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• Using clinical nomograms with low threshold values may lead to unnecessary lymph node dissections. • In patients with prostate cancer, preoperative PSMA PET-CT may fail to detect lymph node metastases. • Sensitivity of PSMA PET-CT to detect lymph node metastases can be improved by utilizing clinical nomograms with higher threshold values. • To reduce the high cost, justified use of PSMA PET-CT could be limited to patients in the D'Amico high-risk group or higher nomogram scores. The aim was to ensure efficient utilization of PSMA PET-CT by examining the correlation of pathological lymph node metastasis with nomogram scores and risk classifications. Robot-assisted radical prostatectomy and bilateral pelvic lymph node dissections for pelvic lymph nodes were performed using the same template. Bilaterally pelvic lymph nodes were removed within the boundaries of genitofemoral nerves, psoas muscle and lateral pelvic wall laterally, ureteric crossing of the iliac vessels superiorly, lateral bladder wall medially, Cooper ligaments distally, and endopelvic fascia, neurovascular bundles and internal iliac arteries posteriorly. Clinical nomograms were used to calculate the probability of lymph node metastasis preoperatively. Using receiver operating characteristics analysis, discriminatory cut-offs were calculated. The diagnostic performance of PSMA PET-CT was determined for detecting lymph node metastasis. For 81 patients, the median age was 64 years. The median PSA was 6.8 ng/ml. Most patients were in the D'Amico intermediate (56.8%) and high (37%) risk groups. Median Briganti 2017, MSKCC, and Partin scores were 35 (4–99), 37 (8–90), and 12 (2–38), respectively, in pN1 patients. The area under the curve for Briganti 2017, MSKCC, Partin nomograms and PSMA PET-CT scans were 0.852, 0.871, 0.862, and 0.588. Sensitivity, specificity, positive predictive value and negative predictive value for Ga-68 PSMA PET-CT for lymph node metastasis detection were 21.4%, 94%, 42.9%, and 85.1%, respectively, for the whole group. By using higher threshold values for clinical nomograms (Briganti 2017 >32, MSKCC >12, Partin >5), PSMA PET-CT had higher sensitivity (42.9, 30, 27.2) in detecting lymph node metastasis. Patients in the D'Amico high-risk group and those with high nomogram scores are the best candidates who will benefit from preoperative PSMA PET-CT staging to estimate lymph node metastasis. [ABSTRACT FROM AUTHOR]

Objective: Docetaxel has been shown to be an effective chemotherapy agent when combined with androgen deprivation therapy for hormone sensitive metastatic prostate cancer (CaP). Since very high risk CaP has a high rate of occult metastatic disease and early recurrence, we hypothesize that patients with very high risk locally advanced CaP may benefit from docetaxel-based neoadjuvant chemohormonal therapy (NCHT). Thus, we conducted a retrospective study to identify the outcome of these patients treated with NCHT followed by radical prostatectomy (RP).Patients and Methods: We retrospectively analyzed data from 177 consecutive patients who had very high risk locally advanced CaP between March 2014 and July 2017. Patients received 3 different therapies: (i) 60 men in NCHT group, (ii) 73 men in neoadjuvant hormonal therapy (NHT) group, and (iii) 44 men received immediate RP without neoadjuvant therapy (No-NT group). Surgical outcomes were analyzed and survival differences were compared by the Kaplan-Meier method.Results: The NCHT group had statistically significant higher preoperative Prostate-Specific Antigen (PSA) (P < 0.002), higher Gleason score (P < 0.002), and more advanced clinical stage (P < 0.001) than other groups. After RP, 81% (42/52) of patients in NCHT group, 73% (51/70) of patients in NHT group, and 48% (21/44) of patients in No-NT group achieved an undetectable PSA (P < 0.001). A total of 14% (6/42) patients achieving a postoperative undetectable PSA experienced biochemical recurrence in the NCHT group, with median biochemical progression-free survival (bPFS) time of 19 months; 47% (24/51) experienced biochemical recurrence in the NHT group, with median bPFS time of 13 months; 81% (17/21) experienced biochemical recurrence in the No-NT group, with median bPFS time of 9 months (P < 0.001). The median follow-up time of 3 groups was 12.5 months in the NCHT group, 18.3 months in the NHT group, and 22.8 months in the No-NT group (P = 0.01).Conclusion: Despite having poorer prognostic factors, the NCHT group had better bPFS time after surgery compared to NHT and No-NT groups. Randomized controlled investigations are needed to validate these results and further follow-up is required for survival endpoints. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: Extended Pelvic Lymph Node Dissection (ePLND) remains the most accurate technique for the detection of occult lymph node metastases (LNMs) in prostate cancer (CaP) patients. Here we aim to examine whether free-Indocyanine Green (F-ICG) could accurately assess the pathological nodal (pN) status in CaP patients during real-time lymphangiography as a potential replacement for ePLND.Materials and Methods: 219 consecutive patients undergoing F-ICG-guided PLND, ePLND and radical prostatectomy (RP) for clinical-localized CaPwere included in this prospective single-center study. The pathological outcomes of F-ICG-guided PLND were compared to confirmatory ePLND. Parameters of a binary diagnostic test for the proper classification of the pN status of patients ('per-patient' analysis) and for the probability of detecting all the metastatic LNs ('per-node' analysis) were calculated. Outcome measures were prevalence, accuracy (Acc), sensitivity (Se), negative predictive value (NPV), and likelihood ratio of a negative F-ICG-guided PLND test result [LR(-)].Results: F-ICG-guided PLND successfully visualized LNs in all procedures with no adverse events. The overall per-patient F-ICG staging Acc was 97.7%, Se was 91.4%, with a NPV of 97.0%, and LR(-) of 8.6%. At the overall per-node level, 4,780 LNs were removed and 1,535 (32.1%) were fluorescent in vivo. F-ICG-guided PLND identified LNMs with a Se of 63.4%.Conclusions: This study confirms that F-ICG-guided lymphangiography correctly staged almost 98% of patients. The high per-patient NPV suggested that avoiding ePLND is safe for most patients when F-ICG stained nodes were pN0. Thus, more conservative approaches might minimise perioperative morbidity during LNMs diagnosis in selected patients. [ABSTRACT FROM AUTHOR]

Introduction The role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer (PCa) is controversial. Despite extensive research in both patterns of lymphatic drainage and the clinical effect of lymph node involvement, the exact role of PLND in PCa is yet to be defined. Methods A systematic search of the MEDLINE database was performed, and all relevant articles were reviewed in depth. Results We included 84 relevant articles in our review and subdivided the information into the following categories: preoperative patient evaluation, procedure/extent of dissection, complications, and robotic surgery era. Most authors agree that the greatest benefit is seen in patients with high-risk PCa undergoing RP. Multiple imaging modalities have been evaluated for assistance in patient selection, but the use of preoperative nomograms appears to be the most helpful selection tool. The role of limited PLND vs. extended PLND (e-PLND) is yet to be defined, though many authors agree that e-PLND is preferred in the setting of high-risk PCa. Although PLND is associated with a higher incidence of complications, especially lymphocele formation, it is unclear whether e-PLND leads to more complications than limited PLND. The introduction of minimally invasive surgery may have had a negative effect on implementation of PLND in the appropriate patients undergoing RP. Conclusion Despite a lack of prospective, randomized trials evaluating PLND in RP, there does appear to be a consistent benefit in patients with high-risk disease. [ABSTRACT FROM AUTHOR]