The Future of Advanced Prostate Cancer Imaging Presentation - Stefano Fanti
September 17, 2019
Stefano Fanti, MD, Professor, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Director of Nuclear Medicine Division of the PET Unit, Director of Speciality School of Nuclear Medicine, University of Bologna, Bologna, Italy.
Stefano Fanti: Let me get this opportunity to thank again the organizer because of the beautiful, incredible event, but also for another reason that possibly would be shown by my slides. This opportunity to networking is so important, the opportunity to meet friend, to meet colleagues, and exchange very important information, plan some future studies and having any future, let's say, information about my presentation. My first topic is about the future. Can we predict if those lights are going to start or not? That's almost impossible. Well, I can introduce to you ... You want to move to the next one or you want to keep on going like that? Keep going like that. Funny. I was suspecting that. I'm a good clinician. I got clues that there may be a technical problem.
Very well done. Well, that was an example of the networking that we got last night. We were avidly discussing the need of randomization, and that's a mantra that will come out, randomize and randomize, and that will come back again. But honestly thanks to the images right now, I will nonetheless disappoint you because I will not talk that much about fancy images, super technological approaches. It would really be disappointing and I will talk not about the future but rather about the present. Because honestly for what about imaging we keep on using at present all the fashion and the approaches which are transrectal ultrasound, CT, and bone scanning. We are not fully using what is already present today which is MRI and PET and that's my main problem. I wrote about that and with the help of Anwar R. Padhani, a great friend and other colleagues that again are here.
We already covered this topic many times and you can refer to this paper in case which is very simple. What are we doing today? We keep on using conventional imaging with CT and bone scanning that are very well known to have incredibly limited sensitivity to the big nodal and bone disease. To see what's important in prostate cancer management. Next-generation imaging, come on, stop talking about next-generation imaging. It's current generation imaging. They should be used, widely used, including MRI and PET. That's the key point because the sooner you demonstrate that there is a lesion, the sooner you can make a decision. It cannot be, let's say none that relevant to see a lesion. The decision is based on full information. Not having the information is a problem, not handling the information. That's an example of the incredible literature that you have about CT.
If it goes to CT, you can see that the literature around is incredibly old. You all show publication in the year 2000. That's 30 and more years, and a number of patients completely ridiculous with scattered data on sensitivity. Well nonetheless, CT is on the list of recommendation of any guideline, and that's even worse for bone scintigraphy. The sensitivity of bone scintigraphy is absolutely ridiculous. So there would be no way to have them at present incorporated into the guidelines. Well, which is the point.
What we hear is if you want to incorporate the next generation imaging, you have to prove that there is an impact on the outcome of the patient. It's really a mantra that I keep on hearing. Clinical benefit. You have to show the clinical benefits. Show me the clinical benefit, randomize, randomize. That's an effect of the pyramid of ABM. When the HDA came on the scene, then it gets this pyramid that everybody knows. Evidence is there. Now please be aware the pyramid of ABM is not that pyramid of God, it's not the eye of God. There's life beyond ABM and beyond the HDA, believe it or not. I tried to get some practical information. What's nowaday the present and the future of imaging? Well for diagnosis, finally we had multiparametric MRI incorporated last year into the EAU guideline at least. So again, the future is the present. Before doing a biopsy, do multiparametric MRI.
But I wonder is that state of the art for everybody in this room? Well, that's an example again from Anwar in London. Beautiful example, multiparametric MRI will perfectly drive you where the best specimen can be taken. For staging, staging high-risk patient, I already showed this case, you will have 12% of the cases with distant [inaudible 00:04:54] in high-risk patients that are not suspected. That makes a clear difference in the management of the patient. That's with PET PSMA. That's an example gentlemen presentation, you can say such spread make a difference in the management of the patients.
Maybe the mantra is back: randomize, randomize. There are something like 27 studies ongoing about PSMA staging and possibly in the next future, so in two years, we will be back with some data to demonstrate that. But the need to demonstrate that honestly, it's a little bit frustrating. Biochemical recurrence, again, it's already there. PSMA PET is already finally incorporated into the EAU guideline, and everybody knows that such cases, identifying two small nodes here, you can probably do that only with PSMA PET. Then the way you use it, it's honestly your key business, but not being aware that those two nodes are positive and thus are very likely met. It's much less important than don't perform the exam.
Planning radiotherapy is also very important of course and again, good news. That's an example. I already showed that yesterday. Patient is scheduled for salvage radiation therapy, which of course is not the candidate or that or at least not for only that approach. The good news is we have 11 ongoing trials on PSMA PET in the setting of radiotherapy planning. Therapy monitoring, Anwar is back, he is not alive, probably is there. Don't use PET for that. It doesn't make a lot of sense to consider PET as the main approach. It's the domain of whole-body MRI. If you want to monitor, in case you feel the need to monitor the successfulness use of one drug or the other, then PET MRI is there.
Ready for the conclusion? Again, no bell before the conclusion. I'm very happy. These are the beautiful images that we can get. It's amazing our PET, in this case, can see inside your body noninvasively. It's truly something unbelievable. You can see the bone, you can see the node, you can see whatever. Now you may ask me, you're talking about PET, you're talking about MRI. So the future is really now just put them together, make a hybrid tomograph and you will have the future. Well, indeed the PET MRI tomograph is already available in something like four to five years. By producing amazing images, and that's an example, you can see where the disease is, you can get all the information. Apparently, I could have solved it, all the question, with one slide only.
Well, honestly, I'm a fan of Star Trek. About the scanning in Star Trek, that's the dream of the future. How should be the scanner of the future? It should be small, easy to use, reproducible, cheap, patient-friendly. PET MRI is nothing about that because it's patient unfriendly. Every exam is very long. It's absolutely known to be not cost-effective. It's poorly reproducible and is super, super expensive. I'm very skeptic that the answer is there.
The answer to me is in very, very basic three principles, the real ABC of next-generation imaging. That's please, please abandon the obsolete imaging approaches. Stop prescribing bone scanning and CT to every single patient every six months because it doesn't make any sense at all honestly. Be aware of the capabilities and the limit of next-generation imaging. If you want to study just the look of recurrency, you have multiparametric MRI, you don't need PSMA PET, but if you want to study biochemical recurrence, you can not get that information for an MRI. Please use it in the current setting every next-generation imaging or current generation imaging. When you have to consider, don't scan the patient just for scanning. You don't need to refer the patients to me if there's no need. When is the need? When the patient management has to be changed, or when you have the plan to change the approach to your patient. Then it makes sense. That's super easy. It's already there.
Well, the time is now. The future is already here. Thank you.