North American population-based validation of the National Comprehensive Cancer Network Practice Guideline Recommendations for locoregional lymph node and bone imaging in prostate cancer patients

Felix Preisser,Markus Graefen,Francesco Montorsi,Michele Marchioni,Zhe Tian,Denis Soulières,Hartwig Huland,Elio Mazzone,Marco Bandini,Derya Tilki,Sebastiano Nazzani,Fred Saad,Shahrokh F Shariat,Pierre I Karakiewicz

doi:10.1038/s41416-018-0323-3

Abstract

BackgroundThe National Comprehensive Cancer Network (NCCN) guidelines provide recommendations for staging of prostate cancer patients in the objective regarding presence of locoregional lymph node metastases (LNM) and bone metastases. We tested the performance characteristics of these recommendations in a community setting.MethodsWithin the Surveillance, Epidemiology, and End Results database (2004–2014), we identified patients with available Gleason, clinical stage and prostatic specific antigen. Performance characteristics endpoints consisted of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NVP), overall accuracy and the number needed to image (NNI).ResultsTotally, 191,308 patients were assessable for the validation of the LNM staging recommendations. Sensitivity ranged from 80.6 to 86.3%, specificity from 74.7 to 79.3%, PPV from 7.8 to 8.0%, overall accuracy from 75.0 to 79.3% and NPV was 99.5%. The respective NNI values were 12.5 and 12.8. 197,408 patients were assessable for the validation of bone scan recommendations. These recommendations resulted in 90.8% sensitivity, 76.3% specificity, PPV of 5.7%, NPV of 99.8% and overall accuracy of 76.5%. The NNI was 17.5.ConclusionThe NCCN recommendations for locoregional LNM miss few patients with clinical LNM (0.3–0.4%) and provide a virtually perfect NPV of 99.5%. Also, the recommendations for bone scan miss a marginal number of patients with established bone metastases (0.14%) and yield a virtually perfect NPV of 99.8%.

Highlights

Clinical staging in the context of prostate cancer (PCa) is important.[1]
We hypothesised that the use of the National Comprehensive Cancer Network (NCCN) guidelines will not result in more than a marginal proportion of patients with missed locoregional lymph node metastases (LNM) or missed bone metastases
The positive and negative likelihood ratios with the use of the Briganti vs. the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram were similar, 3.89 and 0.24 vs. 3.41 and 0.18, respectively. These results demonstrate an acceptable confidence for both nomograms regarding the NCCN recommendations to perform a pelvic computed tomography scan (CT)/magnetic resonance imaging (MRI)

Summary

Introduction

Clinical staging in the context of prostate cancer (PCa) is important.[1]. Treatment of individuals with locally advanced or metastatic PCa differs from that for individuals with localised PCa.The distinction between localised PCa vs. locoregional lymph node metastatic PCa and PCa metastatic to bone can be made using the recommendations of the National ComprehensiveCancer Network (NCCN), as outlined in the clinical practice guidelines in oncology.[2]for staging of patients with suspected locoregional lymph node metastases (LNM) the NCCN PCa guideline (Version2.2017) recommends a pelvic computed tomography scan (CT) or pelvic magnetic resonance imaging (MRI) if clinical tumour stage isT3 or T4 or in clinical tumour stage T1 or T2 when nomogram derived LNM probability is >10%.2for staging of patients with suspected bone metastases, the NCCN PCa guideline recommends a bone scan in clinical tumour stage T1 patients when prostatic specific antigen value (PSA) is >20 ng/ml or if clinical tumour stage is T2 when PSA is >10 ng/ml or if clinical tumour stage is T3 or T4 or if Gleason score is ≥8 or if patients are symptomatic.[2]to the best of our knowledge these recommendations have never been validated in a community setting within a large epidemiological database, such as the Surveillance, Epidemiology, and End Results (SEER) database. For staging of patients with suspected locoregional lymph node metastases (LNM) the NCCN PCa guideline We tested the performance characteristics of the NCCN guidelines regarding presence of locoregional LNM, as well as regarding presence of bone metastases. We hypothesised that the use of the NCCN guidelines will not result in more than a marginal proportion of patients with missed locoregional LNM or missed bone metastases. The National Comprehensive Cancer Network (NCCN) guidelines provide recommendations for staging of prostate cancer patients in the objective regarding presence of locoregional lymph node metastases (LNM) and bone metastases. 197,408 patients were assessable for the validation of bone scan recommendations These recommendations resulted in 90.8% sensitivity, 76.3% specificity, PPV of 5.7%, NPV of 99.8% and overall accuracy of 76.5%. The recommendations for bone scan miss a marginal number of patients with established bone metastases (0.14%) and yield a virtually perfect NPV of 99.8%

Results

Discussion

Conclusion