Management of De Novo miN1 Prostate Cancer in the PSMA-PET Era

Prostate-specific membrane antigen positron emission tomography (PSMA-PET) is reshaping nodal staging in prostate cancer by detecting regional lymph node metastases with greater accuracy than conventional imaging. This has created a new cohort of patients with N1M0 disease detectable only on advanced imaging, raising important questions regarding prognosis, treatment intensification and the applicability of historical management paradigms derived from conventional imaging. The aim of this review is to consider de novo N1M0 management on PSMA-PET and current evidence.

A comprehensive review of the literature was performed using Medline, PubMed and Web of Science. Search terms included combinations of "N1M0", "prostate cancer", "PSMA", "PET", "lymph node" and "metastasis". English-language studies and relevant reference lists were reviewed, with interpretation focused on diagnostic performance, stage migration and management implications of PSMA-PET-detected nodal disease.

PSMA-PET outperforms conventional imaging for nodal staging, improving diagnostic confidence and frequently altering management. However, sensitivity for small-volume nodal disease remains imperfect, limiting exclusion of microscopic metastases. Emerging data suggest PSMA-PET drives stage migration whilst influencing use of surgery, radiotherapy and systemic therapy to better tailor treatment fields. However, high-level prospective evidence demonstrating improved long-term oncological outcomes remains limited.

PSMA-PET is a practice-changing staging modality in N1M0 prostate cancer, but whether earlier detection and treatment escalation translate into meaningful survival benefit remains uncertain.