Salvage Elective Nodal Radiotherapy Guided by PSMA-PET/CT for Lymph Node Recurrence After Radical Prostatectomy
Overview
This retrospective study analyzed 76 patients with lymph node recurrence after radical prostatectomy treated with PSMA-PET/CT-guided salvage elective nodal radiotherapy (sENRT). The study reports promising biochemical recurrence-free survival (BRFS) and distant metastasis-free survival (DMFS) outcomes, highlighting the potential of PSMA-PET/CT to guide targeted radiotherapy and improve patient selection.
Background
Prostate cancer is the most common malignancy among men in Europe and a leading cause of cancer-related death. Radical prostatectomy (RP) is a standard treatment for localized disease, but biochemical recurrence (BCR) occurs in about one third of patients within 10 years post-surgery. Salvage radiotherapy (sRT) is a key second-line treatment for BCR, traditionally delivered using standardized fields due to limitations of conventional imaging. The introduction of PSMA-PET/CT has improved detection of nodal recurrences at low PSA levels, enabling more precise, targeted salvage treatments such as elective nodal radiotherapy (ENRT) or metastasis-directed therapy (MDT).
Data Highlights
Characteristic
Value
Number of patients
76
Median follow-up after sENRT
32.6 months
Initial tumor stage ≥ pT3
63.2%
ISUP score ≥ 3
72.4%
Initial nodal stage pN0
79%
Positive surgical margins (R1)
27.6%
Median PSA at RP
6.83 ng/mL (range 2.00–73.6)
Median post-RP PSA
0.01 ng/mL (range 0.00–0.03)
Patients with prior prostate bed RT
31.6%
Key Findings
PSMA-PET/CT demonstrated high sensitivity for detecting nodal recurrence at low PSA levels, guiding targeted sENRT.
Patients treated with sENRT showed encouraging biochemical recurrence-free survival and distant metastasis-free survival rates over a median follow-up of 32.6 months.
The majority of patients had high-risk features including ≥ pT3 stage and ISUP score ≥ 3.
Concomitant androgen deprivation therapy (ADT) was recommended for 24 to 36 months, individualized by patient factors.
Prior prostate bed radiotherapy was present in nearly one third of patients, indicating sENRT feasibility in this subgroup.
The study supports the use of PSMA-PET/CT to refine patient selection and optimize salvage radiotherapy fields.
Clinical Implications
PSMA-PET/CT should be integrated into the diagnostic workup for patients with biochemical recurrence after radical prostatectomy to accurately localize nodal recurrences. Salvage elective nodal radiotherapy guided by PSMA-PET/CT offers a promising treatment approach that may improve biochemical control and delay metastatic progression. Individualized use of concomitant ADT and careful patient selection based on imaging findings are important to optimize outcomes.
Conclusion
PSMA-PET/CT-guided salvage elective nodal radiotherapy is a valuable strategy for managing lymph node recurrence after radical prostatectomy, demonstrating favorable survival outcomes and enabling personalized treatment planning. Further prospective studies are warranted to establish standardized protocols and confirm long-term benefits.
References
PEACE V-STORM Trial 2023 -- Comparison of MDT and ENRT in Oligometastatic Nodal Recurrence
This twice-monthly newsletter highlights recently published research where Dana-Farber faculty are listed as first or senior authors. The information is pulled from PubMed and this issue notes papers published from February 16 - 28.
