Pathology
Prof. Colecchia’s first take-home message came from the EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP) on the very first day of EMUC21, specifically from Dr. Gladell Paner’s (US) presentation. In this presentation, Dr. Paner gave updates on the new WHO classification of renal tumours. “The new WHO renal tumour classification has included morphologically-defined and molecularly-defined entities,” Prof. Colecchia said.

Later, Prof. Colecchia referred to Prof. Paolo Gontero’s (IT) presentation in Plenary Session 3 for his pathologic takeaways regarding non-muscle-invasive bladder cancer (NMIBC): “Promising urinary markers for surveillance challenge urine cytology and will likely replace it in clinical practice. No prognostic marker can currently be recommended in clinical practice. Molecular classifications are promising but are not yet ready for routine application.”

Having included the conclusions from Prof. Lars Dyrskjøt’s (DK) presentation on the use of circulating tumour DNA (ctDNA) biomarkers in high-risk and metastatic bladder cancer, Prof. Colecchia ended his summary with his vision for the future: “I have great expectations for the coming years. In particular, the molecular characterisation of uro-metastatic patients and the use of liquid biopsy in the routinary management of these patients will be the gold standard. Other useful tools that will become more prevalent are artificial intelligence and digital pathology.”

Radiation oncology
Prof. Pinkawa gave the conclusions on radiation oncology. “There is a lack of data on the treatment outcome of the use of PSMA PET in prostate cancer patients. It has clinical importance, which will be further defined in studies over the next years.” He cited Dr. Stefano Fanti’s (IT) lecture, who had said in Plenary Session 1: “The 2022 EAU Guidelines on Prostate Cancer will recommend using PSMA PET or a whole-body MRI in high-risk patients to increase the sensitivity. The guidelines will emphasise the very important limit of the lack of outcome data on subsequent treatment changes.”

About radio-immunotherapy for bladder preservation, Prof. Pinkawa said, “There are studies taking place on bladder preservation with the combination of radiotherapy and immunotherapy. Specifically in the UK, bladder preservation using radiotherapy is considered as a standard method that is more frequently used than a cystectomy, especially now in these times of COVID. But currently we don’t have convincing data considering this combination. We have some data that showed increasing toxicity that is not tolerable, and we don’t have convincing results yet that really show an improved disease-specific survival.”

Urology
European Urological Scholarship Programme (EUSP) Chair Prof. Merseburger offered the key messages of lectures intended especially for urologists. These included trial updates of “Extended vs limited Pelvic Lymph node dissection in prostate cancer” which was presented  by Dr. Jean Lestingi (BR). “In a subgroup analysis, intermediate- and high-risk patients in particular, benefitted from extended lymph node dissection (EPLND). EPLND remains the gold standard for lymph node staging. Its oncological role still needs to be defined,” stated Prof. Merseburger.

He reiterated one of the key points of the Trial of Imaging and Surveillance in Seminoma Testis (TRISST) presented by oncologist Dr. Stefanie Fischer (CH) during a multidisciplinary case discussion on active surveillance: MRI is non-inferior to computer tomography, avoids irradiation, and should be recommended.

Radiology
Radiologist Prof. Oyen discussed some of lectures centred on radiology such as “The new mpMRI: Biparametric MRI: fast and accurate” by radiologist Dr. Giorgio Brembilla (IT) in Plenary Session 1: The MRI Corner: Faster and cheaper. Prof. Oyen underscored the take-home message that biparametric MRI (bpMRI) lacks dynamic contrast enhanced sequence (DCE-MRI) and may lead to greater uncertainty in lesion detection and scoring.

Oncology
The last presentation of EMUC21 came from Prof. Oldenburg, who took to the stage and provided conclusions from oncology-centric presentations. He stated PSMA PET findings are predictive for decreased biochemical recurrence (BCR) and treatment-free survival. This is one key messages from the debate “Should PSMA PET impact on treatment in newly diagnosed PCa (debate yes vs no)?” wherein Prof. Tobias Maurer (DE) represented “Yes”.

All take-home messages can be found in the EMUC21 Resource Centre. EMUC21 delegates can access all presentations, full-text abstracts, and (e-)posters here.

The 14th European Multidisciplinary Congress on Urological Cancers (EMUC22) will take place from 10 to 13 November 2022 in Budapest, Hungary. We look forward to seeing you there!

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The programme launched with Plenary Session 01 “Prostate cancer management: Implementation without good evidence?” which was chaired by Prof. J. Oldenburg (GB), Prof. Dr. Kerstin Junker (DE), Prof. James N’Dow (GB) and Dr. Bradley Pieters (NL).

In his lecture “Functional imaging for recurrent disease”,  Dr. Stefano Fanti (IT) emphasised the relevance of performing more randomised and multi-centre studies to produce and procure more quality and robust data.

As he showed the model of the levels of the evidence pyramid, he said “You don’t have to take into account only  expert opinion;  you have to go through systematic reviews, randomised control trials, multi-centre trials as these are absolutely fundamental.”

As an example, he stated that data from his team’s study “PET/CT with ¹¹C-choline for evaluation of prostate cancer patients with biochemical recurrence: meta-analysis and critical review of available data” was incorporated into the EAU Guidelines. “It’s not only the matter of the final diagnostic accuracy but the fact that study has robust, validated data and better than the competitors’,” said Dr. Fanti. “We provide good images, as well as, good evidence.”

Digital slides
“Information, diagnostic and therapeutic approaches resulting from Digital GU Pathology can be more accurate with less uncertainty when sources are evaluated separately and/or individually. It requires knowledge of previous studies that contributed to the current utilisation and role of virtual slides and quantitative tissue analysis. An ability to integrate data from diverse tests will be required,” stated Prof. Rodolfo Montironi (IT) in his lecture “Digital GU pathology”.

Digital Pathology, also known as whole slide imaging (WSI), refers to the high-resolution digitization and storage of entire glass slides as digital (virtual) slides. The advantages of using these include image sharing, interactive publication, quantitative image analysis, and information fusion.

Image sharing can be used for teaching, consultation, remote interpretation, and quality assurance. A digital pathology platform allows instant sharing of WSI in review cases, as multiple pathologists can review the same case in parallel.

With regard to interactive publication, Prof. Montironi said “When we submit data to a journal, we like to include the images of the histology. So we upload the virtual slides. This means that the readers that can see the slide and all the details.”

Quantitative image analysis (computational pathology) is used for prostate cancer detection and grading; location and identification of High-Grade Prostatic Intraepithelial Neoplasia (HGPIN); malignancy-associated changes; and biomarker expression in individual cells.

Information Fusion is direct integration with data derived, for instance, from surgery and other imaging techniques, such as mpMRI.

Prof. Montironi also stated that the performance of digital pathology is equivalent to glass slide microscopy [Snead, et al 2016].

Sequencing of novel therapies
In his lecture “Sequencing of novel therapies in urogenital malignancies”, Dr. Sergio Bracarda (GB) stated that at present, Abiraterone (ABI) or docetaxel (DCT) plus androgen deprivation therapy (ADT) are the new standards of care for cases presenting with high-risk metastatic castration-sensitive prostate cancer (HR-mCSPC), but which is better is not yet known. He added that radiotherapy may be evaluated in cases presenting with LV (oligometastatic?) disease.

Dr. Bracarda said that immediate sequencing between ABI and Enzalutamide (ENZA) should be discouraged, while AR-V7 possibly remains only a prognostic tool; and asked about the relevance and role of Radium-223 (Ra-223).

He foresees that non-androgen receptor (AR) novel targeted therapies such as P13K/AKT or poly-ADP ribose polymerase (PARP) inhibitors, and other new agents, such as checkpoint inhibitors will enter the prescription (Rx) scenario. “These new agents, after being tested in biologically designed Phase III studies, will modify the actual clinical sequencing in a genome-based, step-by-step verified sequencing. The future is here!”

To know more, access the EMUC18 Resource Centre.

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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.”

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First held in 2007 as a biennial meeting, EMUC has successfully bridged the interests of experts in onco-urological diseases. Organised as an annual MDT event since 2012, EMUC is now known for providing an effective knowledge and skills-sharing platform to medical oncologists, urologists, radiation oncologists, and pathologists, among other key cancer specialists.

EMUC is led by three of Europe’s frontline professional associations: the European Society for Medical Oncology (ESMO), the European Association of Urology (EAU), and the European SocieTy for Radiotherapy & Oncology (ESTRO). Ranging from updates on new research and clinical developments to identifying best practices, the annual congress critically examines key issues in urological cancers.

Renowned US pathologist Prof. Jonathan Epstein will return to EMUC this year, which will be held for the first time in Amsterdam, The Netherlands, from 8 to 11 November. As Director of Surgical Pathology Department of Pathology at Johns Hopkins Hospital, Epstein is an opinion leader in his field and is known for his body of work on precursors of prostate cancer.

Epstein will deliver a lecture on 10 November, during the session ”New developments in prostate cancer evaluation.” His lecture titled “Everything in prostate cancer pathology you were afraid to ask” is anticipated not only to provide updates in innovative pathology work but to also offer new insights to clinicians.

“My lecture will provide the forum for attendees to answer some of the more confusing and clinically important issues relating to prostate pathology,” said Epstein. Pathology experts say urological tumours are becoming more precisely classified based on a combination of morphology, immunohistochemistry, and molecular findings. With new developments, treatment regimens can, therefore, be tailored more accurately to the specific subtype of the tumour, according to Epstein.

Asked to comment on inter-disciplinary events such as the EMUC, Epstein underlined the benefits to be gained through closer MDT collaboration. “The importance of MDT from the participating pathologists’ standpoint is that the meeting provides an opportunity to inform clinicians about critical and often confusing issues relating to pathology that directly impact patient care,” he said.

Epstein is not only a medical scientist but also an educator and he underscored the central role of sharing expert knowledge. “An MDT event like the EMUC gives clinicians access or a platform to ask from the top experts in the field questions related to pathology, which helps them better understand their pathology reports and better manage their patients,” he said, while adding that two-way dialogue among experts can only boost the cancer care community’s goals for optimal care.

Experts believe current collaboration among onco-urology has improved with more educational activities being held and funded by professional organisations.

The four-day EMUC will be preceded by the 7th Meeting of the EAU Section of Urological Imaging (ESUI18), the EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP), and the EAU-ESMO Bladder Cancer Consensus meeting.  Organised with main congress is the EAU Prostate Cancer Consensus meeting on Active Surveillance (EPCCAS) to be held on Friday. The European School of Urology (ESU) will offer Hands-on Training and specialised courses.

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