To evaluate whether nodal maximum standardised uptake value (SUVmax) improves the positive predictive value (PPV) of prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computerised tomography (CT) for detecting lymph node invasion (LNI) in prostate cancer (PCa), and to develop clinical decision tools to guide decision-making for patients with low- and high-volume nodal disease.
This international multicentre study included patients with histopathologically confirmed PCa who underwent preoperative PSMA-PET and robot-assisted radical prostatectomy with extended pelvic lymph node dissection (2016-2023). Sensitivity, specificity, PPV, and negative predictive value (NPV) for LNI detection were calculated, defining a positive test as non-physiological PSMA uptake classified according to the Prostate Cancer Molecular Imaging Standardised Evaluation (PROMISE) molecular imaging Tumour-Node-Metastasis (miTNM) system. Receiver operating curves analysis identified optimal nodal SUVmax cut-offs for pelvic LNI. Logistic regression assessed predictors for pathological N1 stage (pN1) and high-volume nodal disease (four or more positive nodes). Clinical decision tools were developed to stratify patients into three risk groups for pN1 and high-volume nodal disease.
A total of 521 patients were included, with a median (interquartile range) age of 66 (61-71) years and prostate-specific antigen (PSA) level of 9.9 (6.6-17.0) ng/mL. The PSMA-PET showed 45.0% sensitivity, 94.3% specificity, 64.7% PPV, and 88.3% NPV for LNI detection. Adding nodal SUVmax ≥4.9 improved the PPV to 81.1% and sensitivity to 71.4% and, combined with a PSA level ≥10 ng/mL, magnetic resonance imaging (MRI) T-stage ≥T3a, and miT-stage ≥T3a, identified 95% of pN1 cases in the high-risk group. High-volume nodal disease was found in 3.8%, including 1.1% in miN0 patients. Nodal SUVmax ≥7.2, MRI T-stage ≥T3a, and miN2 (multiple suspicious LNs) were predictors for high-volume nodal disease and, combined in a clinical decision tool, excluded all low-risk patients for high-volume nodal disease.
Nodal SUVmax improves PPV of PSMA-PET for nodal staging and aids in excluding high-volume nodal disease. Clinical decision tools integrating nodal SUVmax with relevant clinical parameters demonstrate potential to guide individualised nodal management. These findings warrant external validation in larger cohorts.
BJU international. 2026 Apr 20 [Epub ahead of print]
Alexandra S Bruins Slot, Vera Sweere, Joris G Heetman, Rick Hermsen, Lieke Wever, Jules Lavalaye, Maarten Vinken, Clinton D Bahler, Mark Tann, Claudia Kesch, Tugce Telli, Wolfgang P Fendler, Peter Ka-Fung Chiu, Kwan Kit Wu, Fabio Zattoni, Laura Evangelista, Francesco Ceci, Marcin Miszczyk, Pawel Rajwa, Akihiro Matsukawa, Tamás Fazekas, Francesco Barletta, Alberto Briganti, Francesco Montorsi, Giorgio Gandaglia, Jean-Paul A Van Basten, Harm H E Van Melick, Roderick C N Van den Bergh, Giancarlo Marra, Timo F W Soeterik, Matthijs J V Scheltema, European Association of Urology‐Young Academic Urologists (EAU‐YAU) Prostate Cancer Working Group
Department of Urology, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands., Department of Nuclear Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands., Department of Nuclear Medicine, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands., Department of Urology, Indiana University Medical Center, Indianapolis, IN, USA., Department of Radiology and Imaging Sciences, Indiana University Medical Center, Indianapolis, IN, USA., Department of Urology, University Hospital Essen, Essen German Cancer Consortium (DKTK) University Hospital Essen, Essen, Germany., Department of Nuclear Medicine, University Hospital Essen, Essen, Germany., S. H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China., Department of Nuclear Medicine and PET, Hong Kong Sanatorium and Hospital, Hong Kong, China., Urological Unit, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy., Department of Biomedical Sciences, Humanitas University, Milan, Italy., Division of Nuclear Medicine and Theranostics, IEO European Institute of Oncology, IRCCS, Milan, Italy., Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria., Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy., Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands., Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands., Division of Urology, Department of Surgical Sciences, Molinette Hospital, Città della Salute e della Scienza and University of Turin, Turin, Italy.