Precision Nodal Staging in Intermediate-Risk Prostate Cancer: A Narrative Review of Molecular Imaging

Lymph node (LN) staging remains critical for risk stratification and treatment selection in intermediate-risk prostate cancer (IR-PCa). Conventional imaging modalities have limited sensitivity, and extended pelvic LN dissection (ePLND) is associated with considerable morbidity.

This narrative review evaluates conventional imaging, molecular imaging, and intraoperative technologies for LN staging in IR-PCa. Conventional computed tomography and magnetic resonance imaging demonstrate low sensitivity for detecting LN metastasis. Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography shows substantially improved diagnostic performance; however, it may still underestimate micrometastatic disease. Intraoperative approaches, including PSMA-targeted fluorescence imaging and sentinel LN biopsy, enable real-time detection and may reduce morbidity while maintaining high diagnostic accuracy in experienced centers. However, these techniques are limited by technical complexity, lack of standardized protocols, and restricted availability in routine clinical practice.

A multimodal, risk-adapted strategy combining preoperative molecular imaging and intraoperative targeted techniques may improve the precision of LN staging. This integrated approach can help minimize unnecessary ePLND and reduce procedure-related morbidity in patients with IR-PCa.