Inguinal lymph node metastases from prostate cancer: clinical, pathology, and multimodality imaging considerations

Woo, Sungmin; Becker, Anton S.; Ghafoor, Soleen; Barbosa, Felipe de Galiza; Arita, Yuki; Vargas, Hebert A.

doi:10.1590/0100-3984.2024.0013

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Original Article • Radiol Bras 57 • 2024 • https://doi.org/10.1590/0100-3984.2024.0013 copy

Inguinal lymph node metastases from prostate cancer: clinical, pathology, and multimodality imaging considerations

Metástases de linfonodos inguinais de câncer de próstata: considerações clínicas, patológicas e de imagem multimodalidade

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To investigate clinical, pathology, and imaging findings associated with inguinal lymph node (LN) metastases in patients with prostate cancer (PCa).

Materials and Methods:

This was a retrospective single-center study of patients with PCa who underwent imaging and inguinal LN biopsy between 2000 and 2023. We assessed the following aspects on multimodality imaging: inguinal LN morphology; extrainguinal lymphadenopathy; the extent of primary and recurrent tumors; and non-nodal metastases. Imaging, clinical, and pathology features were compared between patients with and without metastatic inguinal LNs.

Results:

We evaluated 79 patients, of whom 38 (48.1%) had pathology-proven inguinal LN metastasis. Certain imaging aspects— short-axis diameter, prostate-specific membrane antigen uptake on positron-emission tomography, membranous urethra involvement by the tumor, extra-inguinal lymphadenopathy, and distant metastases—were associated with pathology-proven inguinal LN metastases (p < 0.01 for all). Associations with long-axis diameter, fatty hilum, laterality, and uptake of other tracers on positronemission tomography were not significant (p = 0.09–1.00). The patients with metastatic inguinal LNs had higher prostate-specific antigen levels and more commonly had castration-resistant PCa (p < 0.01), whereas age, histological grade, and treatment type were not significant factors (p = 0.07–0.37). None of the patients had inguinal LN metastasis in the absence of locally advanced disease with membranous urethra involvement or distant metastasis.

Conclusion:

Several imaging, clinical, and pathology features are associated with inguinal LN metastases in patients with PCa. Isolated metastasis to inguinal LNs is extremely rare and unlikely to occur in the absence of high-risk imaging, clinical, or pathology features.

Keywords:
Lymph nodes/pathology; Biopsy; Magnetic resonance imaging; Positron emission tomography computed tomography; Prostatic neoplasms/diagnostic imaging; Urethra/pathology

Characteristic	(N = 79)^* * Data presented as n (%), except where otherwise indicated.
Age (years), median (IQR)	67 (62–75)
ISUP grade group^† † For four patients (all with metastatic inguinal LNs), no data were available, because the diagnosis of PCa was confirmed through analysis of an inguinal LN biopsy specimen.
1	6 (8.0)
2	15 (20.0)
3	18 (24.0)
4	14 (18.7)
5	22 (29.3)
PSA (ng/mL), median (IQR)
At baseline	10.0 (6.3–27.0)
At suspected recurrence	2.8 (0.6–23.9)
Initial treatment
Treatment-naïve	27 (34.2)
RP	38 (48.1)
RT	9 (11.4)
Systemic	5 (6.3)
Castration status
Resistant	21 (26.6)
Sensitive	58 (73.4)
Inguinal LN metastasis	38 (48.1)
Interval (days), median (IQR)
Imaging to biopsy	20 (12–32)
Initial treatment to suspected recurrence	2,329 (699–4,548)
Biopsy to last follow-up	1,100 (343–1,755)
Imaging modalities used to assess inguinal LNs and other aspect
CT^‡ ‡ In one patient, no CT scan was available and metastatic disease was evaluated with whole-body MRI.	78 (98.7)
Prostate MRI	30 (38.0)
Whole-body MRI	2 (2.5)
Bone scan	27 (34.8)
PSMA PET/CT	18 (22.7)
Choline PET/CT	6 (7.6)
Fluciclovine PET/CT	4 (5.1)
FDG PET/CT	13 (16.5)

				Inguinal LN status		P-value
	Characteristic			Metastatic (n = 38)	Nonmetastatic (n = 41)	P-value
Imaging	Inguinal LN	Size (cm)	Long-axis diameter	2.2 (1.7–3.0)	1.9 (1.4–2.4)	0.094
			Short-axis diameter	1.7 (1.3–2.2)	1.2 (0.9–1.6)	0.002
		Fatty hilum		8 (23.5)	15 (36.6)	0.213
		Laterality	Left	19 (50.0)	26 (63.4)	0.229
			Right	19 (50.0)	15 (36.6)
		Radiotracer uptake (SUVmax)^* * Patient subsamples, by type of radiotracer used for PET/CT: PSMA (n = 18; 8 and 10 patients with and without metastatic inguinal LNs, respectively); choline (n = 6; 1 and 5 patients with and without metastatic inguinal LNs, respectively); fluciclovine (n = 4; 1 and 3 patients with and without metastatic inguinal LNs respectively); and FDG (n = 13; 7 and 6 patients with and without metastatic inguinal LNs, respectively)	PSMA	19.5 (14.6–25.1)	2.2 (1.8–3.0)	< 0.001
			Choline	3.4 (3.4–3.4)	3.0 (2.9–4.4)	> 0.999
			Fluciclovine	16.3 (16.3–16.3)	3.6 (3.2–3.7)	0.500
			FDG	8.4 (8.2–14.3)	6.5 (4.8–11.7)	0 .174
	Membranous urethra involvement by primary tumor^† † Analyzed for patients that underwent dedicated prostate MRI (n = 30; 12 and 18 patients with and without metastatic inguinal LNs, respectively), 14 scans having been performed for baseline assessment (7 and 7 patients with and without metastatic inguinal LNs, respectively), and 16 having been performed after RP (5 and 11 patients with and without metastatic inguinal LNs, respectively)		All patients	9/12 (75.0)	1/18 (5.6)	< 0.001
			Baseline	6/7 (85.7)	1/7 (14.3)	0.029
			Post-RP	3/5 (60.0)	0/11 (0.0)	0.018
	Distribution of lymphadenopathy		Unilateral inguinal	2 (5.3)	21 (51.2)	< 0.001
			Bilateral inguinal	0 (0.0)	14 (34.1)
			Inguinal + pelvic or retroperitoneal	28 (73.7)	1 (2.4)
			Inguinal + diffuse	8 (21.1)	5 (12.2)
	Sites of non-nodal metastases		None	17 (44.7)	39 (95.1)	< 0.001
			Bone	15 (39.5)	2 (4.9)
			Visceral^‡ ‡ With or without bone metastases	6 (15.8)	0 (0.0)
	Reactivity explained			0 (0.0)	7 (17.1)	0.012
Clinical/Pathology	Age (years)			68 (62–76)	67 (60–72)	0.370
	ISUP grade group^§ § For four of the 38 patients with metastatic inguinal LNs, the ISUP grade group was not assessed, because the diagnosis of PCa was confirmed through analysis of an inguinal LN biopsy specimen		1	1 (2.9)	5 (12.2)	0.072
			2	4 (11.8)	11 (26.8)
			3	8 (23.5)	10 (24.4)
			4	6 (17.6)	8 (19.5)
			5	15 (44.1)	7 (17.1)
	PSA level at baseline (ng/mL)			13.8 (7.2–41.3)	9.1 (5.7–13.6)	0.027
	PSA level at recurrence (ng/mL)			23.0 (7.4–113.9)	0.6 (0.2–2.6)	< 0.001
	Initial treatment		Baseline	11 (28.9)	16 (39.0)	0.110
			RP	16 (42.1)	22 (53.7)
			RT	7 (18.4)	2 (4.9)
			Systemic	4 (10.5)	1 (2.4)
	Castration status		Resistant	19 (50.0)	2 (4.9)	< 0.001
			Sensitive	19 (50.0)	39 (95.1)
	Days from initial treatment to suspected recurrence^¶ ¶ Analyzed for 46 patients that had previously been treated with RP or RT			3,881 (2585–6287)	737 (272–2272)	< 0.001

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[1] Correspondence: Sungmin Woo, MD, PhD. Department of Radiology, NYU Langone Health, 660 1st Avenue, New York, NY 10016, USA. Email: sungmin.woo@nyulangone.org.