were included in the study. Patients who underwent PLND had higher PSA and higher rates of PIRADS-5 and biopsy grade-group 3 disease. A 1:1 propensity score matching was performed to eliminate patient characteristics differences between groups and 140 patients were included in the final analysis. PSA persistence rates ( ≥ 0.1 ng/dL) and biochemical recurrence (BCR; ≥ 0.2 ng/dL) rates after RP were recorded. Kaplan-Meier curves were constructed to evaluate oncological outcomes. Log-rank test was utilized to compare oncological outcomes in patients with and without PLND.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PSMA PET/CT on nodal staging were 53.3%, 95%, 47.1%, and 96.1%, respectively. The NPV of PSMA PET/CT in patients with biopsy GG3 disease (96.3%) was similar to those with biopsy GG2 disease (95.6%). The median follow-up after propensity score matching was 20.7 months. The 24-month BCR-free survival rates were 83.7% and 86.9% in the PLND-RP group and RP-only groups, respectively (p = 0.078).

CONCLUSIONS

NPV of PSMA PET/CT in determining LNI was remarkable in patients with intermediate-risk PCa and PLND was found to have no impact on oncological outcomes. Therefore PLND may be omitted to decrease surgery-related complications in patients with intermediate-risk PCa a negative PSMA PET/CT for nodal staging.

Pelvic Lymph Node Dissection in Prostate Cancer: Evidence and Implications

The role of extended pelvic lymph-node dissection (ePLND) in prostate cancer has been revisited in light of evidence from studies on staging via prostate-specific membrane antigen positron emission tomography/computed tomography. It is difficult to predict which individuals might benefit from ePLND. Patients should be counselled about this uncertainty and the risks of ePLND-associated morbidity as part of the shared decision-making process.

The Role of PSMA PET Imaging in Prostate Cancer: Current Applications and Future Directions

PURPOSE OF REVIEW

Prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET) imaging has revolutionized prostate cancer detection and management. This review aims to evaluate the latest advancements in PSMA PET imaging, assess its clinical applications in various disease stages, and compare it to conventional imaging techniques. We sought to determine how PSMA PET impacts clinical decision-making, treatment strategies, and patient outcomes, with a focus on its expanding role in precision oncology.

RECENT FINDINGS

Recent studies have demonstrated that PSMA PET exhibits superior sensitivity and specificity in detecting prostate cancer metastases, particularly in cases of biochemical recurrence and early-stage disease. The advent of radiolabeled PSMA ligands, such as 68Ga-PSMA-11 and 18 F-DCFPyL, has led to improved diagnostic accuracy. Furthermore, PSMA-targeted radioligand therapies (e.g., 177Lu-PSMA-617) show promising results in metastatic castration-resistant prostate cancer (mCRPC), offering a novel therapeutic avenue. Studies have also highlighted the role of PSMA PET in refining treatment plans, including guiding surgery and radiotherapy. PSMA PET imaging represents a paradigm shift in prostate cancer diagnostics, staging, and treatment monitoring. It has led to earlier and more accurate detection of metastases, significantly altering management strategies. The growing body of evidence supports its integration into standard-of-care protocols, with ongoing research focusing on optimizing its therapeutic applications. Future studies should explore cost-effectiveness, accessibility, and potential synergies with emerging systemic therapies to further enhance patient outcomes.

PSMA PET as a Tool for Active Surveillance of Prostate Cancer-Where Are We at?

Active surveillance remains the preferred treatment for men with low-risk prostate cancer and select men with favourable intermediate-risk prostate cancer. It involves the close observation of clinicopathological parameters to assess for disease progression, aiming to delay or avoid definitive treatment and related toxicities for as long as possible, without compromising oncological outcomes. A recent advancement in prostate cancer staging is the PSMA PET scan, which uses a tracer that strongly binds a highly expressed cellular biomarker for prostate cancer. Recent articles have also demonstrated that PSMA PET may be a useful tool for risk-stratifying prostate cancer, with the SUVMax of the scan correlated with higher-grade prostate cancer. This has ignited interest in the potential use of PSMA PET to identify men with higher-risk prostate cancer who may be unsuitable for active surveillance, particularly those who were incorrectly classified as lower risk upon initial diagnosis. This review article aims to assess the current state of the literature and clinical guidelines regarding the use of PSMA PET as a tool to risk-stratify prostate cancer, and whether it can be incorporated into active surveillance protocols to identify men who were incorrectly risk-stratified at time of initial diagnosis.

PSMA PET/CT based multimodal deep learning model for accurate prediction of pelvic lymph-node metastases in prostate cancer patients identified as candidates for extended pelvic lymph node dissection by preoperative nomograms

PURPOSE

To develop and validate a prostate-specific membrane antigen (PSMA) PET/CT based multimodal deep learning model for predicting pathological lymph node invasion (LNI) in prostate cancer (PCa) patients identified as candidates for extended pelvic lymph node dissection (ePLND) by preoperative nomograms.

METHODS

[68Ga]Ga-PSMA-617 PET/CT scan of 116 eligible PCa patients (82 in the training cohort and 34 in the test cohort) who underwent radical prostatectomy with ePLND were analyzed in our study. The Med3D deep learning network was utilized to extract discriminative features from the entire prostate volume of interest on the PET/CT images. Subsequently, a multimodal model i.e., Multi kernel Support Vector Machine was constructed to combine the PET/CT deep learning features, quantitative PET and clinical parameters. The performance of the multimodal models was assessed using final histopathology as the reference standard, with evaluation metrics including area under the receiver operating characteristic curve (AUC), calibration curve, decision curve analysis, and compared with available nomograms and PET/CT visual evaluation result.

RESULTS

Our multimodal model incorporated clinical information, maximum standardized uptake value (SUVmax), and PET/CT deep learning features. The AUC for predicting LNI was 0.89 (95% confidence interval [CI] 0.81-0.97) for the final model. The proposed model demonstrated superior predictive accuracy in the test cohort compared to PET/CT visual evaluation result, the Memorial Sloan Kettering Cancer Center (MSKCC) and the Briganti-2017 nomograms (AUC 0.85 [95% CI 0.69-1.00] vs. 0.80 [95% CI 0.64-0.95] vs. 0.79 [95% CI 0.61-0.97] and 0.69 [95% CI 0.50-0.88], respectively). The proposed model showed similar calibration and higher net benefit as compared to the traditional nomograms.

CONCLUSION

Our multimodal deep learning model, which incorporates preoperative PSMA PET/CT imaging, shows enhanced predictive capabilities for LNI in clinically localized PCa compared to PSMA PET/CT visual evaluation result and existing nomograms like the MSKCC and Briganti-2017 nomograms. This model has the potential to reduce unnecessary ePLND procedures while minimizing the risk of missing cases of LNI.

The Role of Robot-Assisted, Imaging-Guided Surgery in Prostate Cancer Patients

Emerging imaging-guided technologies, such as prostate-specific membrane antigen radioguided surgery (PSMA-RGS) and augmented reality (AR), could enhance the precision and efficacy of robot-assisted prostate cancer (PCa) surgical approaches, maximizing the surgeons' ability to remove all cancer sites and thus patients' outcomes. Sentinel node biopsy (SNB) represents an imaging-guided technique that could enhance nodal staging accuracy by leveraging lymphatic mapping with tracers. PSMA-RGS uses radiolabeled tracers with the aim to improve intraoperative lymph node metastases (LNMs) detection. Several studies demonstrated its feasibility and safety, with promising accuracy in nodal staging during robot-assisted radical prostatectomy (RARP) and in recurrence setting during salvage lymph node dissection (sLND) in patients who experience biochemical recurrence (BCR) after primary treatment and have positive PSMA positron emission tomography (PET). Near-infrared PSMA tracers, such as OTL78 and IS-002, have shown potential in intraoperative fluorescence-guided surgery, improving positive surgical margins (PSMs) and LNMs identification. Finally, augmented reality (AR), which integrates preoperative imaging (e.g., multiparametric magnetic resonance imaging [mpMRI] of the prostate and computed tomography [CT]) onto the surgical field, can provide a real-time visualization of anatomical structures through the creation of three-dimensional (3D) models. These technologies may assist surgeons during intraoperative procedures, thus optimizing the balance between oncological control and functional outcomes. However, challenges remain in standardizing these tools and assessing their impact on long-term PCa control. Overall, these advancements represent a paradigm shift toward personalized and precise surgical approaches, emphasizing the integration of innovative strategies to improve outcomes of PCa patients.

Surveillance After Focal Therapy for Prostate Cancer: A Comprehensive Review

Focal Therapy (FT) is an emerging treatment modality for prostate cancer (PCa). Due to its novelty, the research exploring how patients should be followed-up after treatment is limited. There is currently no established role for non-prostate-specific-antigen (PSA) biomarkers and PSMA PET. However, a combination of PSA testing, multiparametric magnetic resonance imaging (mpMRI), and systematic and targeted biopsies should routinely be used for surveillance after FT. PSA values that rise 1.0 ng/mL over the nadir after twelve months or rise 1.5 ng/mL over nadir after twenty-four to thirty-six months should raise suspicion for recurrence. The standard imaging technique is mpMRI, but it can often be difficult to interpret after FT, so using a scoring system such as prostate imaging after focal ablation (PI-FAB) or the transatlantic recommendations for prostate gland evaluation with magnetic resonance imaging after focal therapy (TARGET) allows for greater consistency between readers. This review seeks to summarize the current literature regarding surveillance after FT as it relates to biomarkers, imaging, biopsies, and consensus statements.

[Indications for performing PSMA-PET-CT as part of prostate cancer diagnostics]

Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) is increasingly being applied in the diagnostic landscape of prostate cancer. This study aims to elucidate and assess both established and emerging indications for PSMA-PET/CT imaging. Current evidence on PSMA-PET/CT is summarised, with relevant guideline recommendations and enhanced by recent study findings. PSMA-PET/CT demonstrates superiority over conventional imaging techniques and can be applied either complementarily or substitutively across all stages of prostate cancer based on clinical indications. It offers advantages in terms of reduced time and radiation exposure. PSMA-PET/CT use enables a more accurate assessment of disease status and facilitates optimised treatment planning. Applications span from initial cancer suspicion through diagnosis, staging, and therapeutic planning in cases of biochemical recurrence and metastatic prostate cancer. However, evidence for the prognostic value of PSMA-PET/CT-guided therapy decisions is currently limited. PSMA-PET/CT provides substantial diagnostic and therapeutic benefits for nearly all subgroups of prostate cancer patients. Its use supports the evaluation of possible intensification or de-escalation strategies, thereby enabling personalised treatment planning.

Metastatic lymph nodes outside the extended lymphadenectomy template correlate with advanced staging but not grading in prostate cancer patients undergoing radical prostatectomy

PURPOSE

This study aimed to evaluate the impact of metastatic lymph nodes (LNs) outside the extended pelvic lymph node dissection (ePLND) template on oncological outcomes, staging, grading, and concomitant parameters in prostate cancer (PCa) patients undergoing radical prostatectomy (RP).

METHODS

Data from 860 patients with histologically confirmed, non-metastatic PCa who underwent RP between 2012 and 2022 were retrospectively analyzed. All specimens underwent detailed histopathological examination. Preoperative and postoperative clinicopathological data were collected and analyzed. Subgroup associations were evaluated using the Mann-Whitney U test and the Kruskal-Wallis test. Kendall's tau-b coefficient was employed to evaluate the association between two variables. All tests were performed using a two-tailed approach, with a p value of less than 0.05 considered statistically significant for differences between groups. Kaplan-Meier and Cox regression analyses assessed biochemical recurrence (BCR)-free survival based on lymph node invasion (LNI) (pN0 vs. pN1) and the presence of metastatic LNs outside the ePLND template.

RESULTS

Of the 860 patients, 613 underwent modified-ePLND. Among them, 122 (19.9%) were pN1, with 22 patients (18%) having metastatic LNs located outside the classical ePLND template. Patients with LNs beyond the ePLND template exhibited higher clinical T stages (p = 0.016) and a greater percentage of positive biopsy cores (p = 0.008). However, no correlation was observed with Gleason Grading Group (p = 0.491). Kaplan-Meier analysis showed that pN1 patients had higher BCR rates compared to pN0 patients, but this difference did not reach statistical significance (p = 0.174). Similarly, patients with metastatic LNs outside the ePLND template demonstrated a trend toward increased BCR risk, though this was not statistically significant (p = 0.140).

CONCLUSION

Metastatic LNs beyond the ePLND template correlate with more advanced tumor staging in PCa. However, they show no association with tumor grading. Their influence on BCR remains inconclusive, likely due to the small number of patients included in the BCR-associated analyses. Extended lymphadenectomy may enhance staging accuracy but must be weighed against the potential for increased surgical morbidity.

External validation of a nomogram for unilateral pelvic lymph node dissection in prostate cancer

OBJECTIVES

To explore the rationale of unilateral extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) by external validation of a nomogram for unilateral ePLND (unilat-NG) and comparison to the Briganti 2019 nomogram.

PATIENTS AND METHODS

Patients with magnetic resonance imaging-fusion biopsy and consecutive RP with bilateral ePLND were identified within an institutional database. The primary endpoint was the detection rate of lymph node invasion (LNI) contralateral to the prostatic lobe with adverse cancer characteristics. The performance of the unilat-NG and the Briganti 2019 nomogram to detect contralateral LNI was assessed using descriptive analysis, the receiver operating characteristic curve-derived area under the curve (AUC), and multivariable logistic regression analyses.

RESULTS

Of the overall 406 consecutive patients, 68/406 (16.7%) presented with pathological (p)N1 disease at RP. The AUC for the unilat-NG with a 1%, 2% and 2.5% cut-off was 0.58 (95% confidence interval [CI] 0.53-0.63), 0.67 (95% CI 0.59-0.75), and 0.69 (95% CI 0.60-0. 77), respectively; compared to an AUC of 0.72 (95% CI 0.66-0.78) for the Briganti 2019 nomogram with a 7% cut-off. Applying the unilat-NG with a 2.5% cut-off, contralateral ePLND could be omitted in 303/406 (74.6%) patients, misclassifying 10/406 (2.5%) patients with pN0 disease.

CONCLUSION

The Briganti 2019 nomogram outperformed the novel unilat-NG in contralateral LNI prediction. Yet, a significant proportion of patients undergoing unilateral ePLND would be falsely classified with pN0 disease using any of the nomograms. Therefore, bilateral ePLND should remain the standard of care if PLND is indicated.

Diagnostic Accuracy of Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography for Primary Lymph Node Staging Before Radical Prostatectomy

BACKGROUND AND OBJECTIVE

Prostate-specific-membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) is more accurate than conventional imaging for lymph node (LN) staging in prostate cancer. However, it has limitations in detecting micrometastatic lymph node invasion (LNI). Our aim was to evaluate the accuracy of PSMA PET/CT for overall and size-dependent LNI detection in contemporary patients undergoing radical prostatectomy (RP) and pelvic lymph node dissection (PLND).

METHODS

Within a high-volume center database, we identified 873 patients who underwent PSMA PET/CT for primary staging before RP and PLND between 2016 and 2021. Data for lymph node status on imaging and histology results were analyzed.

KEY FINDINGS AND LIMITATIONS

Of 873 patients, 25% (n = 220) had LNI. Median prostate-specific antigen was 8.3 ng/ml (interquartile range 4.3-14.3). The majority of patients had high-risk (53%) or intermediate-risk disease (45%). In the overall cohort, the per-patient sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy calculated for LNI detection via PSMA PET/CT were 45.5%, 92.6%, 67.6%, 83.4%, and 80.8%, respectively. The median metastatic LN size in the group of 120 patients with false-negative PET/CT results was 2.5 mm. For metastatic LNs ≥5 mm, the sensitivity and NPV increased to 68.8% (+23.3%) and 95.4% (+12.0%), respectively. The main limitation is the lack of central review of PSMA PET/CT scans.

CONCLUSIONS AND CLINICAL IMPLICATIONS

PSMA PET/CT is accurate in the staging of pelvic LNs before RP, especially for detection of metastases in LNs with a diameter ≥5 mm.

Pelvic Lymph Node Dissection in Prostate Cancer: Update from a Randomized Clinical Trial of Limited Versus Extended Dissection

BACKGROUND AND OBJECTIVE

Lymph node dissection (LND) has been standard in cancer surgery for more than a century, yet evidence from randomized trials showing a benefit is scarce. We conducted a clinically integrated randomized trial comparing limited versus extended pelvic LND (PLND) during radical prostatectomy and previously reported comparable biochemical recurrence (BCR) rates. We report updated BCR rates and compare rates of metastasis between the study arms.

METHODS

Between October 2011 and March 2017, 1432 patients undergoing radical prostatectomy were enrolled at a single center. Surgeons were cluster randomized to perform limited (external iliac nodes) or extended PLND (external iliac, obturator, and hypogastric nodes) with crossover for 3-mo periods. Cox proportional-hazards regression with robust standard errors clustered by surgeon was used to assess whether the PLND template affected BCR or distant or locoregional metastasis.

KEY FINDINGS AND LIMITATIONS

There were 452 BCR events at median follow-up of 4.2 yr for participants who did not develop BCR. The results confirm our previous finding of comparable BCR rates between the arms (hazard ratio [HR] 1.05, 95% confidence interval [CI] 0.97-1.13; p = 0.3). However, with 123 metastasis events and median follow-up of 5.4 yr for patients without metastasis, we found a clinically and statistically significant protective effect of extended PLND against metastasis (any metastasis: HR 0.82, 95% CI 0.71-0.93; p = 0.003; distant metastasis: HR 0.75, 95% CI 0.64-0.88; p < 0.001).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Patients undergoing radical prostatectomy should receive extended PLND that includes the external iliac, obturator, and hypogastric nodes. Further research should examine biological mechanisms regarding the anatomic location of affected nodes. Trials of LND for other cancers are warranted and should consider our clinically integrated design. This trial is registered on ClinicalTrials.gov as NCT01407263.

External Validation of Nomograms for the Identification of Pelvic Nodal Dissection Candidates Among Prostate Cancer Patients with Negative Preoperative Prostate-specific Membrane Antigen Positron Emission Tomography

BACKGROUND AND OBJECTIVE

Extended pelvic lymph node dissection (ePLND) is recommended in selected radical prostatectomy (RP) prostate cancer (PCa) patients for staging purposes. We aim to externally validate available tools to predict lymph node invasion (LNI) in men with negative preoperative prostate-specific membrane antigen positron emission tomography (miN0).

METHODS

Overall, 282 intermediate- to high-risk PCa patients with miN0 disease undergoing RP and ePLND at ten centers between 2016 and 2023 were identified. The Memorial Sloan Kettering Cancer Center (MSKCC); Amsterdam-Brisbane-Sydney; and Briganti 2017, 2019, and 2023 tools predicting LNI were validated externally using calibration plots, C-indexes, and decision-curve analyses to assess calibration, discrimination, and net benefit.

KEY FINDINGS AND LIMITATIONS

Overall, 36 (13%) patients had LNI. The C-indexes of the MSKCC, Briganti 2017, Briganti 2019, Amsterdam-Brisbane-Sydney, and Briganti 2023 nomograms were 64%, 69%, 72%, 64%, and 77%, respectively. The Briganti 2023 nomogram exhibited higher net benefit than the other available nomograms, and the use of a 5% cutoff would have spared 47% ePLND procedures (vs 14% and 4.3% for the Briganti 2019 and Amsterdam-Brisbane-Sydney nomograms, respectively) at the cost of missing only five (3.8%) LNI cases. Heterogeneity in patient selection and imaging protocols represents the main limitations.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The Briganti 2023 nomogram outperformed other available tools in predicting LNI in men with miN0 PCa. The use of this tool resulted in a considerable number of unnecessary ePLND procedures spared and optimization of ePLND recommendations in a contemporary clinical setting.

Harmonized technical standard test methods for quality evaluation of medical fluorescence endoscopic imaging systems

Fluorescence endoscopy technology utilizes a light source of a specific wavelength to excite the fluorescence signals of biological tissues. This capability is extremely valuable for the early detection and precise diagnosis of pathological changes. Identifying a suitable experimental approach and metric for objectively and quantitatively assessing the imaging quality of fluorescence endoscopy is imperative to enhance the image evaluation criteria of fluorescence imaging technology. In this study, we propose a new set of standards for fluorescence endoscopy technology to evaluate the optical performance and image quality of fluorescence imaging objectively and quantitatively. This comprehensive set of standards encompasses fluorescence test models and imaging quality assessment protocols to ensure that the performance of fluorescence endoscopy systems meets the required standards. In addition, it aims to enhance the accuracy and uniformity of the results by standardizing testing procedures. The formulation of pivotal metrics and testing methodologies is anticipated to facilitate direct quantitative comparisons of the performance of fluorescence endoscopy devices. This advancement is expected to foster the harmonization of clinical and preclinical evaluations using fluorescence endoscopy imaging systems, thereby improving diagnostic precision and efficiency.

Has the Time Come to Switch From Extensive Lymph Node Dissection to Sentinel Lymph Node Biopsy in Prostate Cancer Patients Treated With Radical Laparoscopic Prostatectomy?

ABSTRACT

The efficacy of the available procedures currently recommended for staging and prognostic evaluation of prostate cancer patients treated with radical laparoscopic prostatectomy is discussed, taking into account the available evidence and potential implications in patient management.

Between Pathological Prostate Cancer Lymph Nodes and Sentinel Nodes: Which Information Is the Leader?

PURPOSE

On the basis of the concept of sentinel lymph node biopsy (SLNB), SLNs should contain decisive information for clinical outcomes. In localized prostate cancer patients, this study assessed retrospectively clinical outcome after radical laparoscopic prostatectomy associated with SLNB and extensive pelvic lymph node dissection.

METHODS

A total of 231 consecutive patients of intermediate to high risk were analyzed. Recurrence-free survival (RFS) was assessed with Kaplan-Meier curves. Various pathological parameters were analyzed using univariable and multivariable analyses through Cox regression analysis. The study was approved and registered under 2007-R41.

RESULTS

The median follow-up was 7.1 years (95% confidence interval, 6.6-7.5). In total, 38/231 (16.5%) patients were pN1. Of these 38 patients, 27 had only SLN involvement (SLNI), 10 patients had both SLN and non-SLNI, and 1 patient had isolated non-SLNI, indicating a false-negative (FN). If the updated Briganti nomogram threshold set at >7% for recommending extensive pelvic lymph node dissection had been applied to these patients, we would have missed 44% (12/27) of patients with SLNI and 50% (5/10) of patients with SLNI and non-SLNI, as well as the FN patient. At the time of final follow-up, 84/231 (36.5%) patients had recurrence. In multivariable analysis, and regarding node status, the most significant prognostic factor was SLN with macrometastases and/or micrometastases, respectively, P = 10 -3 and P < 10 -3 . No more information was obtained with non-SLN status. Probabilities of RFS between negative and positive SLN patients presented a major significant difference ( P < 10 -15 ) with a risk of event 8.75 times more frequent if SLN was involved than if it was metastasis-free.

CONCLUSIONS

SLNB seems to contain decisive information for the clinical outcome of patients with localized intermediate- and high-risk prostate cancer patients. The question raised is thus whether immediate additional postoperative treatment should be offered to patients with metastatic SLN.

Progress of fluorescence imaging in lymph node dissection surgery for prostate and bladder cancer

Fluorescence imaging is a relatively new imaging method used to visualize different tissue structures to help guide intraoperative operations, which has potential advantages with high sensitivity and contrast compared to conventional imaging. In this work, we review fluorescent contrast agents and devices used for lymphatic system imaging. Indocyanine green is the most widely utilized due to its high sensitivity, specificity, low background fluorescence, and safety profile. In prostate and bladder cancer lymph node dissection, the complex lymphatic drainage can result in missed metastatic nodes and extensive dissection increases the risk of complications like lymphocele, presenting a significant challenge for urologists. Fluorescence-guided sentinel lymph node dissection facilitates precise tumor staging. The combination of fluorescence and radiographic imaging improves the accuracy of lymph node staging. Multimodal imaging presents new potential for precisely identifying metastatic pelvic lymph nodes.

Defining the optimal target-to-background ratio to identify positive lymph nodes in prostate cancer patients undergoing robot-assisted [99mTc]Tc-PSMA radioguided surgery: updated results and ad interim analyses of a prospective phase II study

INTRODUCTION

Prostate-specific membrane antigen radioguided surgery (PSMA-RGS) might identify lymph node invasion (LNI) in prostate cancer (PCa) patients undergoing extended pelvic lymph node dissection (ePLND). The optimal target-to-background (TtB) ratio to define RGS positivity is still unknown.

MATERIALS & METHODS

Ad interim analyses which focused on 30 patients with available pathological information were conducted. All patients underwent preoperative PSMA positron emission tomography (PET). 99m-Technetium-PSMA imaging and surgery ([99mTc]Tc-PSMA-I&S) was administered the day before surgery. In vivo measurements were conducted using an intraoperative gamma probe. Performance characteristics and implications associated with different TtB ratios were assessed.

RESULTS

Overall, 9 (30%) patients had LNI, with 22 (13%) and 80 (11%) positive regions and lymph nodes, respectively. PSMA-RGS showed uptakes in 12 (40%) vs. 7 (23%) vs. 6 (20%) patients for a TtB ratio ≥ 2 vs. ≥ 3 vs. ≥ 4. At a per-region level, sensitivity, specificity and accuracy for a TtB ratio ≥ 2 vs. ≥ 3 vs. ≥ 4 were 72%, 88% and 87% vs. 54%, 98% and 92% vs. 36%, 99% and 91%. Performing ePLND only in patients with suspicious spots at PSMA PET (n = 7) would have spared 77% ePLNDs at the cost of missing 13% (n = 3) pN1 patients. A TtB ratio ≥ 2 at RGS identified 8 (24%) suspicious areas not detected by PSMA PET, of these 5 (63%) harbored LNI, with one pN1 patient (11%) that would have been missed by PSMA PET. Adoption of a TtB ratio ≥ 2 vs. ≥ 3 vs. ≥ 4, would have allowed to spare 18 (60%) vs. 23 (77%) vs. 24 (80%) ePLNDs missing 2 (11%) vs. 3 (13%) vs. 4 (17%) pN1 patients.

CONCLUSIONS

PSMA-RGS using a TtB ratio ≥ 2 to identify suspicious nodes, could allow to spare > 50% ePLNDs and would identify additional pN1 patients compared to PSMA PET and higher TtB ratios.

Comparative Performance of 68Ga-PSMA-11 PET/CT and Conventional Imaging in the Primary Staging of High-Risk Prostate Cancer Patients Who Are Candidates for Radical Prostatectomy

This prospective study aimed to (1) compare the diagnostic performance of 68Ga-PSMA-11 PET/CT with respect to conventional imaging (computed tomography (CT) and bone scintigraphy (BS)) in the primary staging of high-risk prostate cancer (PCa) patients and (2) validate PSMA-PET/CT accuracy in pelvic nodal staging in comparison with postoperative histopathology and assess PSMA-PET/CT's impact on patient management. Sixty castration-sensitive high-risk (ISUP 4-5 and/or PSA > 20 ng/mL and/or cT3) PCa patients eligible for radical prostatectomy were enrolled (median PSA 10.10 [IQR: 6.22-17.95] ng/mL). PSMA-PET/CT, compared with CT, identified nodal (N) and/or distant metastases (M1) in 56.7% (34/60) vs. 13.3% (8/60) (p < 0.001) of patients: N + 45% vs. 13.3% (p < 0.001), M1a 11.7% vs. 1.7% (p = 0.03), M1b 23.3% vs. 1.7% (p < 0.001). Compared with BS, PSMA-PET/CT localized unknown skeletal metastases in 15% (9/60) of cases, with no false negative findings. Overall, PSMA-PET/CT led to a TNM upstaging in 45.0% (27/60) of cases, with no evidence of downstaging, resulting in a change in management in up to 28.8% (17/59) of patients. Compared with histopathology data (n = 32 patients), the per-patient accuracy of PSMA-PET/TC for detecting pelvic nodal metastases was 90.6%. Overall, the above evidence supports the use of PSMA-PET/CT in the diagnostic workup of high-risk prostate cancer staging.

The Potential of Iron Oxide Nanoparticle-Enhanced MRI at 7 T Compared With 3 T for Detecting Small Suspicious Lymph Nodes in Patients With Prostate Cancer

BACKGROUND

Accurate detection of lymph node (LN) metastases in prostate cancer (PCa) is a challenging but crucial step for disease staging. Ultrasmall superparamagnetic iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI) enables distinction between healthy LNs and nodes suspicious for harboring metastases. When combined with MRI at an ultra-high magnetic field, an unprecedented spatial resolution can be exploited to visualize these LNs.

PURPOSE

The aim of this study was to explore USPIO-enhanced MRI at 7 T in comparison to 3 T for the detection of small suspicious LNs in the same cohort of patients with PCa.

MATERIALS AND METHODS

Twenty PCa patients with high-risk primary or recurrent disease were referred to our hospital for an investigational USPIO-enhanced 3 T MRI examination with ferumoxtran-10. With consent, they underwent a 7 T MRI on the same day. Three-dimensional anatomical and T2*-weighted images of both examinations were evaluated blinded, with an interval, by 2 readers who annotated LNs suspicious for metastases. Number, size, and level of suspicion (LoS) of LNs were paired within patients and compared between field strengths.

RESULTS

At 7 T, both readers annotated significantly more LNs compared with 3 T (474 and 284 vs 344 and 162), with 116 suspicious LNs on 7 T (range, 1-34 per patient) and 79 suspicious LNs on 3 T (range, 1-14 per patient) in 17 patients. For suspicious LNs, the median short axis diameter was 2.6 mm on 7 T (1.3-9.5 mm) and 2.8 mm for 3 T (1.7-10.4 mm, P = 0.05), with large overlap in short axis of annotated LNs between LoS groups. At 7 T, significantly more suspicious LNs had a short axis <2.5 mm compared with 3 T (44% vs 27%). Magnetic resonance imaging at 7 T provided better image quality and structure delineation and a higher LoS score for suspicious nodes.

CONCLUSIONS

In the same cohort of patients with PCa, more and more small LNs were detected on 7 T USPIO-enhanced MRI compared with 3 T MRI. Suspicious LNs are generally very small, and increased nodal size was not a good indication of suspicion for the presence of metastases. The high spatial resolution of USPIO-enhanced MRI at 7 T improves structure delineation and the visibility of very small suspicious LNs, potentially expanding the in vivo detection limits of pelvic LN metastases in PCa patients.

Contemporary Role of Lymph Node Dissection in Genitourinary Cancers: Where Are We in 2023?

CONTEXT

Lymphadenectomy during surgery for genitourinary malignancies has varying benefits.

OBJECTIVE

To review contemporary evidence on lymph node dissection in genitourinary cancers.

EVIDENCE ACQUISITION

We performed a collaborative review to summarize current evidence supporting lymph node dissection in urothelial, prostate, kidney, penile, and testis cancers. We present the evidence on patient selection and recommended dissection templates, and highlight knowledge gaps and ongoing areas of investigation.

EVIDENCE SYNTHESIS

Lymph node dissection remains the reference standard for lymph node staging. Pathologic nodal stage informs prognosis and guides adjuvant treatment. Appropriate template and patient selection are paramount to optimize outcomes and capitalize on the selective therapeutic benefits.

CONCLUSIONS

Accurate staging with lymphadenectomy is contingent on appropriate template selection. The cumulative benefit will depend on judicious patient selection.

PATIENT SUMMARY

We performed a collaborative review by a diverse group of experts in urology. We reviewed current evidence on lymph node dissection.

Subnodal Correspondence of PSMA Expression and USPIO-MRI in Metastatic Pelvic Lymph Nodes in Prostate Cancer

OBJECTIVES

Two advanced imaging modalities used to detect lymph node (LN) metastases in prostate cancer patients are prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography and ultrasmall superparamagnetic iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI). As these modalities use different targets, a subnodal comparison is needed to interpret both their correspondence and their differences. The aim of this explorative study was to compare ex vivo 111 In-PSMA μSPECT images with high-resolution 7 T USPIO μMR images and histopathology of resected LN specimens from prostate cancer patients to assess the degree of correspondence at subnodal level.

MATERIALS AND METHODS

Twenty primary prostate cancer patients who underwent pelvic LN dissection were included and received USPIO contrast and 111 In-PSMA. A total of 41 LNs of interest (LNOIs) were selected for ex vivo imaging based on γ-probe detection or palpation. μSPECT and μMRI acquisition were performed immediately after resection. Overlay of μSPECT images on MR images was performed, and the level of correspondence (LoC) between μSPECT and μMR findings was assessed according to a 4-point Likert classification scheme.

RESULTS

Forty-one LNOIs could be matched to an LN on ex vivo μMRI. Coregistration of μSPECT and USPIO-enhanced water-selective multigradient echo MR images was successful for all 41 LNOIs. Ninety percent of the lesions showed excellent correspondence regarding the presence of metastatic tissue and affected subnodal site (LoC 4; 37/41). In only 1 of 41 LNOIs, a small metastasis was misclassified by both techniques. Three LNOIs were classified as LoC 3 (7%) and 1 LNOI as LoC 2. All LoC 2 and LoC 3 lesions had PSMA-expressing metastases on final histopathology.

CONCLUSIONS

Coregistration of μSPECT and USPIO-μMRI showed excellent subnodal correspondence in the majority (90%) of LNs. Ex vivo imaging may thus help localize small cancer deposits within resected LNs and could contribute to improved interpretation of in vivo imaging of LNs.

PSMA-Targeted Radiopharmaceuticals for Prostate Cancer Diagnosis and Therapy

ABSTRACT

Prostate cancer (PCa) is the most common noncutaneous malignancy in men. Until recent years, accurate imaging of men with newly diagnosed PCa, or recurrent or low-volume metastatic disease, was limited. Further, therapeutic options for men with advanced, metastatic, castration-resistant disease were increasingly limited as a result of increasing numbers of systemic therapies being combined in the upfront metastatic setting. The advent of urea-based, small-molecule inhibitors of prostate-specific membrane antigen (PSMA) has partially addressed those shortcomings in diagnosis and therapy of PCa. On the diagnostic side, there are multiple pivotal phase III trials with several different agents having demonstrated utility in the initial staging setting, with generally modest sensitivity but very high specificity for determining otherwise-occult pelvic nodal involvement. That latter statistic drives the utility of the scan by allowing imaging interpreters to read with very high sensitivity while maintaining a robust specificity. Other pivotal phase III trials have demonstrated high detection efficiency in patients with biochemical failure, with high positive predictive value at the lesion level, opening up possible new avenues of therapy such as metastasis-directed therapy. Beyond the diagnostic aspects of PSMA-targeted radiotracers, the same urea-based chemical scaffolds can be altered to deliver therapeutic isotopes to PCa cells that express PSMA. To date, one such agent, when combined with best standard-of-care therapy, has demonstrated an ability to improve overall survival, progression-free survival, and freedom from skeletal events relative to best standard-of-care therapy alone in men with metastatic, castration-resistant PCa who are post chemotherapy. Within the current milieu, there are a number of important future directions including the use of artificial intelligence to better leverage diagnostic findings, further medicinal chemistry refinements to the urea-based structure that may allow improved tumor targeting and decreased toxicities, and the incorporation of new radionuclides that may better balance efficacy with toxicities than those nuclides that are available.

18 F-prostate specific membrane antigen positron emission tomography/computerized tomography for lymph node staging in medium/high risk prostate cancer: A systematic review and meta-analysis

BACKGROUND

Lymph node staging of prostate cancer (PCa) is important for planning and monitoring of treatment. 18 F-prostate specific membrane antigen positron emission tomography/computerized tomography ( 18 F-PSMA PET/CT) has several advantages over 68 Ga-PSMA PET/CT, but its diagnostic value requires further investigation. This meta-analysis focused on establishing the diagnostic utility of 18 F-PSMA PET/CT for lymph node staging in medium/high-risk PCa.

METHODS

We searched the EMBASE, PubMed, Cochrane library, and Web of Science databases from inception to October 1, 2022. Prostate cancer, 18 F, lymph node, PSMA, and PET/CT were used as search terms and the language was limited to English. We additionally performed a manual search using the reference lists of key articles. Patients and study characteristics were extracted and the QUADAS-2 tool was employed to evaluate the quality of included studies. Sensitivity, specificity, the positive and negative likelihood ratio (PLR and NLR), diagnostic odds ratio (DOR), area under the curve (AUC), and 95% confidence interval (CI) were used to evaluate the diagnostic value of 18 F-PSMA PET/CT. Stata 17 software was employed for calculation and statistical analyses.

RESULTS

A total of eight diagnostic tests including 734 individual samples and 6346 lymph nodes were included in this meta-analysis. At the patient level, the results of each consolidated summary were as follows: sensitivity of 0.57 (95% CI 0.39-0.73), specificity of 0.95 (95% CI 0.92-0.97), PLR of 11.2 (95% CI 6.6-19.0), NLR of 0.46 (95% CI 0.31-0.68), DOR of 25 (95% CI 11-54), and AUC of 0.94 (95% CI 0.92-0.96). At the lesion level, the results of each consolidated summary were as follows: sensitivity of 0.40 (95% CI 0.21-0.62), specificity of 0.99 (95% CI 0.95-1.00), PLR of 40.0 (95% CI 9.1-176.3), NLR of 0.61 (95% CI 0.42-0.87), DOR of 66 (95% CI 14-311), and AUC of 0.86 (95% CI 0.83-0.89).

CONCLUSIONS

18 F-PSMA PET/CT showed moderate sensitivity but high specificity in lymph node staging of medium/high-risk PCa. The diagnostic efficacy was almost equivalent to that reported for 68 Ga-PSMA PET/CT.

REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), No. CRD42023391101.

The Prognostic Role of Preoperative PSMA PET/CT in cN0M0 pN+ Prostate Cancer: A Multicenter Study

CONTEXT

Despite negative preoperative conventional imaging, up to 10% of patients with prostate cancer (PCa) harbor lymph-node involvement (LNI) at radical prostatectomy (RP). The advent of more accurate imaging modalities such as PET/CT improved the detection of LNI. However, their clinical impact and prognostic value are still unclear. We aimed to investigate the prognostic value of preoperative PET/CT in patients node positive (pN+) at RP.

EVIDENCE SYNTHESIS

We retrospectively identified cN0M0 patients at conventional imaging (CT and/or MRI, and bone scan) who had pN+ PCa at RP at 17 referral centers. Patients with cN+ at PSMA/Choline PET/CT but cN0M0 at conventional imaging were also included. Systemic progression/recurrence was the primary outcome; Cox proportional hazards models were used for multivariate analysis.

EVIDENCE ACQUISITION

We included 1163 pN+ men out of whom 95 and 100 had preoperative PSMA and/or Choline PET/CT, respectively. ISUP grade ≥4 was detected in 66.6%. Overall, 42% of patients had postoperative PSA persistence (≥0.1 ng/mL). Postoperative management included initial observation (34%), ADT (22.7%) and adjuvant RT+/-ADT (42.8%). Median follow-up was 42 months. Patients with cN+ on PSMA PET/CT had an increased risk of systemic progression (52.9% vs. 13.6% cN0 PSMA PET/CT vs. 21.5% cN0 at conventional imaging; P < .01). This held true at multivariable analysis: (HR 6.184, 95% CI: 3.386-11-295; P < .001) whilst no significant results were highlighted for Choline PET/CT. No significant associations for both PET types were found for local progression, BCR, and overall mortality (all P > .05). Observation as an initial management strategy instead of adjuvant treatments was related with an increased risk of metastases (HR 1.808; 95% CI: 1.069-3.058; P < .05).

CONCLUSIONS

PSMA PET/CT cN+ patients with negative conventional imaging have an increased risk of systemic progression after RP compared to their counterparts with cN0M0 disease both at conventional and/or molecular imaging.

Extended pelvic lymph node dissection in robot-assisted radical prostatectomy is an independent risk factor for major complications

The aim of this study is to evaluate the major postoperative complication rate after robot-assisted radical prostatectomy (RARP) and to identify related risk factors. A consecutive series of patients who underwent RARP between September 2016 and May 2021, with or without extended pelvic lymph node dissection (ePLND) were analyzed for postoperative complications that occurred within 30 days following surgery. Potential risk factors related to complications were identified by means of a multivariate logistic analysis. Electronic medical records were retrospectively reviewed for the occurrence of major complications (Clavien-Dindo grade III or higher) on a per patient level. A multivariate logistic regression with risk factors was performed to identify contributors to complications. In total, 1280 patients were included, of whom 79 (6.2%) experienced at least 1 major complication. Concomitant ePLND was performed in 609 (48%) of patients. The majority of all complications were likely related to the surgical procedure, with anastomotic leakage and lymphoceles being the most common. Upon multivariate analysis, performing ePLND remained the only significant risk factor for the occurrence of major complications (OR 2.26, p = 0.001). In contrast to robot-assisted radical prostatectomy alone, the combination with extended pelvic lymph node dissection (ePLND) has a substantial risk of serious complications. Since the ePLND is performed mainly for staging purpose, the clinical contribution of the ePLND has to be reconsidered with the present use of the PSMA-PET/CT.

Comparison of Ga-PSMA PET MRI with mpMRI in localization and regional staging of prostate cancer

PURPOSE

To compare diagnostic accuracy in localization and detection of extraprostatic extension (EPE), seminal vesicle invasion (SVI), lymph node involvement (LNI) between PSMA PET MRI and multiparametric MRI (mpMRI) in carcinoma prostate.

METHODS

We did a prospective study of consecutive men with biopsy-proven prostate cancer who underwent radical prostatectomy between July'2020 and Dec'2021 at our institution. Patients underwent PSMA PET MRI imaging. MpMRI findings were inferred separately by another radiologist who was blinded to the PSMA PET findings. PIRADS > 2 and any standardized uptake value (SUV) were considered positive. Findings were mapped to a 30-region anatomical grid and compared with pathology. The uro-pathologist also marked the presence of the tumor onto the same anatomical grid. The presence of EPE, SVI, and LVI was noted.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The significance in difference: McNemar test. SUVmax and Gleason score: Kruskal-Wallis test.

RESULTS

Seventy-five men (mean age 65) with an average PSA of 21.5 ng/ml were included. The sensitivity of PSMA PET MRI for localization was higher [63.6 vs 41.9] (p < 0.001) while specificity was similar [81.5 vs 83.2] (p 0.103). The former had a higher sensitivity to detect SVI [85.7 vs 57.10] (p = 0.03). No difference in the detection of EPE or LNI was noted. SUVmax > 7 was associated with high-risk disease (Gleason score >/= 7).

LIMITATIONS

non-randomized nature, higher risk population.

CONCLUSION

Ga-PSMA PET MRI improved the localization of prostate cancer and better detection of SVI. Further studies are required. It can act as a single-stop investigation for the primary staging of prostate cancer.

Oncologic Outcome of the Extent of Pelvic Lymph Node Dissection During Radical Prostatectomy: A Systematic Review, Meta-analysis, and Network Analysis

CONTEXT

Some authors propose extended pelvic lymph node dissection (ePLND) to enhance diagnostic and therapeutic outcomes in patients with localized prostate cancer. However, recent evidence found no difference in biochemical recurrence (BCR).

OBJECTIVE

To stratify and analyze available evidence on ePLND and its impact on BCR in patients with localized prostate cancer.

EVIDENCE ACQUISITION

We systematically reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify studies up to November 2023. We identified original articles that presented statistical comparisons through Cox regressions reported as hazard ratio (HR) or survival curve data reported as Kaplan-Meier curve differences in BCR in patients undergoing radical prostatectomy and stratified by the extent of lymph node dissection for localized prostate cancer.

EVIDENCE SYNTHESIS

We identified 12 studies, with two being randomized controlled trials (RCTs). The RCTs showed no benefit of ePLND with an HR of 1.03 ([0.92, 1.14], p = 0.61). A combined analysis with the ten retrospective studies revealed a notable reduction in BCR with an HR of 0.68 ([0.52, 0.88], p = 0.003). A subgroup analysis based on the extent of dissection demonstrated that studies focusing on the more conservative extended template of dissection did not show significant BCR benefit (HR 0.97 [0.72, 1.32], p = 0.86). In contrast, dissections that expanded the anatomical extent showed decreased BCR (HR 0.56 [0.41, 0.75], p < 0.0001). A Bayesian network analysis highlights significant differences in BCR reduction between different dissection approaches, indicating the potential benefits of specific dissection templates.

CONCLUSIONS

Available literature on the extent of pelvic lymph node dissection needs to be improved in quality and varying definitions of the ePLND template. Dissection of the common iliac nodes may be beneficial.

PATIENT SUMMARY

There is a potential benefit in removing more lymph nodes during radical prostatectomy. However, more research is needed to determine whether this strategy benefits certain patient groups.

Prostate-Specific Membrane Antigen-Targeted Radioguided Pelvic Lymph Node Dissection in Newly Diagnosed Prostate Cancer Patients with a Suspicion of Locoregional Lymph Node Metastases: The DETECT Trial

Prostate-specific membrane antigen (PSMA)-targeted radioguided surgery (RGS) aims to optimize the peroperative detection and removal of PSMA-avid lymph node (LN) metastases (LNMs) and has been described in patients with recurrent prostate cancer (PCa). In newly diagnosed PCa patients undergoing pelvic LN dissections, PSMA RGS could guide the urologist toward PSMA-expressing LNMs as identified on preoperative 18F-PSMA PET/CT imaging. The objective was to evaluate the safety and feasibility of 111In-PSMA RGS in primary PCa patients with one or more suggestive LNs on preoperative 18F-PSMA PET/CT. Methods: This prospective, phase I/II study included 20 newly diagnosed PCa patients with at least 1 suggestive LN on preoperative 18F-PSMA PET/CT. PSMA RGS was performed 24 h after 111In-PSMA-I&T administration, and postoperative 18F-PSMA PET/CT was performed to verify successful removal of the suggestive lesions. The primary endpoint was determination of the safety and feasibility of 111In-PSMA RGS. Safety was assessed by monitoring adverse events. Feasibility was described as the possibility to peroperatively detect suggestive LNs as identified on preoperative imaging. Secondary outcomes included the accuracy of 111In-PSMA RGS compared with histopathology, tumor- and lesion-to-background ratios, and biochemical recurrence. Results: No tracer-related adverse events were reported. In 20 patients, 43 of 49 (88%) 18F-PSMA PET-suggestive lesions were successfully removed. 111In-PSMA RGS facilitated peroperative identification and resection of 29 of 49 (59%) RGS-target lesions, of which 28 (97%) contained LNMs. Another 14 of 49 (29%) resected LNs were not detected with 111In-PSMA RGS, of which 2 contained metastases. Conclusion: 111In-PSMA RGS is a safe and feasible procedure that allows peroperative detection of 18F-PSMA PET/CT-suggestive lesions in newly diagnosed PCa patients. The use of a radioactive PSMA tracer and a detection device (γ-probe) during surgery helps in identifying LNs that were suggestive of PCa metastases on the 18F-PSMA PET/CT before surgery and thus may improve the peroperative identification and removal of these LNs.

A comparative analysis of perioperative complications and biochemical recurrence between standard and extended pelvic lymph node dissection in prostate cancer patients undergoing radical prostatectomy: a systematic review and meta-analysis

INTRODUCTION

Pelvic lymph node dissection (PLND) is commonly performed during radical prostatectomy (RP) for prostate cancer staging. This study aimed to comprehensively analyze existing evidence compare perioperative complications associated with standard (sPLND) versus extended PLND templates (ePLND) in RP patients.

METHODS

A meta-analysis of prospective studies on PLND complications was conducted. Systematic searches were performed on Web of Science, Pubmed, Embase, and the Cochrane Library until May 2023. Risk ratios (RRs) were estimated using random-effects models in the meta-analysis. The statistical analysis of the data was carried out using Review Manager software.

RESULTS

Nine studies, including three randomized clinical trial and six prospective studies, with a total of 4962 patients were analyzed. The meta-analysis revealed that patients undergoing ePLND had a higher risk of partial perioperative complications, such as lymphedema ( I2 =28%; RR 0.05; 95% CI: 0.01-0.27; P <0.001) and urinary retention ( I2 =0%; RR 0.30; 95% CI: 0.09-0.94; P =0.04) compared to those undergoing sPLND. However, there were no significant difference was observed in pelvic hematoma ( I2 =0%; RR 1.65; 95% CI: 0.44-6.17; P =0.46), thromboembolic ( I2 =57%; RR 0.91; 95% CI: 0.35-2.38; P =0.85), ureteral injury ( I2 =33%; RR 0.28; 95% CI: 0.05-1.52; P =0.14), intraoperative bowel injury ( I2 =0%; RR 0.87; 95% CI: 0.14-5.27; P =0.88), and lymphocele ( I2 =0%; RR 1.58; 95% CI: 0.54-4.60; P =0.40) between sPLND and ePLND. Additionally, no significant difference was observed in overall perioperative complications ( I2 =85%; RR 0.68; 95% CI: 0.40-1.16; P =0.16). Furthermore, ePLND did not significantly reduce biochemical recurrence ( I2 =68%; RR 0.59; 95% CI: 0.28-1.24; P =0.16) of prostate cancer.

CONCLUSION

This analysis found no significant differences in overall perioperative complications or biochemical recurrence between sPLND and ePLND, but ePLND may offer enhanced diagnostic advantages by increasing the detection rate of lymph node metastasis.

Peritoneal Flap for Lymphocele Prophylaxis Following Robotic-assisted Radical Prostatectomy with Lymph Node Dissection: The Randomised Controlled Phase 3 PELYCAN Trial

BACKGROUND

Symptomatic lymphoceles (SLCs) after transperitoneal robotic-assisted radical prostatectomy with pelvic lymph node dissection (PLND) are common. Evidence from randomised controlled trials (RCTs) on the impact of peritoneal flaps (PFs) on lymphocele (LC) reduction is inconclusive.

OBJECTIVE

To show that addition of PFs leads to a reduction of postoperative SLCs.

DESIGN, SETTING, AND PARTICIPANTS

An investigator-initiated, prospective, parallel, double-blinded, adaptive, phase 3 RCT was conducted. Recruitment took place from September 2019 until December 2021; 6-month written survey-based follow-up was recorded. Stratification was carried out according to potential LC risk factors (extended PLND, diabetes mellitus, and anticoagulation) and surgeons; 1:1 block randomisation was used. Surgeons were informed about allocation after completion of the last surgical step.

INTERVENTION

To create PFs, the ventral peritoneum was incised bilaterally and fixated to the pelvic floor.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was SLCs. Secondary endpoints included asymptomatic lymphoceles (ALCs), perioperative parameters, and postoperative complications.

RESULTS AND LIMITATIONS

In total, 860 men were screened and 551 randomised. Significant reductions of SLCs (from 9.1% to 3.7%, p = 0.005) and ALCs (27.2% to 10.3%, p < 0.001) over the follow-up period of 6 mo were observed in the intention-to-treat analysis. Operating time was 11 min longer (p < 0.001) in the intervention group; no significant differences in amount (80 vs 103, p = 0.879) and severity (p = 0.182) of postoperative complications (excluding LCs) were observed. The survey-based follow-up might be a limitation.

CONCLUSIONS

This is the largest RCT evaluating PF creation for LC prevention and met its primary endpoint, the reduction of SLCs. The results were consistent among all subgroup analyses including ALCs. Owing to the subsequent reduction of burden for patients and the healthcare system, establishing PFs should become the new standard of care.

PATIENT SUMMARY

A new technique-creation of bilateral peritoneal flaps-was added to the standard procedure of robotic-assisted prostatectomy for lymph node removal. It was safe and decreased lymphocele development, a common postoperative complication and morbidity. Hence, it should become a standard procedure.

Size of lymph-node metastases in prostate cancer patients undergoing radical prostatectomy: implication for imaging and oncologic follow-up of 2705 lymph-node positive patients

BACKGROUND

Despite modern imaging modalities, lymph-node staging before radical prostatectomy (RP) remains challenging in patients with prostate cancer (PCa). The visibility of lymph-node metastases (LNMs) is critically influenced by their size.

OBJECTIVE

This study aims to describe the distribution of maximal tumor diameters (i.e., size) in LNMs of pN1-PCa at RP and its consequences on visibility in preoperative imaging and oncological outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A total of 2705 consecutive patients with pN1-PCa at RP, harboring a cumulative 7510 LNMs, were analyzed. Descriptive and multivariable analyses addressed the risk of micrometastases (MM)-only disease and the visibility of LNMs. Kaplan-Meier curves and Cox analyses were used for biochemical recurrence-free survival (BCRFS) stratified for MM-only disease.

RESULTS

The median LNM size was 4.5mm (interquartile range (IQR): 2.0-9.0 mm). Of 7510 LNMs, 1966 (26%) were MM (≤ 2mm). On preoperative imaging, 526 patients (19%) showed suspicious findings (PSMA-PET/CT: 169/344, 49%). In multivariable analysis, prostate-specific antigen (PSA) (OR 0.98), age (OR 1.01), a Gleason score greater than 7 at biopsy (OR 0.73), percentage of positive cores at biopsy (OR 0.36), and neoadjuvant treatment (OR 0.51) emerged as independent predictors for less MM-only disease (p < 0.05). Patients with MM-only disease compared to those harboring larger LNMs had a longer BCRFS (median 60 versus 29 months, p < 0.0001).

CONCLUSION

Overall, 26% of LNMs were MM (≤ 2mm). Adverse clinical parameters were inversely associated with MM at RP. Consequently, PSMA-PET/CT did not detect a substantial proportion of LNMs. LNM size and count are relevant for prognosis.

Continuous innovation in precision radio-guided surgery

Since its origins, nuclear medicine has faced technological changes that led to modifying operating modes and adapting protocols. In the field of radioguided surgery, the incorporation of preoperative scintigraphic imaging and intraoperative detection with the gamma probe provided a definitive boost to sentinel lymph node biopsy to become a standard procedure for melanoma and breast cancer. The various technological innovations and consequent adaptation of protocols come together in the coexistence of the disruptive and the gradual. As obvious examples we have the introduction of SPECT/CT in the preoperative field and Drop-in probes in the intraoperative field. Other innovative aspects with possible application in radio-guided surgery are based on the application of artificial intelligence, navigation and telecare.

Surgical Management and Considerations for Patients with Localized High-Risk Prostate Cancer

OPINION STATEMENT

Localized high-risk (HR) prostate cancer (PCa) is a heterogenous disease state with a wide range of presentations and outcomes. Historically, non-surgical management with radiotherapy and androgen deprivation therapy was the treatment option of choice. However, surgical resection with radical prostatectomy (RP) and pelvic lymph node dissection (PLND) is increasingly utilized as a primary treatment modality for patients with HRPCa. Recent studies have demonstrated that surgery is an equivalent treatment option in select patients with the potential to avoid the side effects from androgen deprivation therapy and radiotherapy combined. Advances in imaging techniques and biomarkers have also improved staging and patient selection for surgical resection. Advances in robotic surgical technology grant surgeons various techniques to perform RP, even in patients with HR disease, which can reduce the morbidity of the procedure without sacrificing oncologic outcomes. Clinical trials are not only being performed to assess the safety and oncologic outcomes of these surgical techniques, but to also evaluate the role of surgical resection as a part of a multimodal treatment plan. Further research is needed to determine the ideal role of surgery to potentially provide a more personalized and tailored treatment plan for patients with localized HR PCa.

De-Escalation of Therapy for Prostate Cancer

Prostate cancer (PCa) is the second most commonly diagnosed cancer in men with around 1.4 million new cases every year. In patients with localized disease, management options include active surveillance (AS), radical prostatectomy (RP; with or without pelvic lymph node dissection), or radiotherapy to the prostate (with or without pelvic irradiation) with or without hormonotherapy. In advanced disease, treatment options include systemic treatment(s) and/or treatment to primary tumour and/or metastasis-directed therapies (MDTs). Specifically, in advanced stage, the current trend is earlier intensification of treatment such as dual or triple combination systemic treatments or adding treatment to primary and MDT to systemic treatment. However, earlier treatment intensification comes with the cost of increased morbidity and mortality resulting from drug-/treatment-related side effects. The main goal is and should be to provide the best possible care and oncologic outcomes with minimum possible side effects. This chapter will explore emerging possibilities to de-escalate treatment in PCa driven by enhanced insights into disease biology and the natural course of PCa such as AS in intermediate-risk disease or salvage versus adjuvant radiotherapy in post-RP patients. Considerations arising from advancements in PCa imaging and technological advancements in surgical and radiation therapy techniques including omitting pelvic lymph node dissection in the era of prostate-specific membrane antigen positron emitting tomography, the potential of MDT to delay/omit systemic treatment in metachronous oligorecurrence, and the efficacy of hypofractionation schemes compared with conventional fractionated radiotherapy will be discussed.

Hotspots and frontiers in PSMA research for prostate cancer: a bibliometric and visualization analysis over the past 20 years

BACKGROUND

Prostate-specific membrane antigen (PSMA)-targeted imaging and therapy have significantly changed the management of patients with prostate cancer (PCa) at different disease stages. This advancement has attracted the attention of scholars, leading to a prolific output of scholarly publications. This study comprehensively outlines the knowledge framework associated with PSMA-based diagnosis and treatment of PCa through the application of bibliometric analysis, and discusses the potential research trends and foci.

METHODS

Articles and reviews related to PSMA for prostate cancer from 2003 to 2022 were retrieved from Web of Science Core Collection. VOSviewer, Citespace, and R-bibliometrix were primarily employed to execute and visually represent co-authorship, co-citation, and co-occurrence analysis of countries, institutions, authors, references and keywords in this field.

RESULTS

A total of 3830 papers were included. The papers on the field of PSMA-based PCa therapy and imaging had been continuously increased since 2003, but the rate has slowed from 2020. The United States made the largest contribution in this field, in terms of publications 997 (26.03%), H-index (110) and total citations (53,167 times). We identified the most productive institution were Technical University of Munich, and Australian institutions had become very active in recent years. Journal of Nuclear Medicine was the most prominent journal in this field. Professors Matthias Eiber and Martin G Pomper made great achievements, while Ali Afshar-Oromieh was the most co-cited author. According to the result of keywords and topics analysis, "ga-68 labeled psma ligand", "radiation dosimetry" and "HBED-CC" were major research areas in the near future, while "Extended pelvic lymph node dissection" was considered to be the future research foci.

CONCLUSIONS

The field of psma-based PCa therapy and imaging is in the stage of vigorous development and has a bright prospect. The United States and Germany have achieved outstanding results in this area, while Australia has recently developed rapidly. It is foreseeable that more research foci will be lied in the early detection of pelvic lymph nodes and the multimodal imaging-guided surgery.

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

BACKGROUND

Although the therapeutic role of extended pelvic lymph node dissection (ePLND) in patients with prostate cancer (PCa) is still under debate, this procedure is recommended for staging purposes in selected cases. Nomograms for predicting lymph node invasion (LNI) do not account for prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging, which is characterized by a high negative predictive value for nodal metastases.

OBJECTIVE

To externally validate models predicting LNI in patients with miN0M0 PCa at PSMA PET and to develop a novel tool in this setting.

DESIGN, SETTING, AND PARTICIPANTS

Overall, 458 patients with miN0M0 disease undergoing radical prostatectomy (RP) and ePLND at 12 centers between 2017 and 2022 were identified.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

Available tools were externally validated using calibration plots, the area under the receiver operating characteristic curve (AUC), and decision curve analyses to assess calibration, discrimination, and the net benefit. A novel coefficient-based model was developed, internally validated, and compared with available tools.

RESULTS AND LIMITATIONS

Overall, 53 patients (12%) had LNI. The AUC was 69% for the Briganti 2012, 64% for the Briganti 2017, 73% for the Briganti 2019, and 66% for the Memorial Sloan Kettering Cancer Center nomogram. Multiparametric magnetic resonance imaging stage, biopsy grade group 5, the diameter of the index lesion, and the percentage of positive cores at systematic biopsy were independent predictors of LNI (all p ≤ 0.04). Internal cross-validation confirmed a coefficient-based model with AUC of 78%, better calibration, and a higher net benefit in comparison to the other nomograms assessed. Use of a 5% cutoff would have spared 47% ePLND procedures (vs 13% for the Briganti 2019 nomogram) at the cost of missing only 2.1% LNI cases . The lack of central review of imaging and pathology represents the main limitation.

CONCLUSIONS

Tools for predicting LNI are associated with suboptimal performance for men with miN0M0 PCa. We propose a novel model for predicting LNI that outperforms available tools in this population.

PATIENT SUMMARY

Tools currently used to predict lymph node invasion (LNI) in prostate cancer are not optimal for men with negative node findings on PET (positron emission tomography) scans, leading to a high number of unnecessary extended pelvic lymph node dissection (ePLND) procedures. A novel tool should be used in clinical practice to identify candidates for ePLND to reduce the risk of unnecessary procedures without missing LNI cases.

[Opportunities for prostate-specific membrane antigen hybrid imaging in prostate cancer]

Prostate-specific membrane antigen (PSMA) hybrid imaging is a promising new technique gaining importance in the field of prostate cancer (PCa) diagnosis and treatment planning. By combining PSMA radioligands and computed tomography (CT) or magnetic resonance imaging (MRI), PSMA hybrid imaging opens up new diagnostic opportunities. PSMA-PET/CT (PET: positron-emission tomography) is already well established in high-risk PCa for primary staging and tumor localization when biochemical recurrence occurs. Further potential indications for PSMA-PET/CT include tumor detection in the initial work-up before a rebiopsy with improved accuracy, the identification of target structures for precise local treatment in recurrent PCa (salvage radiotherapy or radio-guided surgery) as well as a prediction of response to PSMA radioligand therapy. This narrative review is based on a recent literature search and aims to highlight the opportunities of PSMA imaging in different disease stages of PCa.

The role of nuclear medicine tracers for prostate cancer surgery: from preoperative to intraoperative setting

PURPOSE OF REVIEW

There has been a growing interest in the use of novel molecular imaging modalities for the management of prostate cancer (PCa), spanning from diagnostic to therapeutic settings. The aim of this review is to provide a comprehensive overview of recently published studies investigating the use of novel nuclear medicine tracers across different stages of PCa management.

RECENT FINDINGS

Emerging evidence supports the use of molecular imaging for preoperative staging of PCa, where prostate-specific membrane antigen (PSMA) PET has shown superior accuracy compared to conventional imaging for the detection of nodal and distant metastases, which needs to be translated to new risk stratification. A role for PSMA PET has been proposed for PCa diagnosis, with local activity associated with histology. Surgical guidance, using either visual feedback or gamma-ray detectors to identify tissues with accumulated radio-labeled tracers, may improve the ability to resect locoregional diseases and thus maximize oncological control. PSMA targeted therapy (Lu-PSMA) has been mainly investigated in the castration-resistant setting, but might have a role in earlier settings such as neoadjuvant treatment.

SUMMARY

Novel molecular imaging using PSMA-based tracers could significantly improve PCa management in the diagnosis, staging, and intraoperative guidance settings, potentially leading to personalized and effective treatment decisions.

[Prostate cancer-multiparametric MRI and alternative approaches in intervention and therapy planning]

BACKGROUND

In recent years, multiparametric magnetic resonance imaging (mpMRI) of the prostate has gained importance and plays a crucial role in both personalized diagnostics and increasingly in the treatment planning for patients with prostate cancer.

OBJECTIVE

The aim of this study is to present established and innovative applications of MRI in the diagnosis and treatment of localized prostate cancer, evaluating their strengths and weaknesses. Furthermore, it will explore alternative approaches and compare them in a comprehensive manner.

MATERIALS AND METHODS

A systematic literature review on the application of mpMRI for biopsy and therapy planning was conducted.

RESULTS

The integration of modern imaging techniques, especially mpMRI, into the diagnostic algorithm has revolutionized prostate cancer diagnosis. MRI and MRI-guided biopsy detect more significant prostate cancer, with the potential to reduce unnecessary biopsies and the diagnosis of clinically insignificant carcinomas. In addition, MRI provides crucial information for risk stratification and treatment planning in prostate cancer patients, both before radical prostatectomy and during active surveillance.

CONCLUSION

Multiparametric MRI offers significant added value for the diagnosis and treatment of localized prostate cancer. The advancement of MRI analysis, such as the implementation of artificial intelligence algorithms, holds the potential for further enhancing imaging diagnostics.

Comparison of Diagnostic Value between 99mTechnetium-Methylene Diphosphate Bone Scan and 99mTechnetium-Prostate-specific Membrane Antigen Scan in Patients with Prostate Cancer with Osseous Metastases

Background

Prostate cancer (PCa) ranks as the second most prevalent cancer among men globally. The utilization of efficient and cost-effective diagnostic and therapeutic approaches holds paramount importance in the diagnosis and treatment of these patients, significantly impacting treatment outcomes. This study focuses on the investigation and comparison of two commonly employed scans within the treatment process for these patients.

Methods

In this prospective study, which spanned over 2 years, 40 patients diagnosed with PCa underwent examination using two scans: 99m Technetium-Prostate-specific Membrane Antigen (99mTC-PSMA) Scan and between Technetium-Methylene Diphosphate (99mTC-MDP) Bone Scan. The findings of these scans were then compared with each other, as well as with the results obtained from magnetic resonance imaging and the prostate-specific antigen level. The analysis of the results was conducted utilizing SPSS 22 software, and descriptive statistical methods were employed to present the findings.

Results

In this prospective study, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the 99mTC-MDP Bone Scan were found to be 88.2%, 83.3%, 96.7%, 55.5%, and 87.5%, respectively. Similarly, for the 99mTC-PSMA Scan, the corresponding values were 94.1%, 83.3%, 96.4%, 83.3%, and 92.5%, respectively.

Conclusions

Based on the findings of this study, it can be concluded that the diagnostic accuracy of the 99mTC-PSMA Scan is marginally higher compared to the 99mTC-MDP Bone Scan. Therefore, for patients who are limited to only one scan, the 99mTC-PSMA Scan appears to be the preferable choice.

Diagnostic and therapeutic impact of PET/CT with 18F-DCFPyL versus 18F-Fluorocholine in initial staging of intermediate-/high-risk prostate cancer: a pilot study

AIM

To assess the diagnostic and therapeutic impact of PET/CT with 18F-DCFPyL with respect to 18F-Fluorocholine in initial staging of intermediate-/high-risk prostate cancer (PCa).

MATERIAL AND METHODS

Patients with recent diagnosis of intermediate-/high-risk PCa without androgen deprivation therapy and previous 18F-Fluorocholine-PET/CT (negative for extraprostatic disease or with oligometastatic disease) were referred to 18F-DCFPyL-PET/CT. Patients' disease characteristic as grade group, D'Amico risk category (intermediate/high), prostate-specific antigen (PSA) closest to PET/CTs and its kinetics were obtained. The overall detection rate (DR) and molecular imaging TNM (miTNM) stage according to the prostate cancer molecular imaging standardized evaluation (PROMISE) criteria were assessed for both radiotracers, and their concordance (Kappa coefficient) was analyzed. The diagnostic and therapeutic impact of 18F-DCFPyL with respect to 18F-Fluorocholine was evaluated.

RESULTS

Fifty-eight patients were analyzed (84.5% high-risk). 18F-Fluorocholine showed a higher DR than 18F-DCFPyL of prostate gland involvement (100% versus 93.1%) and pelvic node disease (37.9% versus 31%; k = 0.436, p = 0.001). On the other hand, 18F-DCFPyL-PET/CT showed a higher DR of metastatic disease than 18F-Fluorocholine-PET/CT, 9/58 patients (15.5%): 3 M1a, 5 M1b and 1 M1c) versus 5/58 (8.6%) patients: 1 M1a and 4 M1b), k = 0.426; p = 0.001. No significant association was found between clinical characteristics (grade group, risk category, PSA level and kinetic) and 18F-Fluorocholine or 18F-DCFPyL results. The results of 18F-DCFPyL-PET/CT modified the previously planned treatment compared to 18F-Fluorocholine-PET/CT in 13 patients (22.4%).

CONCLUSIONS

18F-Fluorocholine and 18F-DCFPyL PET/CT showed a similar DR of prostate gland and lymph node involvement, although with moderate concordance for the latter. 18F-DCFPyL was superior to 18F-Fluorocholine in detecting regional and distant metastasis with a therapeutic impact in one of every five patients.

Comparative analysis of GOLPH3 expression in lymph node-positive prostate cancer: immunohistochemistry staining patterns and clinical significance

Introduction

Prostate cancer (PCa) is the second most commonly diagnosed cancer in men worldwide. Lymph node metastasis is a poor prognostic factor for PCa. Previous studies have found that Golgi phosphoprotein 3 (GOLPH3) is overexpressed in various cancers, including PCa. We examined GOLPH3 expression in PCa cells from primary tumor and, as the first, also in metastatic lymph nodes to assess its potential as a new risk factor for PCa progression.

Methods

The study included 78 patients diagnosed with lymph node-positive PCa confirmed in the postoperative material. All the patients underwent radical prostatectomy (RP) with extended lymphadenectomy. The clinical data of the patients were retrospectively analyzed, and their histopathological specimens were selected for further analysis. Immunohistochemistry (IHC) staining was performed and the expression of GOLPH3 was assessed by an experienced uropathologist using an immunoreactive scale (IRS). A correlational analysis of the obtained data with the clinicopathological data of patients was performed.

Results

A positive IHC reaction for GOLPH3 was observed in all samples. IRS score for GOLPH3 expression was higher in the metastatic lymph nodes than in the prostate (not statistically significant; p=0.056). Several significant correlations were identified in connection with GOLPH3 expression levels in the prostate and metastatic lymph node tissues. No significant correlations were found between GOLPH3 expression and patient characteristics (e.g. BMI, EAU risk group, or preoperative PSA level), pathological features, or postoperative outcomes. However, we found that lymphovascular invasion (LVI) tended to be more common in patients with a higher percentage of GOLPH3-positive cells (p=0.02). We also found a positive association between the intensity of GOLPH3 staining in metastatic lymph nodes and the EAU classification. Finally, we found a significant negative correlation between the GOLPH3 expression and the efficacy of RP - the higher the expression of GOLPH3, the lower the efficacy of RP was (p<0.05).

Conclusion

GOLPH3 is expressed in both prostate and metastatic lymph nodes, with higher expression in metastatic lymph nodes. High GOLPH3 expression was associated with the occurrence of LVI, higher-risk group in the EAU classification, and lower efficacy of the RP, but there was no significant correlation with other pathological features or postoperative outcomes.

Role of IL-17A and IL-17RA in Prostate Cancer with Lymph Nodes Metastasis: Expression Patterns and Clinical Significance

Prostate cancer (PCa) is the second most frequently diagnosed cancer among men. The use of IL-17A and its receptor IL-17RA as prognostic markers for PCa has shown promising results. We analyzed the clinical data of 77 patients with PCa after radical prostatectomy with lymphadenectomy and lymph node metastasis (LN+). We assessed the expression levels of IL-17A and IL-17RA in cancer cells in prostate and, for the first time, also in LN+. Prostate IL-17A expression positively correlated with BMI (p = 0.028). In LN+, the expression of IL-17A was positively correlated with the percentage of affected lymph nodes (p = 0.006) and EAU risk groups (p = 0.001). Additionally, in the group with high IL-17A expression in LN+, the extracapsular extension (ECE) of the prostate was significantly more frequent (p = 0.033). Also, significant correlations with the level of IL-17RA expression was found-expression was higher in prostate than in LN+ (p = 0.009); in LN+, expression positively correlated with the EAU risk group (p = 0.045), and in the group of high expression in LN+ ECE of lymph nodes was detected significantly more often (p = 0.009). Our findings support the potential role of IL-17A and IL-17RA as PCa markers; however, further studies are needed to determine their roles and potential clinical applications.