In the lecture “Are MRI-targeted and systematic biopsies still a roadmap for therapy?”, Radiologist Dr. Andreas Hötker (CH) stated that MRI-targeted biopsy outperforms TRUS-biopsy alone with more csPCa (clinically significant prostate cancer), and less cisPCa (clinically insignificant prostate cancer) being detected (in both biopsy-naïve and repeat-biopsy). “MRI has the potential to offer significant benefits as part of the MRI pathway with the avoidance of biopsy in ca. 30% of patients and the lower number of cisPCa detected.”

But Dr. Hötker looked a step further to whether MR-targeted biopsy alone is sufficient and pointed out that the benefits and risks of the decision to biopsy have to be balanced out, depending on patient counselling and further risk stratification.

According to Dr. Hötker, “Only 1% of missed csPCa was GS>4+3, and PCa that is not visible on MRI may be less aggressive. The value of additional systematic biopsy is low in patients with PI-RADS 5 or prior negative biopsy. However, PCa is multifocal and small lesions may not be visible on MRI. Multifocality may be important for surgical planning, focal therapy and prognosis”.

“The approach seems safe if an appropriate safety net is in place. Clinical parameters and PSA density may be used as a risk stratification strategy for patients. The 2022 EAU Guidelines suggest that when MRI is negative (i.e. PI-RADS <2), and clinical suspicion of PCa is low (e.g. PSA density < 0.15ng/mL), you can omit biopsy based on shared decision-making with the patient.”

Looking ahead

The reproductivity of prostate MRI/PI-RADS scores were mentioned by Dr. Hötker as a point that needs further work in the future: “Improved standardisation of technical parameters, lesion scoring and reporting is required. Reading certification for radiologists has begun and DMT meetings are in larger centres, but not everywhere. Further work is required on image quality and it’s assessment with the inclusion of scores into the standardised report (PI-QUAL, PSHS), as well as making use of technical advances, such as artificial intelligence (AI).”

“We aim for the best possible diagnostic performance” began urological surgeon Dr. Jochen Walz (FR) in his presentation about the added value of biopsy approaches and risk stratification. “The EAU-EANM-ESTRO-SIOG guidelines all recommend when MRI is positive (i.e. PI-RADS > 3), to combine targeted and systematic biopsy.”

In his opinion, “Not only presence of the disease is relevant, but also the extent of the disease. This is useful to predict extra prostatic extension, seminal vesicle invasion and lymph node invasion, which are all important in risk stratification for surgery. New tools based on imaging and targeted cores need to be validated. Complications are not a reason to skip the increased diagnostic options”.

Radiation oncologist Prof. Peter Hoskin (GB) stated that “MRI-targeted and systematic biopsies are still the roadmap for radiotherapy because of the dose escalation that can be given to the DIL (dominant intraprostatic lesions), sparing of negative glands and reduced toxicity, as well as individualisation of treatment through the molecular analysis of tumour heterogeneity.”

A higher resolution

Focal therapist oncologist Ass. Prof. Clement Orczyk (GB) shared his thought-provoking lecture about the resolution detail required in diagnosis to treat a tumour selectively within the gland. “It is all about resolution. There is a lack of 3D resolution from systematic biopsy to make a good plan, for example: no spatial resolution. The roadmap for a patient-centred treatment in the form of focal therapy needs systematically mpMRI.”

In his opinion, resolution of mpMRI enables the definition of Target for Complete Ablation. “Resolution of standard systematic biopsy is low as it doesn’t detect all foci. Resolution of MRI visibility phenomena is set to detect truly significant disease linked to molecular features. Resolution of mpMRI enables oncological control with focal therapy and can be optimised.”

This followed with the lecture “Should PSMA + MRI guide treatment algorithm in high-risk prostate cancer?”, debated by Nuclear medicine physician Prof. Valentina Garibotto (CH) and Oncologist Dr. Alberto Bossi (FR) and “Biomarkers to guide active surveillance”, presented by Assoc. Prof. Gianluca Ingrosso.

Watch the full presentations from Plenary Session 1 via the EMUC22 Resource Centre.

The post Diagnosing PCa – what’s the best option? 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.

The four-day programme is not only full of important scientific updates in the prevention, diagnosis, and management of genito-urinary (GU) cancers, but delegates will also enjoy a special guest presentation on a different matter: dealing with burn-outs.

Well-known Swiss alpinist Mr. Dani Arnold (CH) will deliver an inspirational speech “Motivation in complicated cases and against burnout.” Through breathtaking pictures of hard-to-reach places, Mr. Arnold will take the audience on a visual mountainous adventure and draw parallels between his high-risk sport and the life of a urologist in terms of the importance of preparation, leadership and dealing with defeat, risk, and change.

Last year Mr. Arnold set a world record for his solo climb up the north face of France’s 3,733m high Petit Dru in the Mount Blanc massif. He also holds the speed record for climbing the treacherous north face of the Eiger, and the fastest solo climb of the north face of the Matterhorn. He recently achieved his 10-year project to speed solo all of the six great north faces of the alps.

Tactics, calculated risks, courage and discipline

In an interview with Mr. Arnold, he shares this thoughts on some of the comparisons between a free solo climber and a urologist. “There’s no room for mistakes in either activity! This creates pressure. Pressure influences our actions, it helps us stay focused, but too much pressure is bad. We both have a high motivation to become better, we do not take the easy way. This is a great quality but also a danger.”

He believes parallels to mountaineering are everywhere, as it is about tactics and calculated risks, about courage and discipline, and about guiding others and oneself. “There are many things in common, although it is also important for me to say that surgeons are essential, but mountaineers are not.”

Mr. Arnold is his own mental coach and a good teacher for anyone who wants to learn from an extreme athlete about how good planning and preparation is the key in successfully dealing with risk and changing processes. “Fortunately, I have never experienced freezing up in a high-risk situation. I think preparation is very important. I have to try to consider every possibility in the planning. For me personally, when things get really tricky, concentrated breathing helps me”.

When asked what he does when the option of failing is simply not possible, Mr. Arnold replied “That also has a lot to do with experience and preparation. I can only go so far or perform a climb so difficult that I still have everything under control. But it is also important to understand and accept that there is a residual risk in every activity.”

“To keep motivated and balanced I think it’s very important not to define oneself only by one activity. Climbing is important for me, I live for it. But there are many more important things.”

• Mr. Arnold will speak on Sunday, 13 November at 10:00. You can view the full EMUC22 scientific programme.
• Registration is still open and you can take advantage of the reduced late fee savings until 26 October 2022 (11:59 CEST).

In conjunction with EMUC22, the 10th meeting of the EAU Section of Urological Imaging (ESUI22) will take place on the 10th November 2022. ESUI22 will investigate how imaging enhances urological diagnostics, intraoperative visualisation and helps define the standardisation of the reporting of urological cancers. There will be extensive assessments of technological applications in image-guiding approaches.

The post The parallels to mountaineering are everywhere, even in urology appeared first on EMUC25.

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.

The post EMUC22 Preview: “Treatment intensification in mHSPC is a hot topic right now” appeared first on EMUC25.

In this article Prof. Arnulf Stenzl (DE), who is one of EMUC22’s esteemed Steering Committee members and the EAU Adjunct Secretary General – Executive Member Science, offers a preview of the most relevant topics at the congress, as well as, his personal EMUC22 highlights.

What are the most relevant topics at EMUC22 and why?

Prof. Stenzl: As a large part of our practice is early detection of prostate cancer, Plenary Session 1: New tools for meaningful questions in early-stage prostate cancer will provide crucial insights into clinically meaningful methods. The session will deliver varying perspectives on whether MRI-targeted and systematic biopsies are still the roadmap for therapy. The delegates will learn how the teamwork among radiologist, a urologist, radiation oncologist and a focal therapist can be the best way in treating patients. In addition, there will be a deliberation on whether or not PSMA (prostate-specific membrane antigen) with MRI is the treatment guide algorithm in high-risk prostate cancer.

The same goes for early detection and monitoring of bladder cancer. Urinary markers will be a topic favourite. During Plenary Session 3: New strategies in bladder cancer, experts will discuss the role of urinary markers in non-muscle invasive bladder cancer; transurethral tumour removal for bladder preservation strategies; molecular subtyping and gene profiling.

Other important topics that EMUC22 will cover are testicular and penile cancers. These rare cancers affect young and usually otherwise healthy men. Fortunately, in most cases, testicular cancer is curable but we must be aware of the long-term physiological and psychological effects of the treatment.  Penile cancer is an orphan tumour with mostly unsuccessful treatment options. Plenary Session 8: Interdisciplinary challenges in penile and testicular cancer will comprise of multidisciplinary case discussions with potentially promising options.

What are your top 3 personal highlights of the EMUC22 programme and why?

Prof. Stenzl: My personal highlights include the:

1. Interactive case-based debates because these show the real-life challenges faced and strategies undertaken in the clinical practice
2. Presentation about artificial intelligence (AI) and on how AI can be used for better and faster exploitation of literature such as “Sense-mining the Literature: How Artificial Intelligence Can Help Us Master the Evidence”
3. Presentation on what can uro-oncologists learn with regards to motivation during the most extreme situations in surgery and oncology by a renowned free climber.

To know more about EMUC22, please explore the congress’ scientific programme now.

EMUC22 will take place from 10 to 13 November 2022 in Budapest, Hungary in conjunction with the 10th Meeting on the EAU Section on Urological Imaging (ESUI22).

Interested in presenting at the congress? Submit your abstract(s) before 1 August 2022 (23:59 CEST) for the opportunity for your research to be part of the EMUC22 stellar scientific programme. Click here for more information.

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