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.

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In the plenary session on bladder cancer, a succession of esteemed experts highlighted some new developments in their field.

Urinary markers

Prof. Lars Dyrskjøt (Aarhus, DK) started the session with an update on the research he and his team are undertaking in urinary markers in non-muscle invasive bladder cancer. He explored the diagnostic, prognostic and predictive values of urine testing.

“Multiple urine tests are available, with relatively high sensitivity and specificity. We need randomised intervention trials to demonstrate that cystoscopy could be skipped in some cases. Quality-of-life and health economy analysis should be included in the design of these trials,” explained Prof. Dyrksjøt.

“Screening may be difficult – but promising results have been shown in patients with haematuria. Analysis of cell-free DNA in urine (supernatant) may identify high-risk patients.”

Significantly, urine markers may also help an earlier selection of patients for more aggressive treatment. Finally, urine analysis during BCG of T-cell exhaustion biomarkers may inform on treatment response.

Prof. Susanne Osanto (Leiden, NL), who chaired the session hailed Prof. Dyrksjøt’s “tremendous work in genomics in BCa.” Earlier on Friday, Prof. Arnulf Stenzl (Tübingen, DE) referred to the Aarhus TOMBOLA trial, saying that there were “high hopes that that will show possibilities of liquid biopsy for indication and monitoring.”

New research

Prof. Morgan Rouprêt (Paris, FR) followed the talk on urinary markers with a fresh look at the role of transurethral tumour removal for bladder preservation strategies, stressing the importance of functional outcomes as well.

Dr. Markus Eckstein (Erlangen, DE) presented a pathologist’s perspective on molecular subtyping and gene profiling. In his pre-recorded presentation he outlined that subtypes of NMIBC and MIBC are based on profound biological features and that consensus subtypes should be used, if possible.

It would have to be discussed if subtypes can be assessed via immunohistochemistry. The prognostic impact also differs between NMIBC and MIBC, while the predictive impact is still promising. As in so many cases with new research, Dr. Eckstein concluded that prospective validation in clinical trials is still missing.

Prof. Thomas Powles (London, GB) was on hand to update the audience on optimal patient selection for adjuvant treatments. While covering a huge amount of considerations, some of the most important conclusions were that tissue-based biomarker PD-L1 was perhaps not the best choice despite being the only approved biomarker in Europe. A new tool for patient selection is ctDNA as demonstrated in the recent IMvigor010 trial. Notably, EMUC22 has the first research on neoadjuvant immune combination therapy: “triplet therapy” in the VOLGA trial (LP166).

• EMUC22 delegates can watch back Plenary Session 3 in its entirety once it becomes available in the EMUC22 Resource Centre.

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In this article, world-renowned cancer researcher and EMUC22 Steering Committee member Prof. Silke Gillessen (CH) shares her personal programme highlights in an interview about the upcoming congress.

In your expert opinion, what are the most relevant topics at EMUC22 and why?

Prof. Gillessen: This is difficult to decide because they are all relevant, but my choice would be perioperative systemic therapy for urothelial cancer, because there are a lot of new potential options, but no new clear standards yet, and some conflicting evidence. Hence, there is a lot to discuss on this topic.

Treatment intensification in mHSPC is also a hot topic right now because there are so many new treatment options. It is not yet clear who needs triplet therapy, and it is also not yet clear if there are patients for whom we can de-intensify treatment.

Lastly, the topic of tailored treatment in kidney cancer. It is important for less frequent forms of RCC including non-clear cell RCC or for hereditary kidney cancer. For ccmRCC there are many possible first line options and it is important to look at how to best select patients.

What are your top three personal highlights of the programme?

Prof. Gillessen: There are many good sessions, but my personal highlights are: Firstly,  Plenary Session 3: New strategies in bladder cancer, which will include many interesting discussions on urinary markers, bladder preservation strategies, molecular subtyping and selecting optimal candidates for adjuvant therapy (this is a big open question).

Another highlight is Plenary Session 5: New trials results, which will offer short, concise updates about the most important trials in the field critically discussed by a specialist. It is always interesting to have a critical view on important, practice changing data.

There is a great opportunity to have specialists from different disciplines discuss complex cases in Plenary Session 10: Multidisciplinary sessions for aggressive prostate cancer.

• How to join EMUC22
  You can register now to participate in EMUC22 here. For the complete scientific programme, please click here.
• ESUI22
  The 10th meeting of the EAU Section of Urological Imaging (ESUI22) will take place on the 10th of November in conjunction with EMUC22. Delegates can expect extensive assessments of technological applications in imagine-guiding approaches. ESUI22 will also investigate how imaging enhances urological diagnostics and intraoperative visualisation, and helps define the standardisation of the reporting of urological cancers.

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The symposium is co-organised by the EAU Sections of Uro-Pathology (ESUP) and Urological Research (ESUR) and the Uropathology Working Group of the European Society of Pathology. Expert speakers were drawn from these bodies, with speakers of a variety of pathology-related backgrounds.

This year, the ESUP Symposium examined the current state of liquid biopsies in uro-oncology, and it possible future applications. What emerged over the course of the afternoon was a future with a promising perspective, but still a lot of work to be done for researchers and pathologists.

Dr. Michelangelo Fiorentino (Bologna, IT), a clinical pathologist, gave an introductory talk on the current applications, and what uro-oncologists should know before using them. Liquid biopsies refers to the use of blood and other bodily fluids as an alternative to tissue samples for diagnostic purposes.

The potential of liquid biopsies is significant, according to Fiorentino: “The major advantages are the non-invasiveness, removing the need for biopsies. Also, liquid biopsies can give a better representation of all the tumour profiles and genetic mutations. Finally, liquid biopsies can give a better indication on the extent of tumour burden.”

In theory, any lab test for tissue can be used to analyse liquids, but they have to be adapted for much lower concentrations of tumour cells. Some tests can require up to 80ml of blood. As it stands, liquid biopsy is currently much more expensive than conventional histology. The reliability of diagnostic accuracy is also inferior. It is also not entirely clear which professional should be in charge of liquid biopsies: pathologists, biochemists, geneticists or (uro-)oncologists.

Potential for BCa

Following talks on kidney cancer (by ESUR Chairwoman Prof. Kerstin Junker, pictured) and prostate cancer and the potential suitability of liquid biopsies for those urological cancers, Prof. Thomas Gevaert (Leuven, BE) spoke on bladder cancer. “In contrast to other urological cancers, BCa has advantage: we can look at blood as well as urine. By combining analysis of the liquids, and with a variety of techniques we can investigate different substances.”

“The majority of patients with metastatic BCa have circulating tumour DNA. This means there is potential value to stratify patients for clinical trials, as well as potential value in diagnostic and follow-up flowcharts. cfDNA/ctDNA is a very sensitive tool to detect early recurrence and minimal residual disease.”

Gevaert postulated that by combining analysis of cfDNA (mutational landscape) and CTC’s (protein expresession), these could be complementary tools with even better results.

Despite aforementioned advantages of liquid biopsies, particularly for BCa, like its non-invasiveness, the combination of urine and blood, and the pre-screening and monitoring, Gevaert pointed out certain hurdles that need to be cleared before liquid biopsies are adopted.

“As with many new techniques, we are still waiting for prospective validation. We also need standardization in our approach. Crucially, we should not be using liquid biopsies unless there is a clear superiority when compared to traditional biopsies. Sensitivity and specificity of liquid biopsies also need to be determined.”

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