Clinical staging – T stage is based on DRE only (i.e. not MRI)
| Tx | Tumour can’t be assessed |
| T0 | No evidence primary tumour |
| cT1a
cT1b cT1c |
Incidental finding in < 5 % TURP chips
Incidental finding in > 5 % TURP chips Diagnosed on biopsy but not palpable |
| cT2a
cT2b cT2c |
Involves less than half of one lobe
Involves more than half of one lobe, but not both Involves both lobes |
| cT3a | Extracapsular extension |
| cT3b | Invades seminal vesicles |
| cT4 | Fixed, or invades other adjacent structures – sphincter, rectum, levator muscle, bladder, pelvic wall |
| Nx | Nodes can’t be assessed |
| N0 | No regional lymph node mets |
| N1 | Regional lymph node mets |
| Mx | Distant mets can’t be assessed |
| M0 | No distant mets |
| M1a
M1b M1c |
Non regional lymph nodes
Bone Other sites |
Pathological local staging is based on histological assessment – note there is no pT1.
| Tx | Tumour can’t be assessed |
| pT0 | No evidence primary tumour |
| pT2 | Organ confined |
| pT3a | Extraprostatic extension
Microscopic invasion of bladder neck |
| pT3b | Invasion of seminal vesicles |
| pT4 | Fixed, or invades other adjacent structures – sphincter, rectum, levator muscle, bladder, pelvic wall |
EAU risk groups:
| Low risk | PSA < 10
ISUP 1 all cT1 – cT2a |
| Intermediate risk | Any of:
PSA 10 – 20 ISUP 2 – 3 cT2b |
| High risk | Any of:
PSA > 20 ISUP 4 – 5 cT2c |
| Locally advanced | cT3-4
cN+ |
NCCN risk groups:
Imaging for nodal and metastatic staging:
- CT and MRI indirectly assess nodal involvement by using lymph node diameter and morphology
- Usually lymph nodes > 8 mm in pelvis and > 10 mm outside pelvis considered malignant
- CT and MRI sensitivity is less than 40 %
PSMA-PET for nodes
- Meta-analyses suggest PSMA PET has a sensitivity of around 75 %, and a specificity of > 95 % for nodal metastases
- EAU – “PSMA PET more appropriate for N-staging compared to MRI, CT or choline PET…however small LN mets under the spatial resolution of PET (4 – 5 mm) may still be missed
Bone scan
- Meta-analysis suggests sensitivity and specificity around 80 % – influenced by PSA level and Gleason score
proPSMA study:
- 300 patients – high risk disease – 98 % ISUP 3+, 27 % cT3+
- PSMA accuracy 92 % vs 65 % for CT/BS
- Sensitivity 85 % vs 38 %
- Specificity 91 % vs 98 %
- Management change 28 % vs 15 %
- Equivocal findings 23 % vs 7 %
- Lower radiation exposure for PSMA
EAU summary:
- The field on non-invasive N and M staging is rapidly evolving
- PSMA is more sensitive at detecting nodes and mets cf. CT/BS
- However – in the absence of prospective studies demonstrating clinical and survival benefit – caution must be used in changing therapeutic decisions
- There is significant ‘stage migration’ with PSMA PET – patients now being made nodal or metastatic who wouldn’t have been otherwise on conventional imaging – and we have no evidence on how to treat these men
EAU guidelines for imaging:
Use pre-biopsy MRI for local staging
Low risk
- Do not use additional imaging for staging
Intermediate risk
- For ISUP 3 – include at least cross-sectional abdominal/pelvic imaging and a bone scan
High risk
- At least cross-sectional abdominal/pelvic imaging and a bone scan
When using PSMA-PET to increase sensitivity, be aware of lack of outcome data of subsequent treatment changes