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ESOU 2019

ESOU 2019: Diagnosis, Biopsy, and Staging of Prostate Cancer

Prague, Czech Republic (UroToday.com) Dr. Steven Joniau gave the first talk for the course, setting the stage with the diagnosis, biopsy, and staging of prostate cancer. This was an extensive talk but set the stage very well. I highlight the key points from the talk below, but the talk itself was quite comprehensive.

First, the two cornerstones of prostate cancer diagnosis still remain the PSA test and the digital rectal exam (DRE).

  • PSA is a continuous variable and the historical cutoff of “4” is no longer applicable. He made it very clear that there is no “normal”. Data from the control arm of the PCPT study (Thompson IM et al. NEJM 2004) highlighted the fact that even men with PSA < 4 can have significant rates of prostate cancer and clinically significant prostate cancer. 27% of prostate cancers have PSA between 3-4 and 7% have PSA <0.5. 7% of men with PSA between 3-4 have clinically significant prostate cancer, but luckily, with a PSA < 1, that number drops to <1%.
  • DRE is a cheap and easy test, and still has value. In men with PSA < 2, an abnormal DRE may indicate cancer in 5-30% of cases. And an abnormal DRE is indicative of higher Gleason score prostate cancer.
However, the main issues with a prostate cancer diagnosis are the overdiagnosis of clinically insignificant prostate cancer and lack of test with good sensitivity for just clinically significant prostate cancer (csPCa). There are several helpful tools developed that improve our detection of csPCa, including PHI, 4K score, urine biomarkers, clinical nomograms (ERSPC and PCPT) and mpMRI. He chose to focus on the mpMRI for the next few slides, due to the recent publication of some major trial data.

The current EAU guidelines recommend mpMRI prior to repeating biopsy when clinical suspicion of prostate cancer persists despite negative biopsies. However, based on the strength of recent data, those are likely to change later this year to getting a mpMRI prior to initial biopsy. However, he makes a point to note that it will replace biopsy and systematic cores are still recommended. The studies he cited are the PROMIS study (Ahmed et al Lancet 2017), PRECISION study (Kasivisvanathan et al. NEJM 2018), and MRI-FIRST (Rouviere et al. Lancet Oncology 2019). The last study highlighted the importance of doing both systematic and targeted biopsies. The drawbacks of mpMRI, as have been cited by others, is the variability in reading mpMRI, even in experienced centers. He cited a more recent systematic review by Moldovan et al. which was the first to show that that PPV of mpMRI targeted biopsies is dependent on the population – those with a higher prevalence of PCa will have a higher PPV. While intuitive, this was the first study to demonstrate that! Based on this data, he recommends the following: in men with positive mpMRI, do a targeted and systematic biopsy; in men with negative mpMRI, use risk calculators to determine who is high risk for prostate cancer and make a decision with the patient regarding the need for biopsy.

If you do a targeted biopsy, the yield increased with additional cores. Kenigsburg et al. (EU Oncology) demonstrated that a single core has a yield of 77%, but the 2nd core adds ~11% diagnostic ability, and the 3rd and 4th cores 6% and 5%, respectively. So, all concerning lesions should get 2 cores minimum (~90% diagnostic ability), but 3-4 cores would be best.

Moving past diagnosis, he focused the rest of the talk on prostate cancer staging. Prostate cancer management has long been driven by risk classification (low-risk, intermediate risk and high risk, primarily driven by histologic grade). If useful, it would probably be useful for high-risk patients to rule out nodal or metastatic disease.

  • T-stage
    • mpMRI for local staging has poor sensitivity, but good specificity. So, if it does identify extracapsular extension (ECE, cT3a) or SV invasion (cT3b), it is real. However, if not seen, cannot safely rule it out.
    • mpMRI prior to RP for surgical planning was NOT associated with reduction in positive surgical margin rates
  • N-stage
    • CT and MRI have poor sensitivity for nodal disease (~0.40-0.50) and moderate specificity (~0.80)
    • Briganti nomogram (including mpMRI data now) is superior to CT imaging and Partin table to predicting LN involvement at the time of RP
    • PSMA PET imaging has promise but cost-effectiveness and tracer availability must be taken into account. Too early to recommend this at this time. Sensivity and specificity better than traditional imaging.
  • M-stage
    • Bone scan remains the most widely used method for assessing bone mets
      • Sensitivity ranges from 60-80%, and specificity 75-85%
    • Early results from PSMA PET staging studies suggest that it does pick-up more lesions that traditional imaging – but unclear what the clinical impact of this is and whether or not management should change based on these findings.
There is a lot of work to do – specifically, one main unmet need is a well-designed trial to assess the management and outcomes of patients whose metastases are detected by a test rather than by another in order to provide strong evidence to suggest one staging pathway over another.

Presented by: Steven Joniau, MD, Ph.D., Department of Urology, Development and Regeneration, Universitair Ziekenhuis, Leuven, Belgium

Written by: Thenappan Chandrasekar, MD. Clinical Instructor, Thomas Jefferson University, Twitter: @tchandra_uromd, @TjuUrology, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic