You are prohibited from using or uploading content you accessed through this website into external applications, bots, software, or websites, including those using artificial intelligence technologies and infrastructure, including deep learning, machine learning and large language models and generative AI.
No AccessJournal of UrologyNew Technology and Techniques1 Apr 2019

Outcomes of Primary Lymph Node Staging of Intermediate and High Risk Prostate Cancer with 68Ga-PSMA Positron Emission Tomography/Computerized Tomography Compared to Histological Correlation of Pelvic Lymph Node Pathology

View All Author Information


The majority of men who undergo pelvic lymph node dissection at radical prostatectomy have benign lymph node histology. The aim of this study was to assess the predictive value of preoperative 68Ga-PSMA (prostate specific membrane antigen) positron emission tomography/computerized tomography to predict histological metastasis on pelvic lymph node dissection performed during radical prostatectomy.

Materials and Methods:

We retrospectively reviewed the sensitivity, specificity, and positive and negative predictive values of preoperative staging 68Ga-PSMA positron emission tomography/computerized tomography to identify histological lymph node metastasis in 208 consecutive men who subsequently proceeded with pelvic lymph node dissection at radical prostatectomy.


Median prostate specific antigen was 7.6 μg/l, the lymph node count was 13 and Gleason score was 4 + 5. On a per patient basis only 21 of the 55 men with metastasis on histological examination were identified on 68Ga-PSMA positron emission tomography/computerized tomography for 38.2% sensitivity. Of the 143 men with no lymph node metastasis on 68Ga-PSMA imaging 34 had metastasis on histology for 80.8% negative predictive value. Specificity was 93.5% and positive predictive value was 67.7%. For the 172 histologically identified malignant lymph node metastases the sensitivity per node was 24.4% and specificity was 99.5%.


If negative 68Ga-PSMA positron emission tomography/computerized tomography is used as the basis of not performing pelvic lymph node dissection, 80% of men would avoid unnecessary pelvic lymph node dissection. However, 68Ga-PSMA positron emission tomography/computerized tomography has poor sensitivity per node to detect all histologically positive lymph node metastases. Thus, pelvic lymph node dissection remains the gold standard to stage pelvic lymph nodes despite its known limitations and complications.


  • 1. : 68Ga-labeled prostate-specific membrane antigen ligand positron emission tomography/computed tomography for prostate cancer: a systematic review and meta-analysis. Eur Urol Focus 2018; 4: 686. Google Scholar
  • 2. : The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: a meta-analysis. Clin Radiol 2008; 63: 387. Google Scholar
  • 3. : Sensitivity, specificity and predictors of positive 68Ga-prostate specific membrane antigen positron emission tomography in advanced prostate cancer: a systematic review and meta-analysis. Eur Urol 2016; 70: 926. Google Scholar
  • 4. : EAU-ESTRO-SIOS guidelines on prostate cancer. Part 1: screening, diagnosis and local treatment with curative intent. Eur Urol 2017; 71: 618. Google Scholar
  • 5. : PET imaging of prostate-specific membrane antigen in prostate cancer: current state of the art and future challenges. Prostate Cancer Prostatic Dis 2016; 19: 223. Google Scholar
  • 6. : North American population-based validation of National Comprehensive Cancer Network practice guideline recommendation of pelvic lymphadenectomy in contemporary prostate cancer. Prostate 2017; 77: 542. Google Scholar
  • 7. : Comparison of bone scintigraphy and 68Ga-PSMA PET for skeletal staging in prostate cancer. Eur J Nucl Med Mol Imaging 2016; 43: 2114. Google Scholar
  • 8. : Comparison of PET imaging with 68Ga-labelled PSMA ligand and 18F-choline based PET/CT for the diagnosis of recurrent prostate cancer. Eur J Nuc Med Mol Imaging 2014; 41: 11. Google Scholar
  • 9. : Diagnostic efficiency of 68gallium-PSMA positron tomography compared to conventional imaging in lymph node staging of 130 consecutive patients with intermediate to high risk prostate cancer. J Urol 2016; 195: 1436. LinkGoogle Scholar
  • 10. : The accuracy of 68Ga-PSMA PET/CT in primary lymph node staging in high risk prostate cancer. Eur J Nuc Med Mol Imaging 2017; 44: 1806. Google Scholar
  • 11. : Use of 68Ga PET PSMA scan in men with biochemical recurrence after definitive treatment of prostate cancer. BJU Int, suppl., 2016; 118: 49. Google Scholar
  • 12. : PET imaging with a 68Ga gallium-labelled PSMA ligand for the diagnosis of prostate cancer: biodistribution in humans and first evaluation of tumour lesions. Eur J Nuc Med Mol Imaging 2013; 40: 486. Google Scholar
  • 13. : Diagnostic performance of 68Ga-PSMA-11 (HBED-CC) PET/CT in patients with recurrent prostate cancer: evaluation in 1007 patients. Eur J Nucl Med Mol Imaging 2017; 44: 1258. Google Scholar
  • 14. : 68Ga-prostate specific membrane antigen (PSMA) positron emission tomography (PET) for primary staging of high risk prostate cancer: a systematic review. World J Urol 2018; 36: 519. Google Scholar
  • 15. : Comparison of 68Ga-PSMA-11 PET-CT with mpMRI for preoperative lymph node staging with intermediate and high risk prostate cancer. J Transl Med 2017; 15: 230. Google Scholar
  • 16. : Initial experience of 68Ga PSMA/PET imaging in high risk prostate cancer patients prior to radical prostatectomy. Eur Urol 2016; 69: 393. Google Scholar
  • 17. : Prospective evaluation of 68 gallium—prostate specific membrane antigen positron emission tomography/computed tomography for pre-operative lymph node staging in prostate cancer. BJU Int 2017; 119: 209. Google Scholar
  • 18. : 68Ga-PSMA positron emission tomography/computed tomography provides accurate staging of lymph node regions prior to lymph node dissection in patients with prostate cancer. Eur Urol 2016; 70: 553. Google Scholar
  • 19. : Initial multicentre experience of 68gallium-PSMA PET/CT guided robot assisted salvage lymphadenectomy: acceptable safety profile but oncological benefit appears limited. BJU Int 2017; 120: 673. Google Scholar
  • 20. : The impact of 68Ga-PSMA PET/CT on management intent in prostate cancer: results of an Australian prospective multicentre study. J Nucl Med 2018; 59: 82. Google Scholar
  • 21. : Patterns of clinical recurrence of node-positive prostate cancer and impact on long term survival. Eur Urol 2015; 68: 777. Google Scholar
  • 22. : Pathological and oncological outcomes for men with positive lymph nodes at radical prostatectomy: the Johns Hopkins 30-year experience. Prostate 2013; 73: 1673. Google Scholar
  • 23. : Reconsidering the role of pelvic lymph node dissection with radical prostatectomy in the era of improving radiological techniques. World J Urol 2018; 36: 15. Google Scholar
  • 24. : Long term oncological outcomes in patients with limited nodal disease undergoing radical prostatectomy and pelvic lymph node dissection without adjuvant treatment. World J Urol 2017; 35: 1833. Google Scholar
  • 25. : Impact of adjuvant radiotherapy on survival of patients with node positive prostate cancer. J Clin Oncol 2014; 32: 3939. Google Scholar
  • 26. : Survival outcomes of men with lymph node positive prostate cancer after radical prostatectomy. A comparative analysis of different postoperative management strategies. Eur Urol 2018; 73: 890. Google Scholar
  • 27. : A critical assessment of the value of lymph node dissection at radical prostatectomy: a population based study. Prostate 2011; 71: 1587. Google Scholar
  • 28. : A prospective randomised multicentre study of the impact of gallium-68 prostate specific membrane antigen (PSMA) PET/CT imaging for staging high risk prostate cancer prior to curative intent surgery or radiotherapy (proPSMA study): clinical trial protocol. BJU Int 2018; 122: 783. Google Scholar

No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article.

The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number.