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Predicting side-specific extraprostatic extension in prostate cancer using an 18F-DCFPyL PSMA-PET/CT–based nomogram

Prostate Cancer and Prostatic Diseases (2025)Cite this article

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Abstract

Background

Extraprostatic extension (EPE) in prostate cancer (PCa) has implications for nerve-sparing approaches. mpMRI-based nomograms show modest accuracy, highlighting the need for improved predictive models. This study evaluates 18F-DCFPyL prostate-specific membrane antigen (PSMA) positron emission tomography/ computed tomography (PET/CT) for predicting side-specific EPE using maximum standardized uptake value (SUVmax).

Methods

This single-center cohort study included patients undergoing RALP by a single surgeon (AKT) from January 2022 to September 2024. Baseline variables included demographics, PSA, biopsy, MRI, and PSMA parameters (SUVmax, EPE, SVI). The primary endpoint was side-specific EPE on final pathology. Univariable and multivariable logistic regression identified significant predictors. A nomogram was built based on this. To evaluate model performance, a 1000-iteration bootstrap approach was used to compare (1) the institutional MRI-only 2018 model, (2) an MRI + PSMA Fixed Model, and (3) a retrained MRI + PSMA Model built on each bootstrap sample.

Results

Three hundred fifty-five patients were analyzed. EPE was detected in 18.9% by MRI and 5.4% by PSMA PET. Median intraprostatic SUVmax was 11.30. EPE-positive sides were more likely to have MRI/PSMA-detected EPE (p < 0.001), PIRADS 5 lesions (p < 0.001), aggressive biopsy GGG (p < 0.001), higher positive cores (p < 0.001), and greater percent tumor involvement (p < 0.001). Median SUVmax was significantly higher in the EPE group (9.1 vs. 5.4; p < 0.001). Multivariable analysis identified PSA, MRI-detected EPE, GGG, tumor involvement percentage, and SUVmax ≥13 as significant predictors. The PSMA + MRI Fixed Model outperformed the MRI-only model (median AUC: 0.7542 vs. 0.7350) with p < 0.001. Calibration plots showed strong agreement between predicted and observed probabilities, and decision curve analysis demonstrated greater net clinical benefit across relevant thresholds.

Conclusion

We developed a nomogram integrating PSMA PET with MRI and clinicopathological variables, outperforming our institutional model. PSMA uptake strongly predicts side-specific EPE, which can enhance preoperative assessment and improve postoperative functional outcomes.

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Fig. 1
Fig. 2: Nomogram for predicting side-specific extraprostatic extension (EPE).
Fig. 3: Bootstrapped AUC comparison of MRI-only, PSMA + MRI Fixed, and PSMA + MRI Retrained models.
Fig. 4: Decision curve analysis for the PSMA + MRI (fixed model) nomogram.

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Data availability

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Authors and Affiliations

  1. Department of Urology, Icahn School of Medicine at Mount Sinai, New York, USA

    Neeraja Tillu, Ashutosh Maheshwari, Kaushik Kolanukuduru, Manish Choudhary, Yashaswini Agarwal, Himanshu Joshi, Shokhi Goel, Hannah Sur, Reuben Ben- David, Asher Mandel, Henry Jodka, Brenda Hug, Lianne Ohayon, Susanna Baek, Coskun Kacagan, Vinayak Wagaskar, Murilo de Almeida Luz & Ashutosh Tewari

  2. Department of Urology, University Hospital Zurich, Zurich, Switzerland

    Basil Kaufmann

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Contributions

NT and AT conceived and designed the study. NT, AMa, AMe, YA, SG, HS, BH, SB, CK and LO contributed to data collection. AMa, RB, BK, and HJ performed statistical analysis. NT, HJod, and KK conducted the literature review and contributed to manuscript drafting. VW and ML provided clinical interpretation and critical input. AT supervised the project and contributed to manuscript revision. All authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Neeraja Tillu.

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The authors declare no competing interests.

Ethics approval and consent to participate

All methods were performed in accordance with the relevant guidelines and regulations, including the principles outlined in the Declaration of Helsinki. Ethical approval for this study was obtained from the Institutional Review Board (IRB) of the Mount Sinai Hospital (Reference Number: MSH IRB 25-00146). The requirement for informed consent was waived by the IRB due to the retrospective nature of the study and the use of de-identified data.

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Tillu, N., Maheshwari, A., Kolanukuduru, K. et al. Predicting side-specific extraprostatic extension in prostate cancer using an 18F-DCFPyL PSMA-PET/CT–based nomogram. Prostate Cancer Prostatic Dis (2025). https://doi.org/10.1038/s41391-025-01001-7

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