Use of staging in intermediate-risk prostate cancer: A real-world data analysis.

Objective: Current EAU guidelines provide only a weak recommendation for staging (computed tomography [CT], magnetic resonance imaging [MRI], bone scan, or prostate-specific membrane antigen [PSMA] positron emission tomography [PET]/CT) in selected intermediate-risk prostate cancer (irPCa) patients. However, data on the real-world application of staging in this group are limited. We aimed to assess the use of various imaging modalities for distant staging in irPCa patients scheduled for radical prostatectomy (RP).

Material and methods: We identified irPCa patients from a high-volume institutional database who underwent primary RP between 2015 and 2021. The use of different staging modalities was assessed, with stratification according to NCCN criteria into favorable and unfavorable intermediate-risk groups. Annual trends were analyzed.

Results: Among 9,512 irPCa patients, 37.4% had favorable and 62.6% unfavorable disease. Overall, 42.0% underwent any form of staging prior to RP, with higher rates in unfavorable versus favorable disease (48.5% vs. 31%, P < 0.001). The detection rates of locoregional or metastatic disease using conventional imaging were low (0%-2.0%). For PSMA PET/CT, the rates were 5.0% and 4.3% in the favorable and unfavorable groups, respectively. Bone scans (34.7%) and abdominopelvic CT (28.0%) were most frequently used in unfavorable cases, with 20.1% undergoing both. Only 6.2% (n = 369) of unfavorable patients received PSMA PET/CT. Among favorable cases, 22.0% underwent bone scans and 17.8% abdominopelvic CT; 11.9% had both, and just 2.8% (n = 100) received PSMA PET/CT. MRI was rarely used (1.7%; 1.9% in unfavorable vs. 1.3% in favorable cases, P = 0.1). Overall staging rates remained stable during the study period (EAPC: 0.04, P = 0.9), whereas PSMA PET/CT usage significantly increased in the total cohort (EAPC: 17.9, P < 0.01) and in the unfavorable group (EAPC: 21.1, P < 0.01).

Conclusions: Less than half of patients with unfavorable irPCa and approximately one-third of those with favorable irPCa underwent distant staging. Positive findings were rare, especially with conventional imaging. Therefore, conventional staging might be safely omitted in irPCa, while PSMA PET/CT may be considered in selected patients when staging is deemed necessary, as it provides more accurate information.