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Anatomical distribution of disease in pN1 prostate cancer with BCR post-RP: A PSMA-PET/CT-based analysis
Lotte G Zuur1, Katelijne C C de Bie2, Lieke Wever2,3,4
1Department of Surgical Oncology (Urology) Netherlands Cancer Institute Amsterdam the Netherlands.
Objectives:
To explore the distribution of metastatic disease in pN1 patients with biochemical recurrence (BCR) assessed by Prostate-Specific Membrane Antigen-Positron-Emission/Computed Tomography (PSMA-PET/CT).
Patients And Methods:
This multicentre, retrospective cohort study included 130 pN1 PCa patients with BCR (PSA ≥ 0.2 ng/ml) post-RP with ePLND (2015-2022). All were preoperatively staged as molecular imaging (mi)N0M0 and underwent restaging PSMA-PET/CT at BCR. Clinical and imaging data were analysed using Mann-Whitney U, chi-square tests and Cox regression.
Results:
Median time to BCR was 9 months (IQR 3-18). Biochemical persistence (BCP) (PSA ≥ 0.1 ng/ml at first follow-up) occurred in 66/130 (51%). At restaging PSMA-PET/CT, median PSA was 0.33 ng/ml (IQR 0.24-0.65). PSMA-PET/CT identified metastases in 63/130 (48%), with 37/63 (59%) having lymph node metastases (LNMs) limited to the ePLND template - 16/37 (43%) on the ipsilateral side of the positive resected node. Additionally, 26/63 (41%) had disease beyond the nodal template (miM+). Univariate Cox regression identified BCP as a predictor for any PSMA-PET/CT-detected recurrence, while a higher ISUP grade group at RP predicted miM+ disease.
Conclusion:
PSMA-PET/CT identified PSMA-expressing recurrent disease in nearly half of pN1 PCa patients at early BCR, with about half confined to the pelvis and a quarter beyond the pelvis. These anatomical patterns indicate that PSMA-PET/CT can inform risk-adapted salvage strategies, including pelvic radiotherapy for nodal recurrences and systemic treatment when disease extends beyond the pelvis.
