Risk factors for lymph node metastasis in a contemporary radical prostatectomy cohort

We sought to assess how centrally reviewed radical prostatectomy (RP) Grade Group (GG), tumor volume (TV), prostate-specific antigen density (PSAD), pathologic stage, tumor topography, patient age, and race and ethnicity relate to regional lymph node metastasis (LN+).

We reviewed patient cases with treatment-naive RPs performed from 2013 through 2026. All specimens underwent centralized histologic review by 1 urologic pathologist. Grade Group was assigned from the highest-grade tumor, and its TV was measured. Tumor volume and PSAD were modeled on the log2 scale (odds ratios per doubling), and multivariable Firth penalized logistic regression assessed factors associated with LN+.

No metastasis was seen in GG1 cases (n = 368). The final cohort comprised 3142 node-staged GG2 to GG5 RP specimens. Positive regional LNs were identified in 135 (4.3%) patients, with a median of 1 positive node (IRQ, 1-2 LNs; range, 1-17 LNs). Cases with LN+ disease had a median of 9 LNs (range, 1-31 LNs) examined compared with 5 LNs (range, 1-45 LNs) in cases without metastasis (P < .001). Grade Group 5 cancer was associated with a clinically significantly lower value for PSAD divided by TV (PSAD/TV) than for GG2 to GG4 cancers. In the augmented multivariable Firth model, PSAD, TV, GG, posterior or extensive bilateral topography, and pT3a/pT3b stage were independently associated with LN+. Age, race, and ethnicity were not independently associated. Anterior topography inversely correlated with LN+.

In this centrally reviewed RP cohort, no LN+ was observed in GG1 cancer. Among GG2 to GG5 cancers, LN+ was associated with increasing GG, larger TV, higher PSAD, pT3a/pT3b stage, and posterior or extensive bilateral topography after adjustment for age, race, and ethnicity. Grade Group 5 cancers showed lower PSA production than did GG2 to GG4 cancers, indicating a different PSAD-TV relationship.