Timo Soeterik

173 General Discussion and Future Perspectives nomograms incorporating ISUP grade as a predictor can be established. The latter was confirmed by a literature review of Dell’Oglio and colleagues. 21 The authors provided an overview of several studies confirming that MRI and MRI-guided target biopsy information improve prostate cancer risk calculators developed for the prediction of pathological outcomes after surgery (EPE, SVI and LNI) and the risk of biochemical recurrence after radical prostatectomy. 21 These findings were confirmed in a recent study by Gandaglia and colleagues, showing that novel MRI-based pre-operative tools improved the prediction of unfavourable pathological outcomes (EPE and seminal vesicle invasion), in terms of model discrimination. 22 In addition, the same study group proposed a novel nomogram for the prediction of LNI, based on MRI target biopsy and MRI information. In their development study, they observed substantial higher model accuracy compared with conventional MRI-naive LNI prediction tools. 23 The latter was confirmed in an additional external validation study, showing that use of the mpMRI and mpMRI target biopsy based nomogram resulted in the highest AUC compared to the 2012 and 2017 Briganti nomograms and the MSKCC 2018 pre-radical prostatectomy nomogram (79% vs. 75% vs. 65% vs. 74%). 24 Another novel nomogram including MRI information for prediction of LNI was developed bij Draulans and colleagues. 25 This nomogram also showed favourable characteristics on internal validation (AUC 0.80), and acceptable characteristics on external validation (AUC: 0.73). 25 Main advantage of this nomogram is it can be used independently of biopsy technique, since the nomogram does not include MRI target or systematic biopsy specific variables. It can be expected that the number of mpMRI-based nomograms for the prediction of prostate cancer treatment outcomes and pathological features will continue to grow. The most important question that future studies should attempt to answer in this context is whether use of these improved pre-treatment tools also leads to better clinical and patient-reported outcomes. PSMA PET-CT Imaging Rapid evolvements currently ongoing in the field of prostate membrane specific positron emission computer tomography (PSMA PET-CT) are promising, and are expected to greatly impact prostate cancer staging. In a study by Hofman and colleagues, PSMA PET-CT outperformed conventional imaging (CT and bone scan) with regard to detection of metastasis at initial prostate cancer staging. 26 The use of PSMA PET-CT in high-risk patients led to 27% greater accuracy for the detection of pelvic nodal or distant metastatic disease compared with CT and bone scan. 26 PSMA PET-CT also resulted in significant higher rates in change of management (23% vs. 7%). 26 Unarguably, adoption of PSMA PET-CT and standard implementation within the diagnostic pathway will result in stage migration of the general patient population; especially those classified with high-risk disease. Given the widespread adoption of PSMA PET-CT, it is to be awaited if nomograms predicting the probability of LNI remain relevant for clinical practice. For instance, in case PSMA PET-CT shows pelvic 10