How do you reconcile discrepancies in clinical prostate cancer staging with AJCC and NCCN?
In particular, in the modern era of multi-parametric prostate MRI and PSMA-PET, certain findings such as EPE, SVI, or pelvic lymphadenopathy may be noted which otherwise may have been undetected by DRE or conventional CT C/A/P and NM bone scan imaging
NCCN v4.2023 states:
- mpMRI can be used in the staging and characterization of prostate cancer.
- mpMRI may be used to better risk stratify patients who are considering active surveillance.
- Additionally, mpMRI may detect large and poorly differentiated prostate cancer (Grade Group ≥2) and detect extracapsular extension (T staging) and is preferred over CT for abdominal/pelvic staging.
- mpMRI has been shown to be equivalent to CT scan for pelvic lymph node evaluation
Whereas the AJCC 8th edition states:
- Clinical T category should always reflect DRE findings only
- Neither imaging information or tumor laterally information from the prostate biopsy should be used for clinical T category.
- A tumor that is found in one or both sides by needle biopsy, but is not palpable is classified as T1c
- Although imaging, particularly multi-parametric prostate MRI, has improved, imaging should NOT be used for T-category assessment.
What is your practice in regard to clinical prostate cancer staging with these newer imaging modalities (e.g., not after radical prostatectomy and PLND)?
Answer from: Radiation Oncologist at Academic Institution
Fundamentally, I use NCCN risk categories to help steer conversations about staging and treatment options for very low vs low vs fav int vs unfav int vs high risk diseases. Therefore, I use NCCN staging in my clinical practice and notes and incorporate mpMRI into staging. I find it comforting that N...
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Answer from: Radiation Oncologist at Academic Institution
I don’t. I use the Gleason score, PSA, T stage, PSMA PET when appropriate, MSKCC and Briganti nomograms, and medical comorbidities to guide recommendations.
Answer from: Radiation Oncologist at Community Practice
This is a common question that, unfortunately, there is not a super simple answer if getting to the core of it.What is the goal of AJCC? Risk stratification with standardized risk groups. It in no way is meant to guide treatment itself. Unfortunately, the AJCC 8th edition was made solely by 'expert ...
Answer from: Radiation Oncologist at Academic Institution
I generally do not use MRI for clinical staging, though with exceptions for very discordant and aggressive findings. Mostly I view MRI findings like Decipher -- a useful tool in risk stratification without actually changing risk groups. For example, consider a patient w/ PSA 11, DRE negative, Gleaso...
Answer from: Radiation Oncologist at Academic Institution
There are two somewhat separate issues at play - staging and assessment of the cancer for the purpose of individual patient recommendation. Staging allows us to roughly organize patients into groups for a variety of purposes including making treatment recommendations but also for research and admini...
Answer from: Radiation Oncologist at Community Practice
My first thought upon reading this was, "This is an excellent example of the importance of clinical judgment!"
Similar to armed conflict, where the weapons are often initially way ahead of the tactics, the rapid and continuing evolution of advanced imaging and molecular analysis is moving beyond ou...
Answer from: Radiation Oncologist at Academic Institution
While NCCN may allow for T3a to be defined by MRI, traditional risk-stratification (such as NCCN risk groups) did not, and the same story with historical recurrence risk nomograms, such as the MSKCC pre-prostatectomy nomogram, which is critical in my ability to counsel unresected patients who are de...