EAU 2018: Clinical Data and Imaging are Doing the Job

Copenhagen, Denmark (UroToday.com) Dr. Bangma, Rotterdam, Netherlands,  introduced this section of the plenary session. The focus of this debate was on the role of genomic testing in the setting of active surveillance. With current series demonstrating an approximately 25-40% transition to active treatment in the AS population, Dr. Bangma questions whether current clinical + imaging paradigms are sufficient. The two debaters are Dr. Cooperberg (San Francisco, USA), arguing that genomic screening should be done, and Dr. Rouviere (Lyon, France), arguing that clinical + imaging are doing the job.

Presentation: Dr. Rouviere provided a nice argument for the continued use of MRI and imaging, and they are doing a good job selecting patients for treatment. However, he made sure to not argue to MRI in lieu of prostate biopsies.

Long-term adherence to AS protocols requires trust (between physician and patient that aggressive tumor is not being missed) and protocols compatible with long-term follow-up (ie infrequent biopsies). 

1. Can mpMRI improve patient selection for AS?

- Schoots I, Curr Opin Urol, 2017 – systematic review of 8 studies of mpMRI prior to confirmatory biopsy
- Re-classification rate on confirmatory biopsy was 32% - but 8% were only on targeted biopsy, while 11% were on systematic biopsy alone
- mpMRI and targeted biopsy cannot be exluded: account for 24% increased detection of higher grade cancer
- but, systematic biopsy was doing pretty well by itself!
- 2018 EAU guidelines: perform mpMRI prior to systematic +/- targeted confirmatory biopsy (Strong recommendation)

2. Can mpMRI improve detection of clinically significant PCa during AS follow-up?

- Schoots I, Curr Opin Urol, 2017 – systematic review of 3 studies of mpMRI at the start of AS and before each follow-up biopsy. 
- Progression at mpMRI was associated with 35-70% upgrading on following biopsy
- Stable disease on mpMRI was still associated with 16-32% upgrading on following biopsy!

Unfortunately, this just means mpMRI has low specificity but high sensitivity. Better definitions of mpMRI progression are needed.

3. Combining mpMRI and clinical data?

-  Clinical data and mpMRI provide independent information, so they can complement each other
- Nassiri JUrol 2017
- 206 men on AS after fusion biopsy
- On MV analysis, the only predictors of progression were Grade group 2 at the time of diagnosis, PSA density >= 0.15, and MRI PIRADS 5
- University of Lyon cohort – 365 patients on AS
- PSA density + MRI exceeded MRI alone in terms of improving specificity and sensitivity
- Adding MRI to clinical data provides better initial staging

Conclusions:

1. Obvious benefit prior to confirmatory biopsy, as patient is being evaluated for AS. Hence, strongly recommend prior to a systematic+targeted confirmatory biopsy
2. However, the role of mpMRI in AS follow-up is less clear. For now, a negative mpMRI does not exclude progression of disease. 



Presented by: O. Rouviere, Lyon, France


Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark
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