Virtual Global Summit on Precision Diagnosis and Treatment of Prostate Cancer Archives

Updates of Changes in the Early Detection of Prostate Cancer NCCN Guidelines 2021

Posted by Preston C. Sprenkle, MD | Dec 2021

Preston C. Sprenkle, MD, Associate Professor of Urology at Yale University School of Medicine in New Haven, Connecticut, offers an update of changes in the National Comprehensive Cancer Network (NCCN) guidelines for 2021 regarding the early detection of prostate cancer. Dr. Sprenkle first explains the rationale behind the early detection of prostate cancer guidelines, with the NCCN recognizing that prostate cancer is a spectrum of disease, that early detection is for men who opt-in to screening, and that early detection allows for treatment of aggressive cancer, realizing the challenge of not treating indolent disease. Dr. Sprenkle then displays a schematic to outline the format and elements of the NCCN guidelines before highlighting some changes made since 2020. The revised guidelines clarify language regarding race and ancestry as well as germline mutations. The revisions strengthen statements supporting the use of magnetic resonance imaging (MRI), reflecting an understanding that the benefit of MRI fusion prostate biopsy is clear and that data on multi-parametric (mp)MRI are no longer simply “emerging.” Additionally, the new recommendations remove the prostate cancer antigen 3 gene (PCA3) from the list of recommended biomarkers that further define risk. Guidelines now also recommend that high-grade prostatic intraepithelial neoplasia (HGPIN) be treated as benign disease. Dr. Sprenkle emphasizes that while these 2021 guidelines do not introduce major changes, the addition in 2020 of intraductal carcinoma (IDC) as a concerning pathological feature was a major change that merits continued attention.

Urologic Perspective on the Clinical Utility of and Emerging Data on Micro-Ultrasound

Posted by Rafael Sanchez-Salas, MD | Dec 2021

In part 2 of a 2-part series on micro-ultrasound for prostate cancer imaging, Rafael Sanchez-Salas, MD, Associate Professor of Urology at McGill University in Montreal, Quebec, reviews data on micro-ultrasound (microUS) from a urologic perspective, comparing it to MRI in order to evaluate its clinical utility. He explains that there is more and more data suggesting microUS’s superiority to multiparametric (mp)MRI in screening and the benefits of using it in addition to MRI in clinically significant prostate cancer (csPCa). Dr. Sanchez-Salas discusses microUS’s comparable detection rates to mpMRI as shown by a balanced forest plot with ratios ranging between .94 and 1.05 and its ability to help 23% of patients avoid biopsy with no cases of missed csPCa. He then looks at a study testing a proposed protocol for assessing risk based on microUS which showed a much higher sensitivity than mpMRI in microUS of 87.5% vs. 55-61% but lower specificity of 80% vs. 87-88%. Dr. Sanchez-Salas states that there are still several questions to be answered about microUS’s utility on its own, during active surveillance, for focal therapy, and for bladder cancer staging. He concludes with a discussion of the OPTIMUM trial, which will conclude in spring of 2023 and which is meant to provide level-1 evidence regarding the use of microUS in prostate biopsy.

Radiologic Perspective on the Clinical Utility of and Emerging Data on Micro-Ultrasound

Posted by Sangeet Ghai, MD, FRCR | Dec 2021

In part 1 of a 2-part series on micro-ultrasound for prostate cancer imaging, Sangeet Ghai, MD, FRCR, Deputy Chief of Research and Associate Professor in the Joint Department of Medical Imaging (JDMI) at the University of Toronto in Ontario, Canada, considers micro-ultrasound and data evaluating its ability to produce better results than conventional imaging from a radiologic perspective. He explains that micro-ultrasound is a system that functions on a higher frequency than conventional options and uses the PRIMUS protocol, a prostate risk identification system similar to PIRADS. Dr. Ghai states that micro-ultrasound has been shown to increase detection rates by 12%, have sensitivity as high as 91%, and find cancer that was missed by MRI. He also discusses data comparing micro-ultrasound to other imaging modalities that shows that micro-ultrasound can find 1.05 times as much grade group 2 and higher disease as multiparametric MRI and has a 14.6% higher detection rate than robotic elastic fusion. Dr. Ghai concludes by reviewing data looking at micro-ultrasound visibility of MRI lesions and real-time targeting showing that 90% of MRI lesions were visible on micro-ultrasound and that 61% of those harbored clinically significant prostate cancer (csPCa) on targeted biopsy, that 43% of MRI lesions were retrospectively visible on TRUS and that 58% of those harbored csPCa, and that 24% of micro-ultrasound lesions with normal MRI were positive for csPCa.

Emerging Role of PSMA Imaging

Posted by Steven P. Rowe, MD, PhD | Dec 2021

Steven P. Rowe, MD, PhD, Associate Professor of Radiology and Radiological Science at Johns Hopkins University in Baltimore, Maryland, discusses the emerging role of prostate-specific membrane antigen (PSMA) imaging. He defines PSMA as a transmembrane carboxypeptidase highly expressed in prostate cancer cells. This expression has been observed in over 95 percent of prostate cancer tumors, with a direct correlation between expression levels and tumor aggressiveness. Due to this, Dr. Rowe asserts that PSMA is an excellent target for molecular imaging of prostate cancer. Dr. Rowe displays a PSMA structure and activity diagram and explains that PSMA positron emission tomography (PET) has moderate sensitivity and very high specificity for pre-operative nodal staging, high detection efficiency for sites of biochemical recurrence (BCR), and can effectively guide focal therapy for oligometastases and is effective in selecting patients for endoradiotherapy. He then discusses each of these in more detail, highlighting data from a study that evaluated the diagnostic performance of PSMA-targeted 18F-DCFPyL PET/computerized tomography in the preoperative staging of men at high risk for harboring metastatic prostate cancer. Dr. Rowe shows data on PSMA-based therapy and points out that for patients with more widespread metastatic disease, treatment may include PSMA inhibitors such as lutetium-177. Dr. Rowe expects that lutetium-based PSMA therapy will be approved by the FDA and become part of the standard of care for patients with widespread metastatic disease. Dr. Rowe then outlines lingering questions about PSMA PET imaging, including how prognostic findings may look for different patient populations, how doctors should follow response to therapy given that decreasing androgen signaling leads to increase in PSMA expression, and what role artificial intelligence (AI) is going to play. Dr. Rowe illustrates data from the Observation vs. Stereotactic Ablative Radiation for Oligometastatic Prostate Cancer (ORIOLE) trial results for oligometastatic disease, pointing out that patients who had all lesions visible on a PSMA scan treated had better outcomes than those who only had a subset of their PSMA-positive lesions treated. Dr. Rowe predicts that in the near term, AI will provide lesion classification, whole-body tumor burden assessments, and prognostication and decision-making based on scan findings and clinical data. In conclusion, Dr. Rowe explains that, based on existing studies, there are already multiple indications for diagnostic PSMA-based imaging, with the caveat that researchers are just starting to understand PSMA-targeted PET findings as imaging biomarkers, and currently there are still questions about the interface of PSMA PET with AI.

Image-Guided Focal Treatment of Prostate Cancer

Posted by Scott Eggener, MD | Nov 2021

Scott Eggener, MD, Professor of Surgery and Radiology and Vice-Chair of Urology at University of Chicago Medicine, discusses image-guided focal therapy and why, despite the challenges of research and adoption of the treatment, it should be researched and taken seriously as a potential standard of care. He explains that focal therapy can be used to minimize unnecessary biopsies and preserve organs. Dr. Eggener then compares the state of breast cancer focal treatment to that of prostate cancer focal treatment by presenting a randomized trial in breast cancer which suggests that prostate cancer care is 50 years behind breast cancer care in this regard. He then states the pros of focal imaging, noting that there have been multiple high-quality trials, that it lowers patients’ likelihood of needing a biopsy, and that it optimizes detection rates. Dr. Eggener then considers the cons of image-guided focal therapy, stating that not all prostate cancer is MR-visible, that MRI tends to underestimate tumor volume, and that MRI is poor at predicting extraprostatic extension. He then summarizes available data on focal therapy showing that vascular targeted photodynamic therapy has much higher outcomes than standard of care, HIFU hemi-ablation has very low rates of salvage therapy or metastases, and gold nanoparticle thermotherapy can result in metastasis-free survival at 1 year after treatment. Dr. Eggener concludes by stating that image-guided focal therapy is worthy of study and physicians should be attentive to results of ongoing and future studies.