4th EMUC: diagnostic issues and treatment options in metastatic prostate cancer

Fri, 16 Nov 2012

The first plenary session of the 4th European Multidisciplinary Meeting on Urological Cancers (EMUC) opened today in Barcelona, tackling the diagnosis and treatment of oligo-metastatic prostate cancer with various experts presenting their strategies for optimal treatment.

With around 600 registered participants from 49 countries in the session room, W. Artibani (IT), K. Fizazi (FR) and D. Hollywood (IE) opened the two and half-day event, highlighting in their remarks the need for a multi-disciplinary approach to obtain optimal care for patients with uro-oncological diseases.

In presenting the first case discussion, A. Alcaraz (ES) provided the following details of a real-life prostate cancer case:

A 55-year old commercial pilot, right renal traumatism followed by nephrectomy- GFR: 55ml/mn; no DM. no HTA, no DL, non-smoker; At first PSA control: 54ng/ml; Asymptomatic; Digital rectal examination at least T2b disease (left lobe); Eco TR: vol 31 cc; ssvv normal; bilateral hypoecogenic areas; IPSS: 8; MRI: suggestive of T3a disease.

The audience was asked to vote on three questions, namely:

1. What would be the ideal image technique for lymph node extension diagnosis?2. What would be the ideal imaging of bone metastasis?3. What will be your initial therapeutic approach? T3a N1M1 (oligometastatic)

The following were the results of the audience voting:

Question 1: CT Scan- 19%; MRI- 19%; MRI using iron particles- 19%; FDGlucose PET-Scan- 12%; Choline PET Scan-31%

Question 2: Bone scan: 63%; Total body MRI- 26%; PET Scan- 11%

Question 3: has the following responses, with immediate androgen deprivation getting the most votes:

Radical prostatectomy/lymphadenectomy plus stereotactic radiation of bone metastasis- 20%
EBRT on prostate plus stereotactic radiation of bone metastasis and lymph node- 16%
Immediate androgen deprivation- 62%
Delayed androgen deprivation at onset of symptoms- 2%

Following the voting, speakers F. Lecouvet (BE) spoke on the topic “What is the optimal diagnostic assessment of bone metastasis?” N. Mottet lectured on the limits of hormone therapy as single systemic modality and V. Khoo, a radiation oncologist from the UK, spoke on the role of local treatment in metastatic disease.

“There is a need for new bone screening tools that would have high diagnostic value, is reproducible, which minimizes radiation exposure and able to monitor response,” according to Lecouvet. He explained that there are emerging options that can improve on current standards such as MRI axial skeleton (ASMRI), PET or whole body MRI (WBMRI) plus diffusion-weighted imaging (DWI).

Regarding hormone therapy, Mottet said the main questions for doctors regarding androgen deprivation therapy (ADT) would be when, how, the modality and whether it is sufficient as monotherapy. He also noted that currently there is no place for upfront chemotherapy.

Meanwhile, Khoo stressed on the prognostic factors in oligometastatic PCa, saying that physicians should take note of the timing of presentation, the extent and the site of the disease. In his concluding remarks he said: “Aggressive “ablative” therapy may yield good local control (LC) and perhaps long term remission,” and added that further study is warranted and randomized trials needed.

Interestingly, the votes on the same questions slightly changed after the lectures particularly with the following results on Question 3, namely the EBRT option gaining more votes compared to immediate androgen deprivation:

Radical prostatectomy/lymphadenectomy plus stereotactic radiation of bone metastasis- 20%• EBRT on prostate plus stereotactic radiation of bone metastasis and lymph node- 30%• Immediate androgen deprivation- 45%• Delayed androgen deprivation at onset of symptoms- 5%