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External validation of nomograms for predicting pelvic lymph-node metastases in prostate cancer and evaluating the added value of the PSMA PET-based PRIMARY score. The authors commend rigorous inclusion criteria, standardized PSMA PET protocol, and experienced pathological assessment, and note concordance with superior diagnostic performance of the Amsterdam-Brisbane-Sydney nomogram. They also discuss verification bias, overlapping AUC improvement, and emphasize translational relevance of intraprostatic PSMA uptake patterns. They conclude by encouraging prospective multicenter studies with centralized imaging review.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/external-validation-of-nomograms-for-predicting-pelvic-lymph-node-metastases-in-prostate-cancer-letter-to-the-editor/433028/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/external-validation-of-nomograms-for-predicting-pelvic-lymph-node-metastases-in-prostate-cancer-letter-to-the-editor/433028.png","ImageObject",300,407,{"name":92,"@type":93},"Mafia Boss","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-05","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the main purpose of this letter to the editor?","Question",{"text":112,"@type":113},"It provides a critical but supportive response to the external validation study assessing nomograms and the added value of the PSMA PET-based PRIMARY score for pelvic lymph-node metastases prediction in prostate cancer.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"Which methodological factors does the letter commend?",{"text":117,"@type":113},"The authors commend rigorous inclusion criteria, a standardized PSMA PET protocol, and detailed pathological evaluation by experienced uropathologists.",{"name":119,"@type":110,"acceptedAnswer":120},"What concerns does the letter raise about incorporating PSMA PET results into decision-making?",{"text":121,"@type":113},"It highlights potential verification bias, since patients with positive PET findings are more likely to undergo extensive lymph-node dissection, increasing the chance of detecting pN1 disease.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},433028,1790860197,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":81,"preview_page_count":4},962090760730,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","EUROPEAN U ROLOGY OPEN SCIENCE 8 3 ( 2 0 26 ) 1 19  \navailable [at www.sciencedirect.com](at www.sciencedirect.com)  \njournal [homepage: www.eu-openscience.europeanurology. com](homepage: www.eu-openscience.europeanurology. com)  \nLetter to the Editor  \nRe: Muhammet Demirbilek, Göktu˘g Kalender, Said Bıyıkoglu, et al. External Validation of Nomograms for Predicting Pelvic Lymph Node Metastases in Patients with Prostate Cancer and the Added Value of the Prostatespecific Membrane Antigen Positron Emission Tomography–based PRIMARY Score. Eur Urol Open Sci 2025;82:170–7  \nWe read with great interest the article by Demirbilek et al [1] on their external validation of nomograms for predicting pelvic lymph-node metastases and assessment of the added value of the prostate-specific membrane antigen (PSMA) positron emission tomography (PET)-based PRIMARY score. Their findings provide meaningful contributions to the ongoing refinement of preoperative lymph-node staging in prostate cancer.  \nFrom a methodological perspective, we commend the authors for their rigorous inclusion criteria, standardized PSMA PET protocol, and detailed pathological evaluation by experienced uropathologists. Their confirmation of the superior diagnostic performance of the Amsterdam-Brisbane-Sydney nomogram (area under the receiver operating characteristic curve [AUC] 0.862) aligns with emerging evidence supporting PSMA-informed staging tools in contemporary clinical practice [2].  \nNonetheless, several methodological considerations merit discussion. The incorporation of PSMA PET findings into clinical decision-making may introduce verification bias: as patients with positive PET findings are more likely to undergo extensivelymph-node dissection, the likelihood ofidentifying pN1 disease in this group inherently increases [3]. The marginal improvement in AUC after adding the PRIMARY score (0.870 vs 0.862) showed overlapping confidence intervals, which emphasizes the need for larger prospective trials to confirm true clinical significance beyond statistical refinement.  \nFrom a translational standpoint, the study highlights the biological relevance of intraprostatic PSMA uptake patterns. Higher PRIMARY scores for pN1cases are consistent with prior evidence linking PSMA expression to tumor aggressiveness, alterations in androgen-receptor signaling genes, stromalepithelial interactions, and hypoxia-driven PSMA upregulation [4,5]. Such biological insights support the integration of intraprostatic PSMA metrics (maximum and mean standardized uptakevalues, PRIMARY score)into decision-makingtools for a more molecularly grounded approach to nodal staging.  \nIn conclusion, the study by Demirbilek et al [1] represents an important contribution to the evolving landscape  \nof PSMA-based prostate cancer staging. We encourage future prospective multicenter studies with centralized imaging review to better define the clinical impact of PRIMARY-integrated nomograms on surgical decision-making and long-term oncological outcomes.  \nConflict of interest: The authors have nothing to disclose.  \nReferences  \n[1] Demirbilek M, Kalender G, Bıyıkoglu S, et al. External validation of nomograms for predicting pelvic lymph node metastases in patients with prostate cancer and the added value of the prostate-specific membrane antigen positron emission tomography–based PRIMARY score. Eur Urol Open Sci 2025;82:170–7. [https://doi.org/10.1016/j](https://doi.org/10.1016/j). euros.2025.10.020.  \n[2] Vis AN, Meijer D, Roberts MJ, et al. Development and external validation of a novel nomogram to predict the probability of pelvic lymph-node metastases in prostate cancer patients using magnetic resonance imaging and molecular imaging with prostate-specific membrane antigen positron emission tomography. Eur Urol Oncol 2023;6:553–63. [https://doi.org/10.1016/j.euo.2023.03.010](https://doi.org/10.1016/j.euo.2023.03.010) .  \n[3] Emmett LM, Papa N, Buteau J, et al. The PRIMARY score: using intraprostatic PSMA PET/CT patte","cbCaioZt4BWkBj2c","https://ap.wps.com/l/cbCaioZt4BWkBj2c","pdf",246654,"English","# Letter to the Editor\n## Response and assessment of findings\n## Methodological considerations\n## Translational relevance\n## Conclusion and future directions\n## Conflict of interest and references","[{\"question\":\"What is the main purpose of this letter to the editor?\",\"answer\":\"It provides a critical but supportive response to the external validation study assessing nomograms and the added value of the PSMA PET-based PRIMARY score for pelvic lymph-node metastases prediction in prostate cancer.\"},{\"question\":\"Which methodological factors does the letter commend?\",\"answer\":\"The authors commend rigorous inclusion criteria, a standardized PSMA PET protocol, and detailed pathological evaluation by experienced uropathologists.\"},{\"question\":\"What concerns does the letter raise about incorporating PSMA PET results into decision-making?\",\"answer\":\"It highlights potential verification bias, since patients with positive PET findings are more likely to undergo extensive lymph-node dissection, increasing the chance of detecting pN1 disease.\"}]","External Validation of Nomograms for Predicting Pelvic Lymph Node Metastases in Prostate Cancer - Letter to the Editor | PDF",1790662406]