The session will feature insights of esteemed urologist Dr. Rafael Sanchez-Salas (FR) who specialises in intervention and surgery; and  prominent radiooncologist Prof. Dr. Thomas Wiegel (DE). The renowned specialists will provide a binary perspective on the patient cases.

“The session’s objective is to show where things can go wrong especially with alternative treatment, and how to approach that optimally,” stated Prof. Dr. Arnulf Stenzl (DE), EAU Adjunct Secretary General – Executive Member Science.

Prof. Stenzl and Dr. Cesare Cozzarini (IT) will chair the session, which is part of the popular Nightmare Session series introduced at the EAU’s annual congress held in London in 2017.

The EMUC19 Nightmare Session will show varied perspectives and outcomes of opting for an intervention (e.g. focal therapy) or a radiooncological treatment. “It is interesting for both the radiooncologists and urologists to know which treatment addresses and solves the case,” said Prof. Stenzl said. “It is also important to know where the problems and pitfalls lie in each treatment possibility.”

The cases
Each discussant will present patient cases where treatment were done with curative intent.

“The cases in the session represent typical clinical situations commonly feared by clinicians. For example, a patient was just treated with curative intent with either radical prostatectomy or radical radiotherapy. However immediately after, the clinician realises that metastasis was already present even before the patient underwent radical treatment. Unfortunately for some reason, this was not initially recognised. How should the clinician approach this situation? This is the type of cases that the Nightmare Session will highlight,” stated Dr. Cesare Cozzarini.

Radiooncologist viewpoint
“The objective of my lecture is to inform urologists and radiation oncologists about a significant pitfall in the treatment of patients with locally advanced PCA,” explained Prof. Wiegel. “In locally advanced PCa, one standard is radiation therapy (RT) plus two to three years of Luteinising Hormone Releasing Hormone (LHRH)-analogue; the increase of overall survival of about two years is proven in phase III trials.”

Prof. Wiegel will present a case wherein a patient conformed to start androgen-deprivation therapy (ADT) treatment. Then after 50 Gray (Gy), the prostate-specific antigen (PSA) was controlled and showed a significant increase in contrast which was expected. However according to the patient, he had not received ADT due to fear of the side effects concerning potency. “This has been detected with the PSA and if it wasn’t, the treatment was not standard in combination with the clear early progression of the disease,” said Prof. Wiegel.

During the Nightmare Sessions at EMUC19, Prof. Wiegel and Dr Sanchez-Salas will share more valuable insights and advice.

About EMUC19
EMUC19 is a frontline, multi-disciplinary congress designed to encourage relevant discussions on innovative treatment, the limits of standard therapies, and the impact of new research outcomes. Its reputation as prime European platform for professional and scientific exchanges in genitourinary oncology has been well-established throughout the years.

The congress brings together esteemed specialists and healthcare professionals from various disciplines, thanks to the collaborative efforts of the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).

EMUC19 will take place on 15-17 November 2019 in Vienna, Austria. For more information about the congress and how to join, explore the EMUC19 website.

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“Focal therapy for PCa is today an ‘epidemic subject’ in urological oncology,” said Dr. Rafael Sanchez-Salas (FR) of the Department of Urology at the Institute Mutualiste Montsouris in Paris, as he noted that although a promising option, focal therapy still requires additional evidence for it to occupy a crucial role in managing recurrent disease. Sanchez-Salas will speak on the latest evidence for focal therapy during the 8th European Multidisciplinary Meeting on Urological Cancers (EMUC16) to be held in Milan (IT) from 24 to 27 November.

An inclusive meeting which provides a platform for onco-urological experts, the EMUC is now on its eight year of gathering leading opinion leaders, researchers and cancer specialists to critically examine new and current treatment strategies in urological malignancies. The event is annually organised by three of Europe’s leading and specialised medical associations- the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).

Focal therapy for PCa, according to Sanchez-Salas, has been evaluated in the context of salvage therapy, but mainly for disease recurrence following radio- or brachytherapy. He explained that although brachytherapy, cryotherapy and high-intensity focused ultrasound (HIFU) are used as salvage therapies, the long-term oncological outcomes of these approaches are still unknown. Moreover, there is the concern about debilitating side-effects.

Potential challenges

“The potential problems of focal therapy in radio-recurrent disease include accurately localizing recurrent disease within the prostate, and the margins of safe treatment which preserve oncological efficacy whilst minimizing harms and strategies of follow-up,” said Sanchez-Salas.

Despite this drawback, initial studies offer a hint of promise, according to Sanchez-Salas as he mentioned that outcomes regarding disease-free survival rates are relatively favorable.  “Recently published systematic review including cryoablation, brachytherapy and HIFU, showed that one, two, three and five-year biochemical disease-free survival ranges for focal salvage are, respectively, 69-100, 49-100, 50-91 and 46.5-54.5%.  Severe genitourinary, gastrointestinal and sexual function toxicity rates are 0-33.3%,” he noted.

“This data confirm the feasibility of these treatment modalities in selected patients in the attempt to reduce the risk of adverse events while maintaining cancer control. If we look at the development of focal therapy, we can see how radio-recurrent PCa has been like a “boot camp” for energy development,” he said.

He also conceded that although that there is a lack of prospective studies assessing the results of focal therapies, there are improvements which may yet favor the efficacy of focal therapies.

“This (lack of prospective studies) is completely true, but the trends are changing,” he said as he highlighted some factors that may lead to an expanded adaption of focal therapies such as cancer control, its use of image-guided technology, and the strong trend to find a middle ground option between active surveillance and more radical options.

“At this point, the available outcomes to support focal therapy in PCa may still be limited (based) on evidence and we clearly understand that there is a great deal more to be done to further develop this field,” Sanchez-Salas said. “However, we are very confident that developments have passed a point of no return. Today, the die is cast for focal therapy in localized PCa.”

Consolidating gains

What is important is to consolidate the gains made in focal therapy, he pointed out.  He a noted this consolidation can be based on solid imaging and objective planned prostatic biopsies. Based on high-performance imaging, Sanchez-Salas believes the evolution towards a rationalized approach to tackle prostatic tumors is natural.

“Focal therapy for PCa is part of the personalized medicine wave, which is a potential shift in clinical practice that provides a tissue-sparing approach to the PCa armamentarium,” he added.

Whether or not the optimism for less radical approaches in malignant disease will find favor or a wider acceptance among cancer experts is also reflected in the plenary sessions during the EMUC where specialists are known to enthusiastically argue for or against emerging therapies vis-à-vis standard treatments. The fact that expert discussions and meetings may not necessarily find unanimity in a multidisciplinary gathering such as the EMUC does not dampen the optimism of Sanchez-Salas for the opportunities of knowledge-sharing in this international event.

“It is exactly the fact of having multidisciplinary opinions to deal with difficult therapeutical decisions that we see the benefit of the EMUC. We live at a time of personalized medicine but in order to particularize treatment one needs more than just one specialty-isolated view. Team work is of utmost importance,” he said.

The three-day EMUC will be preceded by the 5th annual meeting on November 24 of the EAU Section of Urological Imaging (ESUI) whose programme will focus on new developments, challenges and prospects in imaging.  On the same day, the 2016 EMUC Symposium on Genitourinary Pathology (ESUP) will also take place to highlight new and current diagnostic issues in genitourinary cancers.

For details on the Scientific Programme click here.

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