Prague, Czech Republic (UroToday.com) F & # 39; this session, Dr. Michiel Sedelaar present its options "Best of Prostate Cancer" 2018. It is noteworthy that this last year there were more than 10,000 manuscripts, and most of them can & # 39; impact on clinical management. However, he chose to highlight 4 x & # 39; likely to be "game changing" and justifies more attention. They cover two specific areas: diagnosis of prostate cancer and treatment & # 39; metastatic prostate cancer.
- PRECISION Study of Kasivisvanathan et al.1
F & # 39; this study, randomized authors 500 man b & # 39; clinical suspicion of PCA or MRI (with or without biopsy, according to results) (TBX) standard biopsy guided TRUS 10-12 heart (SBx).
- 28% of the MRI group had no abnormalities on MRI and therefore did not receive a biopsy (which was critical for the study)
- PCA – clinically identified group 38% while 26% identified SBx branch
- PCA – clinically insignificant group MRI identified 13% below SBx group (9 vs. 22%)
- He noted that patients & # 39; & # 39 lesions; PIRADS 3 (which were targeted), had a very low yield – 67% were negative, only 12% were csPCa
- On & # 39; this authors noted that 28% of patients could avoid biopsy – and those who received one would get only 4 cores, less pain, less risk
However, a & # 39; noted that the NPV for csPCa of & # 39; MRI was only 76% – so about 1/4 can & # 39; have some 4 foot model.
His summary of the evidence is here:
- 4M study by van der Leest et al.2 – a & # 39; noted, Dr. Sedelaar is one of the co-authors in & # 39; this study.
F & # 39; this study, over & # 39; & # 39 into two, four centers, 699 men underwent mpMRI, TRUS Bx (12 core) biopsy and targeted to each wound PIRADS 3-5.
- mpMRI discovered 25% & # 39; csPCA and 14% & # 39; ciPCa
- TRUS Bx alone found 23% of csPCa, but 25% of ciPCa
- The MRI was to avoid passing 49% of biopsies in & # 39; patients, and reduce the number of & # 39; & # 39 biopsies b; 89%
- In 49% was avoiding biopsy, f & # 39; year only 4% were found to have csPCa
- The full diagram patients is below:
It is noteworthy that, with & # 39; & # 39 contrasted with; the first study, only 6% of the lesions were mpMRI & # 39; PIRADS 3 – so the radiologists with their experience had better call PIRADS lesions and confident or 1-2 or 4-5.
On & # 39; these results, the authors conclude that mpMRI advance will deliver higher performance & # 39; csPCa and performance & # 39; lower ciPCa. The experience of the radiologist is crucial to success.
Together the two together, his message would take home:
mpMRI should be considered prior to patient, but generally when at & # 39; of & # 39 centers; experience in & # 39; & # 39 patients; high risk & # 39; PCA. Otherwise, be prohibited on costs and time.
Therapeutic in metastatic PCA: The role of radiation therapy
- Proof HORRAD by Boeve et al.3
F & # 39; this very important RCT multiċentru completed between 2004 and 2014, 432 patients were randomized to ADT b'mPCa (standard of care at the time) + ADT or radiation to the primary tumor. The radiotherapy was 70 Gy in 30 fractions or 59 Gray in 19 fractions.
- There was no difference in OS in both groups (43 months vs. 45 months)
- There was no difference in time for the progress of PSA in both groups (12 months vs. 15 months)
- However, a & # 39; noted that this population & # 39; patients with metastatic burden & # 39; very high volume – Many had Gleason 8-9,> 50% had bone mets 5+, and 60% were cT3
- On subgroup analysis, there was evidence that men with & # 39; <5 bone mets can & # 39; have some benefit (HR 0.68, CI 0.42 to 1.1).
At the end of the day, while there were several limitations, this study has provided some important negative data. Likely, these patients were too advanced to take any benefit. But, f & # 39; & # 39 sub b; smaller volume & # 39; metastatic disease, <CT2 disease status & # 39; good performance, can & # 39; there is some benefit OS.
- Stampede radiotherapy by Parker et al.4
Soon after, the Stampede investigators issued this part of the study with several arms, by comparing men with mPCa with standard therapy (ADT +/- docetaxel) with SOC + radiotherapy (55Gy fx or 36Gy in 20 fractions 6). While slightly lower dose than HORRAD, this study would benefit a planned subgroup analysis based on criteria CHAARTED & # 39; & # 39 metastatic burden; low / high volume.
- F & # 39; non-selected patients (those who came), radiotherapy did not improve OS
- However, in selected patients with a low volume metastatic weight (<4 mets of bone and all the pelvic bone), there was a benefit of OS. It proved a & # 39; beneficial to all endpoints.
To make these two studies together, here is the slide & # 39; take home:
Presented by Michiel Sedelaar, Onco Urologist, Deputy Head of Department, Area Nijmegen, Netherlands, Hospital and Health Care
Written by: Thenappan Chandrasekar, MD. Clinical Teacher, Thomas Jefferson University, Twitter: @tchandra_uromd, @TjuUrology, at the 16th Meeting of the European oncology Urology Section, # ESOU19, 18-20 & # 39; in January, 2019, Prague, Republic Czech
1. Kasivisvanathan V, et al. PRECISION Group & # 39; Study Collaborators. Targeted biopsy or standard for MRI for Diagnosis of Prostate Cancer. N Engl J Med. 2018 May 10; 378 (19): 1767-1777. Doi: 10.1056 / NEJMoa1801993. EPUB 2018 18 & # 39; March
2. van der Leest M, et al. head to head comparison of & # 39; Prostate biopsy of prostate guided by ultrasound images Transrettali b & # 39; Resonance Prostate Multiparametrika with & # 39; Subsequent biopsy guided by & # 39; Magnetic resonance f & # 39; m men & # 39; & # 39 b are biopsy; Antigen Known for Prostate Prostate: Clinical Large Prospective multicenter study. Eur Urol. 2018 November 23. PII: S0302-2838 (18) 30880-7. Doi: 10.1016 / j.eururo.2018.11.023. [Epub ahead of print]3. LMS Boeve, et al. Effect on of androgen deprivation therapy of Survive Alone Compared with the androgen deprivation therapy combined with & # 39; & # 39 therapy; Concurrent Radiation for Prostate f & # 39; patients & # 39; Kanker of Primary Metastatic Prostate Bone envisaged in randomized Clinical Trial: Data from Trial HORRAD. Eur Urol. 2018 September 25. PII: S0302-2838 (18) 30658-4. Doi: 10.1016 / j.eururo.2018.09.008. [Epub ahead of print]4. Parker CC, et al. Cancer Systemic Therapy for Advanced or Metastatic Prostate: Evaluation of investigators Drug Effectiveness (Stampede). Radiotherapy for a new primary tumor diagnosed metastatic prostate cancer (Stampede): randomized controlled trial & # 39; phase 3 Lancet. December 1 2018; 392 (10162): 2353-2366. Doi: 10.1016 / S0140-6736 (18) 32486-3. EPUB October 21 2018.
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