AUA 2022: Which Patients with cN1 Disease at PET/CT Are Affected by Systemic Disease? Implications for Tailored Treatment Approaches Based on a Large Multi-Institutional Series

(UroToday.com) The 2022 American Urological Association (AUA) Annual Meeting included a session on advanced prostate cancer and a presentation by Dr. Elio Mazzone discussing implications for tailored treatment approaches by highlighting which patients with cN1 disease at PET/CT are affected by systemic disease. The role of local therapies including radical prostatectomy in prostate cancer patients with clinical lymphadenopathy at PET/CT has been infrequently evaluated. Limited data is available to identify men more likely to have non-localized disease and who may benefit from multi-modal approaches. This study presented by Dr. Mazzone and colleagues assessed predictors of PSA persistence in surgically managed prostate cancer patients with clinical lymphadenopathy at PET/CT by integrating clinical, magnetic resonance imaging (MRI) and PET/CT parameters.


This study identified 93 men treated with radical prostatectomy and extended lymph node dissection with pelvic or retroperitoneal lymphadenopathies at choline (n = 46, 49%) or PSMA (n = 47, 51%) PET/CT between 2010 and 2021 at four referral centers. The study outcome was PSA persistence, defined as a first PSA ≥0.1 ng/ml after radical prostatectomy. Multivariable logistic regression tested predictors of PSA persistence. Covariates were biopsy ISUP grade group (1-3 vs 4-5), MRI stage (organ-confined disease vs extracapsular extension), and number of positive spots at PET/CT. Regression tree analyses stratified patients into risk groups based on their preoperative characteristics.

The median number of positive lesions on PET/CT was 2 (IQR 1-3). Overall, 70 (75%) and 23 (25%) men had biopsy ISUP grade 4-5 and extracapsular extension at MRI, and 42 (45%) patients experienced PSA persistence. On multivariable analyses, ISUP grade 4-5 was the strongest predictor of PSA persistence (OR 4.35, 95% CI 1.38-16.7; p=0.001). At regression tree analysis, patients were stratified into four risk groups according to ISUP grade, number of positive spots, and MRI stage, with good model discrimination (AUC 77%). Clinical N1 patients with ISUP grade 4-5 disease and extracapsular extension at MRI had a rate of 75% of PSA persistence regardless of the number of positive spots at PET/CT, thus being likely to have upfront systemic disease. 

Dr. Mazzone concluded his presentation by discussing implications for tailored treatment approaches by highlighting which patients with cN1 disease at PET/CT are affected by systemic disease with the following take-home messages:

  • PSA persistence is non-negligible in patients with a positive lymph nodes at preoperative PET/CT
  • Patients with ISUP grade 1-3, as well as patients with ISUP grade 4-5, organ-confined disease at MRI and 1-2 positive lesions at PET/CT are those where radical prostatectomy may achieve good oncological outcomes
  • Conversely, patients with high ISUP grade and extracapsular extension at MRI should be considered for integrated multi-modal approaches including systemic therapies 

Presented by: Elio Mazzone, PhD, San Raffaele Scientific Institute, Milan, Italy

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2022 American Urological Association (AUA) Annual Meeting, New Orleans, LA, Fri, May 13 – Mon, May 16, 2022.

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