PSMA PET/CT在避免不必要手术中的决策价值

2.2.7 Decision Value in Avoiding Unnecessary Surgery The high negative predictive value (NPV) of PSMA PET/CT provides a basis for reducing overtreatment. Regarding the controversy over whether intermediate-risk prostate cancer patients need pelvic lymph node dissection (PLND), the study by Incesu R B's team provided important evidence: among 371 intermediate-risk patients with PSMA PET-negative lymph nodes, there was no significant difference in 36-month biochemical recurrence-free survival between the non-PLND group and the PLND group (76.7% vs 78.7%, p=0.8). Although 10% of patients in the PLND group were confirmed to have lymph node metastasis postoperatively, the median diameter of these metastases was only 2.2 mm, and the minimal metastatic burden did not affect short-term prognosis. This finding strongly supports the selective avoidance of PLND, which can reduce the incidence of surgery-related complications such as lymphoceles and lymphedema. 3 Latest Advances in PSMA-Targeted Therapy 3.1 Breakthroughs in Radioligand Therapy 3.1.1 Phase III Clinical Evidence and Survival Benefits The phase III clinical trial results published by Fizazi K's team in 2025 for the treatment of PSMA-positive mCRPC patients who had progressed after one androgen receptor pathway inhibitor (ARPI) and had not received taxane-based chemotherapy using [(177)Lu]Lu-PSMA-617 showed that the radioligand therapy group significantly outperformed the control group across all patient-reported outcome dimensions. The median time to worsening FACT-P total score was extended by 75% (7.46 vs 4.27 months, HR=0.61), the EQ-5D-5L utility value deterioration was delayed by 62% (6.28 vs 3.88 months, HR=0.67), and the time to worsening BPI-SF pain intensity was postponed by 38% (5.03 vs 3.65 months, HR=0.72). [(177)Lu]Lu-PSMA-617 demonstrated excellent efficacy in preventing symptomatic skeletal events (SSE), with the median SSE time not reached in the treatment group (i.e., more than half of the patients did not experience an event) compared to 17.97 months in the control group (HR=0.41), indicating a 59% reduction in SSE risk. This "triple protection" mechanism—targeting PSMA to deliver radiation to simultaneously kill tumor cells and the microenvironment—provides a new approach to improving the quality of life for mCRPC patients and represents the most influential breakthrough in the field of PSMA-targeted therapy.