Diagnosing PCa – what’s the best option?

Diagnosing PCa – what’s the best option?

The objective of the 14th European Multidisciplinary Congress on Urological Cancers is to work together to achieve the best possible patient care and the importance of this was seen during Plenary Session 1 on Friday morning, with an expert panel from different medical fields sharing vital information to help achieve that overall goal. The session “New tools for meaningful questions in early-stage prostate cancer” was chaired by Urologist Prof. Francesco Montorsi (IT), Nuclear Medicine physician Dr. Ken Herrmann (DE), Pathologist Prof. Eva Compérat (AT), and Oncologist Assoc. Prof. Pierre Blanchard (FR).

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.