Speakers included urologists, pathologists, medical oncologists and a urological researcher, each giving the audience of around 50 different insights on bladder cancer treatment from their respective specialities. Urologist Prof. Hein Van Poppel (Leuven, BE) and pathologist Prof. Montironi (Ancona, IT) chaired the session, although the latter was briefly replaced by Prof. Antonio Lopez-Beltran (Lisbon, PT) (also a pathologist) in his absence.

Update on BCa Treatments

The symposium started with a broad and up-to-the-minute update on BCa treatment by medical oncologist Prof. Susanne Osanto (Leiden, NL). Prof. Osanto first gave an overview of the current treatment options for bladder cancer, listing some recent developments and their implications for treatment. She then highlighted some trends that point to the future of the field: the increasing importance of the molecular pathologist.

“Molecular profiling will become increasingly relevant for choosing the right treatment for our patients,” Osanto said. “They already offer prognostic or predictive markers. In future, mutations will be actionable. In 2014, Nature published a so-called ‘genomic landscape of bladder cancer’, featuring many subsets and profiles. It is not yet known if the data are strong enough, and validation will be required. This will be an expensive process.”

Looking ahead, Prof. Osanto pointed to an increased use of checkpoint inhibitors (metastatic 2L and 1L, neo and adjuvant space and even in non-muscle invasive bladder cancer). Combinations of chemo- and immunotherapy and in future systemic therapy will be used in metastatic and high-risk non-muscle invasive and invasive or metastatic bladder cancer.

“All these strategies in muscle and non-muscle invasive bladder cancer should also be tested in upper urinary tract cancers,” Prof. Osanto emphasised.

Pathology

A significant part of the Symposium was then dedicated to the pathologist’s perspective, as Dr. Maurizio Colecchia (Milan, IT) explained their methods and standards. The International Collaboration on Cancer Reporting (ICCR) has established international standards for evaluation and reporting.

“Our goals are to provide accurate macroscopic and microscopic evaluation of features with diagnostic, prognostic and therapeutic value. We then offer personalised pathology reports based on the latest international standards (ICCR). Additional tissue studies including molecular investigations for personalized therapies are strongly recommended.”

Prof. Van Poppel then raised the surgeon’s perspective, eliciting clear and practical advice from Dr. Colecchia and the other pathologists. Prof. Lopez-Beltran explained the necessity for both the ‘freshness’ of the tissue sample and its shape. “Urologists need to realise how to best deliver the specimen. I ask the clinicians in my centre to give a cut, transversal or otherwise. This allows the formalin to fully penetrate the sample, which should not be too big or surrounded by layers of fat.”

Prof. Lopez-Beltran proceeded to give an overview of changes in the bladder resulting from treatment for non-muscle invasive bladder cancer, including BCG, mitomycin-C, and also ketamine, which might have been taken in a recreative setting. Prof. Montironi then did the same for muscle-invasive.

Potential of immuno-oncology

Medical oncologist Prof. Andrea Necchi (Milan, IT) gave a talk on the role of checkpoint inhibition in bladder cancer, introduced as a particularly hot topic by Prof. Van Poppel.

Necchi gave a wide-ranging overview of the latest developments in the field of immuno-oncology (IO), citing the latest studies as presented at ESMO 2018 in Munich only days before. The first data regarding neoadjuvant use of pembrolizumab and chemotherapy for locally advanced urothelial cancer (C. Holmes et al) were briefly summarised by Necchi, who gave the personal recommendation. “In selected patients, we should really be brave and continue immunotherapy instead of complicating the process with chemotherapy. Patients are also often happy to not receive chemotherapy.”

Speaking generally and looking to the near future, Necchi pointed out that pathologic response rates observed in single-agent IO studies are promising: “but we need to confirm the association with long-term improved outcomes.”

“Chemotherapy plus IO combinations are now even more attractive in neoadjuvant setting. IO, on its own or combined, is poised to make a significant impact in the management of localised muscle-invasive disease. This requires the right trial design.”

Prof. Van Poppel latched onto Prof. Necchi’s point about recommending single rather than combined immunotherapy. Necchi conceded that there was also a commercial dimension at play between the academic perspective and the perspective of the companies. “The bigger trials are initiated by companies that have an interest in offering chemotherapy options and these trials are currently pushing developments in that direction.”

The post ESUP Symposium: a multidisciplinary look at the future of bladder cancer treatment appeared first on EMUC25.

The upcoming 8th European Multidisciplinary Meeting on Urological Cancers (EMUC16) to be held in Milan (IT) from 24 to 27 November reflects the central role of pathologists with the three-day event preceded by the 2016 EMUC Symposium on Genitourinary Pathology which aims to provide the latest updates in genitourinary pathology.

Prof. Jonathan Epstein, the Reinhard Professor of Urologic Pathology at Johns Hopkins Medical Institutions and Director of Surgical Pathology Department of Pathology, Johns Hopkins Hospital, is an opinion leader in his field and is known for his body of work on precursors of prostate cancer, grading prostate cancer, the diagnosis of limited adenocarcinoma on needle biopsy and predicting progression following radical prostatectomy. Epstein would open the half-day symposium with his lecture “Latest novelties on the WHO morphological classifications of genitourinary cancers.”

“The last edition of the WHO Classification of Tumours of the Urinary System and Make Genital Organ was in 2004. Since that publication, there have been numerous changes in the field of urological pathology which have been updated in the new 2016 WHO morphological classification of genitourinary cancers,” said Epstein.

New knowledge and classifications have been developed in the pathology and genetics of these tumours. One of these is intraductal carcinoma of the prostate, a newly recognized entity which is included in the 2016 WHO classification. In many cases this carcinoma involves intraductal spread of aggressive prostatic carcinoma and should be separated from high-grade prostatic intraepithelial neoplasia (PIN). Epstein is known for his extensive work in high-grade PIN and intraductal carcinoma. At the EMUC he will also elaborate on the impact or significance of a new grading system for prostate cancer that is more patient-centric which is easier to understand and more in line with prognosis.

“Urological tumors are becoming more precisely classified based on a combination of morphology, immunohistochemistry, and molecular findings. Treatment protocols can therefore be tailored more precisely to the specific subtype of the tumor,” said Epstein as he noted that the goal is not only for the doctor to determine proper treatment, but also – and equally important- to avoid unnecessary intervention.

“At the other end of the spectrum, there is growing recognition that some urological cancers do not need aggressive therapy and can be followed carefully with active surveillance,” according to Epstein. “The terminology of some of these tumors in different GU organ systems has been changed to better reflect their more indolent behavior to, hopefully, help in preventing overtreatment.”

New molecular tests

Unfortunately, diagnosing prostate cancer and the pathology work involved in examining diseased cells is complex and even two pathologists looking at the same biopsy tissue may come up with conflicting opinions. Aside from expertise and experience, new technologies, however, can make a difference and can help both the pathologist and clinician.

“Newer molecular tests will be combined with morphology and immunohistochemistry to further our classification and improve prognostication of various GU malignancies. It has already been shown the combination of both molecular and more standard tests are better than either of them by themselves,” said Epstein.

He also said that with modern approaches and technology-centered diagnostics, it is essential that hospitals maximise the role of multidisciplinary teams.

“Every institution should have a routine multi-disciplinary GU Oncology conference attended by urologists, medical oncologists, radiation oncologists, radiologists, and pathologists to go over unusual and problematic cases to insure the best possible treatment for these patients. Follow-up on the same cases should also be presented so that everyone can learn on the success of the conference recommendations,” he added.

Not only a medical scientist, Epstein as an educator highlights the importance of knowledge and skills-sharing.

“Meetings like the EMUS are one of the best ways to disseminate the latest information about GU malignancies to a multi-disciplinary audience. In contrast to publications, these meetings allow back and forth dialogue between the disciplines,” he said. “For example, as it relates to my discipline, it allows GU oncologists to ask questions to a urological pathology expert and for me to hear about how our diagnoses affect therapy and what additional pathological issues need clarification.”

Future developments

Asked what he expects to be major developments in the coming years, Epstein said he sees a more expanded role of so-called ‘personalised treatment.’

Epstein: “Therapies in 10 years from now will be more “personalised” to specific genetic abnormalities within the patient’s own specific tumor. However, these molecular findings will still need to be taken in the context of routine morphology and special testing done by pathologists which will also evolve over the next decade.  In 10 years, there will also be additional tests to better identify those indolent tumors that may be more safely followed.”

He mentioned that by far the most numerous changes in the classification of GU malignancies have been in renal cell carcinoma. “In the not too distant past, tumors were classified descriptively as ‘clear cell, ‘papillary’ and ‘eosinophilic.’ Currently, these general non-specific terms have been replaced by a more precise classification based on a combination of clinical, cytogenetics, immunohistochemistry, and molecular findings.

Nonetheless, there is still a greater percentage of renal cell carcinomas that currently remain unclassified compared to any other GU organ.”

In the next decade, according to Epstein, it is likely that this unclassified category in renal cancer will shrink as new entities are discovered.

“The correct diagnosis of these new subtypes of renal cell carcinoma, some of which can only be done in select centers, is not that critical since for most of them the treatment does not differ. Hopefully, this will change in the future with more targeted therapies,” said Epstein.

The EMUC symposium programme will also feature a lecture on the 8th edition of the TNM staging (AJCC and UICC) of the genitourinary tumors with M. B. Amin (USA) focusing on the implications from January 2017 and beyond. The lecture will be followed by a round table forum on the topic “From morphology to personalised medicine in genitourinary cancers.”

For other details on EMUC 16 and the 2016 EMUC Symposium on Genitourinary Pathology, click on this link: http://emuc16.org/

The post EMUC16: Indolent cancers: The fine art of sophisticated pathology appeared first on EMUC25.