Prostate-specific membrane antigen (PSMA)-guided radical prostatectomy (RP) can remove positive lymph nodes missed during extended pelvic lymph node dissection (ePLND) in patients with locally advanced prostate cancer, investigators suggest.

In a retrospective study of 35 patients undergoing open RP with ePLND for primary treatment, preoperative PSMA positron emission tomography (PSMA-PET) detected 78 locoregional lymph node metastases. In 14 patients, 20 lymph node metastases (26%) were located outside the ePLND template field. In 7 patients, lymph node metastases were exclusively outside the standard ePLND field.

PSMA-PET radio-guided surgery resulted in resection of PSMA-positive lymph node metastases in 33 of the 35 patients (94%), Matthias M. Heck, MD, of Technical University of Munich in Germany, and colleagues reported in European Urology Oncology. Postoperative follow-up indicated false-positive PSMA PET results for 5 of the 78 lymph nodes (6%). Histopathology showed that 22 patients harbored lymph node metastases within the ePLND field that were not seen on PSMA PET, “underlining the necessity of performing ePLND,” the investigators pointed out.

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Patients with 1-2 PSMA-positive lymph node metastases had better postoperative outcomes than those with a higher number of positive lymph nodes. Detection of more than 2 positive lymph nodes on PSMA-PET was significantly associated with a 2.6-fold higher risk of both biochemical recurrence and further treatment and a 3.1-fold higher risk of distant metastases.

This was a small case series, so large-scale prospective data are still needed to assess the clinical utility of PSMA-PET in this setting.


Lunger L, Steinhelfer L, Korn P, et al. Prostate-specific membrane antigen-radioguided surgery facilitates pelvic lymph node dissection during radical prostatectomy for the treatment of locally advanced prostate cancer with regional lymph node metastases. Eur Urol Oncol. 6(1):95-98. doi:10.1016/j.euo.2022.12.001