Can a negative PSMA PET/CT limit the indication for lymphadenectomy in patients with localized moderate -⁠ and high-risk prostate cancer?

Czech version

Authors: MUDr. Kristýna Dianová ¹; doc. MUDr. Vladimír Šámal, Ph.D. ^1,2; MUDr. Vít Paldus ¹
Authors‘ workplace: Urologie, Krajská nemocnice Liberec, a. s. ¹; Urologická klinika LF UK a FN Hradec Králové ²
Published in: Klin Onkol 2026; 39(5): 320-324
Category: Review
doi: https://doi.org/10.48095/ccko2026320

Overview

The aim is to summarize recent findings on the diagnostic value of Ga-68 PSMA PET/CT imaging in patients with intermediate -⁠ and high-risk prostate cancer scheduled for radical prostatectomy and its impact on decision-making regarding simultaneous performance of pelvic lymphadenectomy. The focus is on sensitivity, specificity, and negative predictive value of this imaging modality in detecting lymph node metastases; the limitations of the examination are discussed, and situations in which the results may influence therapeutic management are outlined. Based on currently available data, a negative PSMA PET/CT result significantly reduces the probability of lymph node involvement. However, despite a negative PSMA PET/CT scan, risk of lymph node involvement remains approximately 10% in intermediate-risk tumors and 20–40% in high-risk tumors. Nomograms for estimating the risk of lymph node involvement are already available and incorporate PSMA PET/CT findings into their calculations. Therefore, the decision to perform lymphadenectomy should be individualized according to the patient’s risk profile.

Keywords:

prostate cancer – Radical prostatectomy – pelvic lymphadenectomy – lymph node metastasis – Ga-68 PSMA PET/CT

Sources

1. Cornford P, van den Bergh RC, Briers E et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on prostate cancer-2024 update. Part I: Screening, diagnosis, and local treatment with curative intent. Eur Urol 2024; 86 (2): 148–163. doi: 10.1016/j.eururo.2024.03.027.

2. Makarov DV, Trock BJ, Humphreys EB et al. Updated nomogram to predict pathologic stage of prostate cancer given prostate-specific antigen level, clinical stage, and biopsy Gleason score (Partin tables) based on cases from 2000 to 2005. Urology 2007; 69 (6): 1095–1101. doi: 10.1016/j.urology.2007.03.042.

3. Gandaglia G, Fossati N, Zaffuto E et al. Development and internal validation of a novel model to identify the candidates for extended pelvic lymph node dissection in prostate cancer. Eur Urol 2017; 72 (4): 632–640. doi: 10.1016/j.eururo.2017.03.049.

4. Memorial Sloan Kettering Cancer Center. Dynamic prostate cancer nomograms: coeficients [online]. [cited 2026 22 Feb 2026]. Available from: https: //www.mskcc.org/nomograms/prostate/pre_op/coefficients.

5. Gandaglia G, Ploussard G, Valerio M et al. A novel nomogram to identify candidates for extended pelvic lymph node dissection among patients with clinically localized prostate cancer diagnosed with magnetic resonance imaging-targeted and systematic biopsies. Eur Urol 2019; 75 (3): 506–514. doi: 10.1016/j.eururo.2018.10.012.

6. Cimino S, Reale G, Castelli T et al. Comparison between Briganti, Partin and MSKCC tools in predicting positive lymph nodes in prostate cancer: a systematic review and meta-analysis. Scand J Urol 2017; 51 (5): 345–350. doi: 10.1080/21681805.2017.1332680.

7. Lestingi JF, Guglielmetti GB, Tring QD et al. Extended versus limited pelvic lymph node dissection during radical prostatectomy for intermediate -⁠ and high-risk prostate cancer: early oncological outcomes from a randomized phase 3 trial. Eur Urol 2021; 79 (5): 595–604. doi: 10.1016/j.eururo.2020.11.040.

8. Preisser F, van den Bergh RC, Gandaglia G et al. Effect of extended pelvic lymph node dissection on oncologic outcomes in patients with D’Amico intermediate and high risk prostate cancer treated with radical prostatectomy: a multi-institutional study. J Urol 2020; 203 (2): 338–343. doi: 10.1097/JU.0000000000000504.

9. Touijer KA, Sjoberg DD, Benfante N et al. Limited versus extended pelvic lymph node dissection for prostate cancer: a randomized clinical trial. Eur Urol Oncol 2021; 4 (4): 532–539. doi: 10.1016/j.euo.2021.03.006.

10. Touijer KA, Vertosick EA, Sjoberg DD et al. Pelvic lymph node dissection in prostate cancer: update from a randomized clinical trial of limited versus extended dissection. Eur Urol 2025; 87 (2): 253–260. doi: 10.1016/j.eururo.2024.10.006.

11. Mattei A, Guechsel FG et al. The template of the primary lymphatic landing sites of the prostate should be revisited: results of a multimodality mapping study. Eur Urol 2008; 53 (1): 118–125. doi: 10.1016/j.eururo.2007.07.035.

12. Abbasi A, Wyre HW, Ogan K. Use of full-length metallic stents in malignant ureteral obstruction. J Endourol 2013; 27 (5): 640–645. doi: 10.1089/end.2012.0448.

13. Cacciamani GE, Maas M, Nassiri N et al. Impact of pelvic lymph node dissection and its extent on perioperative morbidity in patients undergoing radical prostatectomy for prostate cancer: a comprehensive systematic review and meta-analysis. Eur Urol Oncol 2021; 4 (2): 134–149. doi: 10.1016/j.euo.2021.02.001.

14. May M, Gilfrich Ch, Bründl J et al. Impact of peritoneal interposition flap on patients undergoing robot-assisted radical prostatectomy and pelvic lymph node dissection: a systematic review and meta-analysis of randomized controlled trials. Eur Urol Focus 2024; 10 (1): 80–89. doi: 10.1016/j.euf.2023.07.007.

15. Pose RM, Knipper S, Beyer B et al. Impact of peritoneal bladder flap in robot-assisted radical prostatectomy patients on lymphoceles: a prospective randomised trial. World J Urol 2025; 43 (1): 148. doi: 10.1007/s00345-025-05518-3.

16. Wani M, Al-mitwalli A, Mukherjee S et al. Venous thromboembolism (VTE) in post-prostatectomy patients: systematic review and meta-analysis. J Clin Med 2023; 12 (12): 3979. doi: 10.3390/jcm12123979.

17. Hofman MS, Lawrentschuk N, Francis RJ et al. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. Lancet 2020; 395 (10231): 1208–1216. doi: 10.1016/S0140-6736 (20) 30314-7.

18. Stabile A, Pellegrino A, Mazzone E et al. Can negative prostate-specific membrane antigen positron emission tomography/computed tomography avoid the need for pelvic lymph node dissection in newly diagnosed prostate cancer patients? A systematic review and meta-analysis with backup histology as reference standard. Eur Urol Oncol 2022; 5 (1): 1–17. doi: 10.1016/j.euo.2021.08.001.

19. Zhang Q, Zang S, Zhang Ch et al. Comparison of 68Ga-PSMA-11 PET-CT with mpMRI for preoperative lymph node staging in patients with intermediate to high-risk prostate cancer. J Transl Med 2017; 15 (1): 230. doi: 10.1186/s12967-017-1333-2.

20. Meijer D, de Barros HA, van Leeuwen P et al. The predictive value of preoperative negative prostate specific membrane antigen positron emission tomography imaging for lymph node metastatic prostate cancer. J Urol 2021; 205 (6): 1655–1662. doi: 10.1097/JU.0000000000001592.

21. Incesu RB, Preisser F, Nohe F et al. Negative PSMA PET can be used to avoid unnecessary pelvic lymph node dissection in intermediate risk prostate cancer. Prostate Cancer Prostatic Dis 2025; 28 (4): 874–878. doi: 10.1038/s41391-024-00930-z.

22. Yaxley JW, Raveenthiran S, Nouhaud FX et al. Risk of metastatic disease on 68gallium-prostate-specific membrane antigen positron emission tomography/computed tomography scan for primary staging of 1253 men at the diagnosis of prostate cancer. BJU Int 2019; 124 (3): 401–407. doi: 10.1111/bju.14828.

23. Touijer KA, mazzola CR, Sjoberg DD et al. Long-term outcomes of patients with lymph node metastasis treated with radical prostatectomy without adjuvant androgen-deprivation therapy. Eur Urol 2014; 65 (1): 20–25. doi: 10.1016/j.eururo.2013.03.053.

24. Hope TA, Eiber M, Armstrong WR et al. Diagnostic accuracy of 68Ga-PSMA-11 PET for pelvic nodal metastasis detection prior to radical prostatectomy and pelvic lymph node dissection: a multicenter prospective phase 3 imaging trial. JAMA Oncol 2021; 7 (11): 1635–1642. doi: 10.1001/jamaoncol.2021.3771.

25. Gandaglia G et al. Identification of the optimal candidates for nodal staging with extended pelvic lymph node dissection among prostate cancer patients who underwent preoperative prostate-specific membrane antigen positron emission tomography. External validation of the Memorial Sloan Kettering Cancer Center and Briganti Nomograms and Development of a Novel Tool. Eur Urol Oncol 2023; 6 (6): 543–552. doi: 10.1016/j.euo.2023.05.003.

26. Meijer D, van Leeuwen P, Roberts MJ et al. External validation and addition of prostate-specific membrane antigen positron emission tomography to the most frequently used nomograms for the prediction of pelvic lymph-node metastases: an international multicenter study. Eur Urol 2021; 80 (2): 234–242. doi: 10.1016/j.eururo.2021.05.006.

27. Vis AN, Meijer D, Roberts MJ et al. Development and external validation of a novel nomogram to predict the probability of pelvic lymph-node metastases in prostate cancer patients using magnetic resonance imaging and molecular imaging with prostate-specific membrane antigen positron emission tomography. Eur Urol Oncol 2023; 6 (6): 553–563. doi: 10.1016/j.euo.2023.03.010.