Prof. Bedke stated, “Overall survival (OS) and disease-free survival (DFS) can be prolonged with this neoadjuvant approach. Furthermore, in terms of drugs, immunotherapy combinations seem to be very favourable. However, we can only use what is approved or what is available in the metastatic setting, where we have data on efficacy. The NESCIO trial which demonstrated the efficacy of nivolumab + ipilimumab combination.”

According to Prof. Bedke when discussing surrogate markers, “Imaging such as a conventional CT scan is poor with no good correlation.” In terms of pathology, its importance in the definition of pathological complete response (pCR) or nearly pCR of less than 10% viable tumour cells; and to assess and correlate them. In addition, he pointed out that a biomarker of molecular disease is missing.

During his presentation, he also discussed trials such as aforementioned NESCIO, NIAGARA, IMvigor011, and KEYNOTE-905.

(Re)watch his presentation on the EMUC25 Resource Centre.

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Grounds for RCC screening

“RCC screening is a topic of great interest to patients, clinicians, and policymakers. Fascinating data will come from the Yorkshire Kidney Screening Trial (YKST),” stated urologist Prof. Grant Stewart (GB) during his presentation “Rationale for renal cell carcinoma screening”.

A sub-study of the Yorkshire Lung Screening Trial, the YKST is a targeted screening of high-risk individuals already attending for another screen test. The recruitment of 4,000 participants was completed in October 2022 and the six-month outcome review came out in May 2023. In January 2024, the report will be published.

Prof. Stewart referred to the Wilson and Jungner/WHO screening criteria, which often represent the de facto starting point for screening decisions today. The criteria comprised 10 principles and Prof. Stewart correlated each principle with the current data available for kidney cancer:

1. The condition sought should be an important health problem
   “In the UK, kidney cancer is the 7th most common cancer wherein 50% of patients die. An increase in the disease’s incidence in the next 10 years is predicted.”
2. Facilities for diagnosis and treatment should be available.
   “There are well-established diagnostic and treatment pathways.”
3. There should be an accepted treatment for patients with recognised disease.
   “The range of options for patients include surgery, ablation, and active surveillance.”
4. There should be a latent or early symptomatic stage.
   “Yes, there is when it comes to small renal cancer but the vast majority is asymptomatic. This is why we need a way of identification.”
5. The natural history of the condition, including the development from latent to declared disease, should be adequately understood.
   “Yes, it is partially as all lethal RCCs start as small cancers. However, currently, it cannot be predicted which small renal cancers will progress.”
6. There should be a suitable test or examination.
   “Yes, ultrasound or LDCT (low-dose nonenhanced computed tomography) is used.”
7. The test should be acceptable to the population.
   “There is apparent patient accessibility.” Prof. Stewart presented the findings of an online survey concerning public attitudes toward screening for kidney cancer regarding the five screening modalities: urine, blood, ultrasound, kidney computed tomography (CT), combined kidney and lung CT. The majority have opted for the combined kidney and lung CT.
8. There should be an agreed policy on whom to treat patients.
   “Yes, there is with all renal mass patients but not necessarily with Sx/TA.”
9. The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.
   “It is theoretically proven for surgery to be more economical when compared to drugs.”
10. Case-finding should be a continuing process and not a “once and for all” project.
    “This is still unknown. Is repeated screening economically viable?”

Interception to prevent urothelial cancer

During the presentation “Large-scale interception using personalised prevention algorithms – an opportunity for urothelial cancer screening”, medical oncologist, Asst. Prof. Ronan Flippot (FR), stated that urothelial cancer is the 6th most common cancer type wherein 25% to 30% is muscle-invasive presentation, and a five-year survival rate (i.e. 70% localised, 40% regional and <10% distant). The disease affects the ageing population (the median age of onset is 75 years) and frail comorbid patients.

According to Prof. Flippot, a large-scale interception programme has the potential to improve bladder cancer screening. Adherence of patients and ambulatory care professionals, and funding are paramount. He underscored that an interception programme can be significant for prospective screening trials and interventional strategies evaluation in multiple-risk settings. Furthermore, the constitution of biobanks will bring value to molecular detection programmes.

To learn more, access the full presentations of Plenary Session 1 through the EMUC23 Resource Centre.

The post EMUC23: What’s new in GU screening? appeared first on EMUC25.

Collaborative efforts are required to drive game-changing advancements in medical research and patient care. The upcoming 15^th European Multidisciplinary Congress on Urological Cancers (EMUC23) is the perfect platform to showcase and review important GU cancer trial results and new technologies.

Plenary Session 7 on day three (Saturday, 4 November, 08:45 – 10:05) of EMUC23 will feature clinical trial presentations and multidisciplinary discussions. This “Game-changing session” will be chaired by Prof. Axel Merseburger (DE), radiotherapist Prof. Valerie Fonteyne (BE) and medical oncologist Prof. Karim Fizazi (FR).

Merseburger: “Multidisciplinary meetings in onco-urology play a pivotal role in fostering collaboration among various medical specialists dedicated to the care of GU cancer patients. The EMUC Congress excels in bringing together experts from diverse fields such as medical oncology, radiation oncology, surgical oncology, pathology, nuclear medicine, urology, and radiology. This inclusive approach cannot be overstated, as it facilitates a comprehensive and holistic evaluation of complex cases and clinical trial presentations”.

“Each specialist contributes unique insights based on their expertise, allowing for a thorough analysis of treatment options and potential challenges. This collaborative strategy helps prevent tunnel vision. It ensures that all available options, from surgery to radiation to systemic therapies and supportive care, are considered in the context of the patient’s overall well-being.”

GU cancer trials to be discussed at EMUC23

Urologist Prof. Maxine Tran (GB) will present on nephron sparing treatment (NEST) for small renal masses: A feasibility cohort-embedded randomised controlled trial (RCT) comparing percutaneous cryoablation (passing small needles through the skin to freeze the kidney tumour) and robot-assisted partial nephrectomy. This RCT is of significant interest due to the lack of high-level evidence on small renal mass (SRM) management, with previous classical RCTs failing to meet accrual targets.

Prof. Stephen Freedland (US) will share the latest progress on the phase 3 EMBARK trial, whereby trial data has shown that adding enzalutamide to leuprolide cuts the risk of metastasis or death by 50% in patients.

Prof. Merseburger: “This is a hot topic right now as the FDA granted priority review of enzalutamide for nmCSPC with high-risk biochemical recurrence. The FDA decision is expected in Q4 of this year for the new drug application that has been supported by data from this phase 3 EMBARK trial. Discussion remains on the value of PSMA-PET in this situation.”

Medical oncologist Dr. Yohann Loriot (FR) will present details on the THOR study reinforcing the activity of erdafitinib as personalised therapy for metastatic urothelial patients with FGFR mutations. Erdafitinib is included in the current EAU bladder cancer guidelines. The THOR study leads to precision medicine in advanced bladder cancer for 3^rd line treatment for patients with EGFR alterations. All metastatic urothelial patients should be tested for FGFR3/2 alterations.

Other trial results that will be presented and discussed by the multidisciplinary panel include TALAPRO-2 and PROpel, as well as an update on PSMA targeting.

Uniting medical experts for innovation and progress

The EMUC23 congress is a collaboration of the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy and Oncology (ESTRO) and the European Association of Urology (EAU). Other sessions that will take place in conjunction with EMUC23 include the EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP), the Meeting of the EAU Section of Urological Imaging (ESUI), European School of Urology (ESU courses and Hands-on Training) and the Young Academic Urologists Meeting (YAU).

If you register by 19 October (23:59 CEST) you will benefit from some registration savings. Don’t miss your opportunity to participate within this collaborative learning environment! Browse the full scientific programme.

The post EMUC23: GU cancer game-changers for 2023 appeared first on EMUC25.

In her lecture “The new WHO classification of renal tumours”, Pathologist Dr. Maria Rosaria Raspollini (IT) shared an update on the 2022 classification changes, addressing the concept of molecularly defined renal tumour entities in particular. According to Dr. Raspollini, traditionally, renal tumour subtypes have been named on the basis of predominant cytoplasmic features (clear cells/pink cells RCC) and chromophobe RCC. Now there are renal tumour subtypes named on the basis of architectural features (papillae RCC).

Dr. Raspollini stated: “Clear cell RCC account for 60-75% of all RCC’s and are characterised by neoplastic cells with predominantly clear and occasionally eosinophilic cytoplasm, accompanied by an abundant network of blood vessels and associated with biallelic VHL inactivation. Chromophobe RCC accounts for 5-7% of cases and are characterised by large pale and/or smaller eosinophilic tumour cells with wrinkled nuclei and perinuclear haloes. The WHO 2022 papillary RCC is characterised by papillary and tubular structures lined by cuboidal cells with scant or lightly basophilic cytoplasm with an overall basophilic appearance. Foamy histiocytes and psammoma bodies may also be present.”

On the topic of new renal tumour entities, Dr. Raspollini stated that clear cell papillary renal cell carcinoma has been reclassified as clear papillary renal cell tumour, because there is not a described metastatic event. “These tumours are mainly pT1 well-circumscribed, encapsulated and cystic change can occur. Specific molecular pathological features that it lacked were chromosome 3p loss and alterations of VHL, as well as mutations in TSC1, TSC2, MTOR or ELOC (TCBE1).”

According to Dr. Raspollini, another new entity is Eosinophilic solid and cystic renal cell carcinoma (ESC-RCC). “These are typically well-circumscribed, tan, solid and cystic, with reported sizes ranging from <10 to 135mm. ESC-RCC is characterised by solid and cystic architecture, eosinophilic cytoplasm and coarsely granular, basophilic cytoplasmic stippling. The majority of ESC-RCC’s appear to have been cured by resection. Rare cases with metastases have been reported.”

Morphological and molecular reporting strategy

During his lecture “The new WHO classification of bladder tumours – why the morphology is important in the molecular age”, Prof. Antonio Lopez-Beltran (PT) shared details on non-invasive urothelial neoplasms, points of practice and novelties, including urothelial papilloma and inverted urothelial papilloma.

“The classification papillary urothelial hyperplasia has disappeared” stated Prof. Lopez-Beltran. “We should report cases even if the WHO does not recognise it”.

Prof. Lopez-Beltran questions the correctness of the newly classified urothelial carcinoma “subtypes”, which were previously “variants”. The term “variant” has been exclusively reserved for genomic alternations. In his opinion, they are genetic variations.

Looking at what lies ahead in the future, Prof. Lopez-Beltran voiced the proposal of a combined morphological and molecular reporting strategy.  “This is an evolving process from WHO in 1973 to WHO 2002/2016 to molecular subtyping using immunohistochemistry. Advantages of combined reports include providing the clinician with more information sooner, leading ultimately to a more personalised approach to current therapies.”

Prof. Lopez-Beltran ended his lecture with the comment “classifications are getting more difficult and more complicated, but we need to tell clinicians that we are going forward. We are driving towards a new time for pathology”.

The post What’s new in GU Pathology and WHO classification? appeared first on EMUC25.

Dr. Capitanio was upfront about his inexperience on the subject: “I am not a geriatrician but a urologist. Before preparing this presentation, I was not used to assessing the frailty of patients. This is my take, as a urologist, on why frailty is an important factor in RCC, and how it ought to impact our decision-making.”

A small audience survey revealed that a majority had some idea of the definition of frailty, but did not routinely assess the frailty of their patients. This made the talk all the more useful for the urologists and oncologists present.

Definition and implications for treatment

In its broadest sense, Capitanio defined patient frailty as a state of reduced resilience and increased vulnerability and also one in which minor events can trigger disproportionate adverse outcomes. “Frailty is related to, but distinct from ageing, comorbidity and disability.” Capitanio identified two main theoretical concepts of frailty: the frailty phenotype and the accumulation of deficits.

The frailty phenotype is based on five criteria: shrinking (weight loss), weakness (declining grip strength), self-reported fatigue, a decrease in walking speed and self-reported low activity.

The “accumulation” model sees an increase of deficits as people age, with a variety of symptoms collecting in a patient over time. The rate and the deficits will vary between people. The frailty index will count these deficits and generate a score.

There is a variety of ways to establish frailty, some based on measurements. There is also a quicker way that a urologist or oncologist might first identify the characteristics of frailty: “You might be familiar with the Geriatric 8 (G8) screening tool. This survey takes mere minutes to fill out, offering a score between 0 and 17. The EAU PCa Guidelines, for example, use anything below 14 as the cut-off point, requiring a simplified geriatric evaluation.”

Capitanio also pointed to developments in the use of imaging as an objective way to measure frailty. “Cross-sectional imaging can be used to identify lean-muscle cross-sectional surface area in screening for sarcopenia or several skeletal muscle wasting.”

Frailty of the patient has direct implications when it comes to RCC treatment. For instance, frailty means that the toxic effects of treatment are greater, and adverse events are more dangerous. Frail patients may also be less willing to accept the toxic side effects of their treatment.

“A correct evaluation and management can avoid minor events triggering adverse outcomes,” Capitanio concluded. “A baseline evaluation of frailty is mandatory in RCC, especially in elderly patients. Always consider referring the patient to a geriatrician once frailty is identified.”

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