EAU 2021: Introduction and Setting the Stage: Prostate Cancer: cN+ in Newly Diagnosed Patients

(UroToday.com) Dr. Nicolas Mottet,  the chair of this session "Guideline Session II: Prostate Cancer: cN+ in Newly Diagnosed Patients" provided an introduction and set the stage for the talks to follow. 

He starts by noting that it might sound like an “easy topic” – node positive prostate cancer are nodes that are discovered in the pelvis (nodes outside the pelvis are not cN+, but rather M+) on imaging. Historically, the standard of care (SOC) was clear – ADT.

When it comes to clinical staging, he notes that the current guidelines recommend cross-sectional imaging for intermediate risk prostate cancer (if ISUP >= 3) and any high risk localized prostate cancer. But this has been conventional imaging with CT A/P and/or MRI pelvis – and the cutoff for cN+ has generally been a node with short axis > 8 mm in the pelvis. 

He then brings the first major modifying factor – what if you change the imaging? Do the results change? As noted by Hofman et al.1,  in 399 patients with high risk prostate cancer, the sensitivity of novel PSMA PET/CT (in this study, 68-Gallium) was significantly higher than conventional CT (85% vs 38%). So, we are now going to be identifying more patients with cN+ disease if novel imaging is used.

Next, if a patient has cN+ disease (regardless of modality of identification), what should be the the SOC? Historically this has been ADT alone. However, currently guidelines recommend offering patients a local treatment (RP or IMRT and image guided radiotherapy) plus long-term ADT – but this carries a “weak” recommendation status. 

So, the first question is “Is local treatment needed”? Most available data are for EBRT, as the data for RP are limited. Is there a best local option?

Secondly, if systemic therapy is given, do we give the same “old” ADT or intensity ADT (with chemotherapy, oral agents, etc)?

To address these questions, the following speakers will detail:

1) Imaging – what are we talking about? Does cN+ = pN+?
2) Systemic therapy intensification – yes or no?
3) Local treatment – provide a guideline point of view.


Presented by: Nicolas Mottet, MD, PhD, Professor and Head of the Urology Department at Centre Hospitalier Universitaire de Saint-Étienne, and Professor of Surgery at Université Jean Monnet in Saint-Etienne, France.

Written by: Thenappan (Thenu) Chandrasekar, MD – Urologic Oncologist, Assistant Professor of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, @tchandra_uromd on Twitter during the 2021 European Association of Urology, EAU 2021- Virtual Meeting, July 8-12, 2021.


1. Hofman MS, Lawrentschuk N, Francis RJ, et al. proPSMA Study Group Collaborators. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. Lancet. 2020 Apr 11;395(10231):1208-1216. doi: 10.1016/S0140-6736(20)30314-7. Epub 2020 Mar 22. PMID: 32209449.