Frontiers in Oncologic Prostate Care and Ablative Local Therapy Archives

Transperineal vs Transrectal Biopsy Clinical Trials: Mo’ Data Mo’ Problems

Posted by Arvin George, MD | Dec 2024

Arvin K. George, MD, delves into the nuances of prostate cancer biopsy techniques, focusing on the comparison between transperineal and transrectal approaches.

In this 14-minute presentation, Dr. George shares that transperineal and transrectal biopsies demonstrate equivalent cancer detection rates, particularly for clinically significant prostate cancer. However, some retrospective data suggest potential advantages of transperineal biopsy in specific anatomical areas, with notable studies emphasizing the reduced risk of infections with transperineal biopsy. Dr. George also discusses a decreased need for antibiotics and the use of local anesthesia in a transperineal approach.

Further, Dr. George reflects on the implications for clinical practice, antibiotic stewardship, and cost-effectiveness for transperineal and transrectal approaches. His talk provides a comprehensive synthesis of current evidence, encouraging a balanced and thoughtful approach to biopsy method selection.

PSMA PET for Preoperative Planning of Prostate Cancer: Nodes, Nerves and Margins

Posted by James S. Wysock, MD, MSc | Dec 2024

James Wysock, MD, MS, highlights the transformative role of novel imaging techniques, particularly PSMA PET and MRI, in improving prostate cancer diagnosis, staging, and management.

In this 14-minute presentation, Dr. Wysock explains the combination of PSMA PET and MRI significantly improves the detection of extraprostatic extension and seminal vesicle invasion compared to conventional imaging.

Meta-analyses confirm PSMA PET’s superior accuracy, particularly its high negative predictive value. This suggests that some intermediate-risk men with negative scans might safely omit extended lymph node dissection. This evidence raises important discussions about refining surgical planning and patient consent to balance risks and outcomes.

Wysock addresses emerging data supporting direct prostatectomy based on highly suspicious PSMA PET findings, bypassing biopsies. While controversial, this approach underscores the potential for imaging advancements to redefine standard workflows, especially as artificial intelligence enhances interpretation and decision-making.

Dr. Wysock emphasizes that while PSMA PET and MRI improve staging and management, these tools are still primarily validated in high-risk populations, with sensitivity challenges in lower-risk groups. The evolving role of advanced imaging, coupled with ongoing technological progress, promises to reshape prostate cancer treatment pathways.

PET Scanning in Primary Detection of Prostate Cancer

Posted by Steven P. Rowe, MD, PhD | Dec 2024

Steven P. Rowe, MD, PhD, examines the current role of PSMA PET imaging in prostate cancer detection and management, emphasizing its strengths, limitations, and areas requiring further research.

Dr. Rowe asserts in this detailed 15-minute talk that PSMA PET excels in identifying metastatic sites and aiding metastasis-directed therapy. He references advanced trials, such as OSPREY and Lighthouse, revealing its utility’s nuances.

Much of the discussion underscores the need for caution in interpreting data on extra-prostatic extension, with Rowe questioning recent claims of PSMA PET’s superiority over MRI. Challenges in standardizing interpretation across different scoring systems, such as PIRADS and Primary Score, are addressed, suggesting the potential oversimplification of tumor categorization. The talk also introduces technological barriers inherent in PET imaging.

Practical insights are provided into PSMA PET’s use in clinical settings. The societal and financial implications of widespread PSMA PET adoption are highlighted, stressing the need for cost-effective implementation strategies.

Can Imaging Replace Prostate Biopsy – Primary Detection, Active Surveillance and Recurrent PCa?

Posted by Veeru Kasivisvanathan, MBBS, BSc, FRCS, PhD, MSc, PGCert | Dec 2024

Veeru Kasivisvanathan, MBBS, BSc, FRCS, PhD, MSc, PGCert, reflects on the significant advancements in prostate imaging over the last decade, emphasizing the transformative role of MRI. A central question in this 15-minute presentation is whether prostate cancer can be diagnosed and managed without a biopsy. While biopsies are the current standard, they carry risks such as sepsis, patient discomfort, and financial burden.

The PROMIS study demonstrated MRI’s ability to detect all Gleason 4+3 cancers, though it also revealed MRI’s high number of false positives. Combining PSMA PET with MRI improves sensitivity to 97%, particularly for detecting clinically significant cancers, but specificity remains a challenge, raising concerns about unnecessary treatment. New scoring systems, like the P score, integrate PET avidity and PI-RADS scores to refine risk assessment and treatment decisions.

Kasivisvanathan discusses the concept of “biopsy-light” pathways, citing cohorts where patients undergo fewer biopsies, with monitoring driven by MRI and PSA changes. This approach shows promising compliance and oncological outcomes comparable to standard active surveillance but with less patient burden. Despite advancements, a fully biopsy-free pathway remains unfeasible due to limitations in MRI standardization, interpretation variability, and a lack of high-volume data.

CAPTAIN: A Randomized Controlled Trial of MRI-Guided Transurethral Ultrasound Ablation of the Prostate versus Radical Prostatectomy

Posted by Xiaosong Meng, MD, PhD | Dec 2024

Xiaosong Meng, MD, PhD, explores the ongoing CAPTAIN trial, a multinational, randomized clinical study comparing transurethral ultrasound ablation (TULSA) with radical prostatectomy in patients with intermediate-risk prostate cancer. The CAPTAIN trial builds on the TACT study, which demonstrated the safety and efficacy of whole-gland ablation using TULSA.

In this 11-minute presentation, Dr. Meng outlines the eligibility criteria for the CAPTAIN trial participants and reviews the study schema. The trial aims to provide level 1 evidence of safety and efficacy, addressing the need for robust comparative studies to support guideline adoption of ablative technologies.

The trial evaluates outcomes including quality of life, urinary continence, erectile function, and long-term efficacy, with follow-up extending to 10 years. The study’s findings are anticipated to substantiate the use of TULSA as an effective and patient-preferred alternative to radical prostatectomy, potentially influencing clinical practice and reimbursement policies.