So Armando, thanks so much for joining us on UroToday today.
Armando Juliao: It's my pleasure and honor, Zach.
Zachary Klaassen: So just give us a high-level view of the topics and why this was a really big session at SCU looking at prostate cancer.
Armando Juliao: Actually, just to give you a little bit of history, it's a course that we have been hosted with a co-op of the AUA and it used to be a highlights course.
Zachary Klaassen: Excellent.
Armando Juliao: And then this year we did a little bit of a shift and trying to make the course, I mean, not like a standard prostate cancer course, but making it a little bit more practical in very novel topics and having all the road trip between screening, diagnosis, risk stratification. Then deciding when to treat how to treat. And then a topic around surgical area behind the extended length of the dissection. That was about all the road that we took yesterday.
Zachary Klaassen: Yeah, it was awesome. I mean, looking at the Congress and looking at those topics, really as you said, just a real broad spectrum.
Armando Juliao: Yes.
Zachary Klaassen: Couple of interesting topics just to get your take on. You had a bunch of clinical cases, challenging cases for when PSMA PET should be used. What was sort of the take home messages from those cases talking about PSMA PET?
Armando Juliao: Actually as I said yesterday, we have had this storm of usage of PSMA. That's why I labeled it PSMA PET 2024/2025 Uses and Misuses. And what we have had is that many urologists, once they make diagnosis, even though guidelines established in a very concrete way when to do a stratification imaging, here in the country we have had this blast of usage of PSMA. And in many times the PSMA or none of the conventional imagery are needed, we have had misusage and that shifts the treatment many times to wrong areas, or maybe over diagnosis in the imaging part and there has been a problem to us. So yesterday we tried to, with those cases, trying to establish when to use it and how to interpret the results.
Zachary Klaassen: Yeah, I think that's great. I mean, you just look at the conventional imaging trials, interpreting conventional imaging data in the PSMA PET area, lots of stage migration. And I think that there's targeted therapy we can do, but there's also stage migration where we're maybe not moving the endpoints even though we're picking the disease up earlier. Would you say that's fair?
Armando Juliao: Yes. But then going back to localized disease and low risk, very low risk, intermediate favorable, intermediate unfavorable, when to use a PET and how to interpret it and how will it change your management?
Zachary Klaassen: That's right.
Armando Juliao: Here, Zach, urologists are using PET many times in low risk and favorable intermediate risk, which is not indicated.
Zachary Klaassen: That's right.
Armando Juliao: And many times these PETs have to be integrated in the clinical scenario of that specific patient.
So the idea yesterday was to give the audience exactly when to use it, give an interpretation, and try to integrate that into the clinical scenario that they are actually looking at this specific patient. So going back again, I think that PET, once you use it correctly in the staging, the primary staging of the disease works very good when you use it in the correct area.
And then actually you remember with Dr. Secin from Cleveland, using it in the biochemical recurrence moment gives you another spectrum of when to do the salvage radiotherapy.
Zachary Klaassen: Absolutely. I think good teaching point for our listeners, NCCN really states unfavorable in intermediate risk of higher, and I think that's an important teaching point.
Armando Juliao: And that has to be, I think that the key point to take home is that. Do not use it in low-grade or favorable intermediate.
Zachary Klaassen: Yeah. Well said.
Let's switch topics to pelvic lymphadenectomy. Always a hot topic no matter whether we're in Europe or in the US or we're in South America. Let's break it into two points. Talk about why we do it, what's the evidence for it? And what's the evidence for extended versus, say, standard template lymph node dissection.
Armando Juliao: Okay. If you go to the NCCN guidelines, actually I think it's you, I think guidelines sometimes it might be like what we call in Spanish [Spanish 00:05:08] or I don't know how you say it in English or a forced shirt. And it says that you do not need to use it unless you have a nomogram that states that you might have between four and 7% risk of having a lymph node positive. And I think PET has also come there and give us lessons to try, and I would say do the extended pelvic node dissection in a more intelligent way.
So having said that, I think that once you decide that you're going to do a pelvic lymph node dissection, do it extended. Having explained the patient that it could be a morbid procedure, that it would raise the costs of the to the payer, to the insurance to the hospital, and that the patient is not unlikely to have some morbidity that can go up to 10%, including lymphoceles that may need some treatment, some vascular lesions that sometimes can occur and some kind of neuropraxia with the obturator nerve.
And I think that the paper from Memorial from Karim Touijer brought us also teaching lessons that we're waiting for some info and maybe some time to see if the benefit of having less biochemical recurrence with the extended can lead us to OS, an extended OS overall survival. I don't know if I answered the question.
Zachary Klaassen: It's perfect. No, I think too, I think we just pivoted from PSMA PET to lymph node dissection, but I think it ties together nicely. I think in a perfect world, maybe we'll get there one day with the sensitivity of imaging where we can eliminate lymph node dissection. Knowing how good our imaging is, I don't think clearly right now we have that. But certainly with copper and maybe some other agents, maybe we'll get there one day. What are your thoughts?
Armando Juliao: My thoughts as right now until we have our nuclear medical partners getting to understand better the physiology of the tracer that they're using, because in nodes it's very different if you use F18 or gallium, that's where they can have some errors in the interpretation of the PET. So once I think they learn to interpret better the PET, maybe we can have those negative predictive value go to the upper part, and maybe we can get to that point where we can avoid the lymph node dissection. But when the lymph node dissection is indicated, if you use a normogram and it gives you a percentage that you need to do the lymph node, even though the PET is negative, you need to do the extended lymph node dissection.
Zachary Klaassen: That's right. Well said.
It's been a great conversation. Anything we haven't hit on that you want to talk about? Any take home messages?
Armando Juliao: Yes. I think that there is a very good take home messages. I think prostate cancer in each of the moments of the road, if you do not embrace a multidisciplinary approach, you will not get to the end point of the road. And I think that's a very good message for the international community. Even though in screening you can do it with the general practitioner, but you need to embrace other tools, then need certification, you need the nuclear medical guys, you need the radiologists. AI I think it's going to bring us a lot of info. And then biochemical recurrence, our radiologists, our nuclear medical partners. So you have to integrate everyone in each of the moments of that road trip of prostate cancer.
Zachary Klaassen: It really is a multidisciplinary disease space from the beginning to the end. And I think ultimately for better outcomes for our patients.
Armando Juliao: But Zach, we as urologists, and I'm maybe a little bit older than you, but we used to think that we knew everything so we used to handle prostate cancer from the beginning of the road until the end. Is that not the case right now? And I think that the message for the international urologic community is that.
Zachary Klaassen: Absolutely.
Armando Juliao: We do not know all the way. We do not have one car to get through the road.
Zachary Klaassen: That's right.
Armando Juliao: You need more cars. You need different cars to get to the end of the road.
Zachary Klaassen: Yeah. Well said.
Armando, thanks for taking time out of the busy Congress to joining us. It's been a delight on behalf of UroToday to be here. The SCU has been so welcoming. Thank you for joining us.
Armando Juliao: Thanks. Thank you very much.