The added value of PSMA PET to nomograms in identifying optimal candidates for extended pelvic lymph node dissection in intermediate-risk prostate cancer patients

BACKGROUND: Extended pelvic lymph node dissection (ePLND) is the standard approach for nodal staging in prostate cancer (PCa) patients undergoing radical prostatectomy (RP). However, its utility in intermediate-risk cases remains debated due to potential complications and uncertain oncologic benefits. This study aimed to assess whether incorporating prostate-specific membrane antigen positron emission tomography (PSMA PET) nodal staging into traditional nomograms could enhance the selection of patients for ePLND. METHODS: We retrospectively analyzed 110 intermediate-risk PCa patients who underwent preoperative PSMA PET and subsequently received RP with ePLND within six months at three referral centers in Italy between 2019 and 2023. RESULTS: PSMA PET demonstrated significantly higher specificity and positive predictive value (PPV) than nomograms in detecting lymph node invasion (LNI), potentially sparing 84% of patients from ePLND while missing only 0.9% of LNI cases. Additionally, combining PSMA PET with the Briganti 2017 nomogram improved predictive accuracy, theoretically reducing ePLND procedures by 91%. CONCLUSIONS: Our findings suggest that integrating PSMA PET with nomograms in intermediate-risk cases could optimize patient selection for ePLND, potentially reducing unnecessary surgeries without increasing the risk of missed LNI cases. Preoperative staging with PSMA PET may play both exclusive and inclusive roles in the intermediate-risk setting. If PSMA PET shows N0, it may exclude candidates from ePLND. Additionally, when combined with nomograms, it may help select candidates for ePLND among patients who show a high risk of LNI according to risk calculators.