Surgery for cN1 M0 prostate cancer Classical Imaging | Novel Imaging - - PowerPoint PPT Presentation

▶
surgery for cn1 m0 prostate cancer classical imaging
SMART_READER_LITE
LIVE PREVIEW

Surgery for cN1 M0 prostate cancer Classical Imaging | Novel Imaging - - PowerPoint PPT Presentation

Oct 17, 2023 416 likes •761 views

Surgery for cN1 M0 prostate cancer Classical Imaging | Novel Imaging Professor Declan G Murphy Urologist & Director of GU Oncology| Peter MacCallum Cancer Centre Associate Editor | BJUI @declangmurphy Honorary Clinical Professor |

slide-1
SLIDE 1

Surgery for cN1 M0 prostate cancer Classical Imaging | Novel Imaging

Urologist & Director of GU Oncology| Peter MacCallum Cancer Centre Associate Editor | BJUI Honorary Clinical Professor | University of Melbourne

Professor Declan G Murphy

@declangmurphy #APCCC19

slide-2
SLIDE 2

Disclosures

  • None relevant
slide-3
SLIDE 3

Surgery for cN1 M0 prostate cancer | Outline

  • 1. cN1 by conventional imaging
  • 2. cN1 by PSMA PET/CT
slide-4
SLIDE 4

Staging of high-risk localized/locally advanced disease

EAU Prostate Cancer Guidelines 2019

slide-5
SLIDE 5

Briganti et al Eur Urol 2012; Gabriele et al World J Urol 2016

Staging of high-risk localized/locally advanced disease

CT performs very poorly for staging pelvic lymph nodes

Definition of pelvic cN1 by CT criteria 8mm short axis of a round lymph node 10mm in an oval lymph node

  • Sensitivity 11-13%
  • Specificity 93-94%

MRI performs poorly for staging pelvic lymph nodes

  • Sensitivity 39-56%
  • Specificity 89-94%

Woo et al AJR 2018 EAU Prostate Cancer Guidelines 2019

slide-6
SLIDE 6

EAU Prostate Cancer Guidelines 2019

Surgery for high-risk locally advanced prostate cancer

slide-7
SLIDE 7

EAU Prostate Cancer Guidelines 2019

Surgery for high-risk locally advanced prostate cancer

1 2

slide-8
SLIDE 8

Moschini et al Eur Urol 2016

N=302 RP + ePLND |1988-2003 All were pN1 50 (17%) were cN1 | 252 (83%) were cN0 Median follow-up 17.4y cN0 and cN1 compared Hypothesis – no difference in survival

1

Patient profile Mean PSA 32.2ng/mL 65% NCCN high risk Median node yield = 13

Cancer-Specific Mortality cN0 = 23% cN1 = 26%

slide-9
SLIDE 9

Moschini et al Eur Urol 2016

1

MVA Gleason 8 and number of positive nodes predicted survival cN status did not predict survival Conclusion “cN+ status should not be a contraindication to surgery” Predictors of CaP mortality

slide-10
SLIDE 10

Seisen et al Eur Urol 2018

  • National Cancer Database 2003-2011
  • N=2967 cN1
  • Local therapy (LT) +/- ADT vs ADT alone
  • 67% received LT +/- ADT
  • 37.8% surgery
  • 32% received ADT
  • 62% radiotherapy
  • 85% received ADT
  • Instrumental variable analysis

Overall survival

HR 0.31 95% CI 0.13-0.74; p=0.007

2

LT +/- ADT ADT alone

71% survival benefit in favour of local therapy

slide-11
SLIDE 11

Seisen et al Eur Urol 2018

Surgery vs Radiotherapy Compared using instrumental variable analysis

2

slide-12
SLIDE 12

Seisen et al Eur Urol 2018

HR 0.54 95% CI 0.19-1.52; p=0.2

Surgery vs Radiotherapy Compared using instrumental variable analysis

OS benefit for surgery Not significant

2

RP +/- ADT RT +/- ADT

slide-13
SLIDE 13

Take home messages 1 | Conventional imaging

  • Conventional imaging performs poorly for staging cN status
  • There is some low quality evidence to support surgery for cN1

prostate cancer

  • Must be discussed within a multimodal framework
slide-14
SLIDE 14

Surgery for cN1 M0 prostate cancer | Outline

  • 1. cN1 by conventional imaging
  • 2. cN1 by PSMA PET/CT
slide-15
SLIDE 15

Perera et al Eur Urol 2019

slide-16
SLIDE 16

PSMA PET | Primary LN staging

Perera et al Eur Urol 2019

Sensitivity 0.77 (0.46-0.93) Specificity 0.97

slide-17
SLIDE 17

EAU Prostate Cancer Guidelines 2019

  • Novel imaging is more sensitive
  • However, benefit of detecting metastases earlier is

unclear

  • Not clear if PET-only metastases should be treated

systemically, or aggressive local and metastasis-directed therapy

  • RCTs evaluating management impact awaited (proPSMA)
slide-18
SLIDE 18

Princess Alexandra Hospital

Hofman et al BJUI 2018

  • N=300
  • High-risk localized

prostate cancer

  • Randomised squence
  • CT/Bone scan
  • PSMA PET/CT
  • Endpoints
  • Accuracy
  • Management impact
slide-19
SLIDE 19

Hofman et al BJUI 2018

Patient Selection: untreated, biopsy-proven prostate cancer, being considered for curative intent treatment. § PSA ≥ 20 ng/mL or Gleason Grade Group 3-5 or clinical stage≥T3 Randomisation 1:1

PSMA PET/CT CT + bone scan

Implementation of Final Management 6 months follow-up: repeat imaging Crossover to other arm unless ≥3 distant metastases

Up to 54 months follow-up for PSMA negative patients

  • Accuracy

Primary

  • Management impact
  • Health economics
  • Radiation exposure
  • Reporter agreement
  • Safety

Secondary

Trial Design Objectives

proPSMA | Prospective randomized study of PSMA PET/CT vs conventional imaging

Primary endpoint to be presented EAU 2020

slide-20
SLIDE 20

proPSMA study

69yo | PSA 12.2 | cT2b right | PIRADS 5 right | Grade group 5 (targeted bx only; 6/6 cores)

1

slide-21
SLIDE 21

46 year old; PSA 14; cT3; PIRADS 5; Grade group 5 cancer proPSMA study | CT and bone scan normal 2

slide-22
SLIDE 22

46 year old; PSA 14; cT3; PIRADS 5; Grade group 5 cancer proPSMA study | CT and bone scan normal 2

slide-23
SLIDE 23

46 year old; PSA 14; cT3; PIRADS 5; Grade group 5 cancer proPSMA study | CT and bone scan normal 2

slide-24
SLIDE 24

46 year old; PSA 14; cT3; PIRADS 5; Grade group 5 cancer proPSMA study | CT and bone scan normal 2 Proceed with primary rx alone? Best systemic therapy? Plus local therapy?

slide-25
SLIDE 25

Considerations | Management impact

  • If conventional imaging is negative, how

much should we abandon standard of care?

– ie surgery or radiotherapy

  • Should we try harder for tissue diagnosis?

(No)

  • How should we assess the management

impact?

  • Can prospective trials embrace novel

imaging? (yes please)

slide-26
SLIDE 26

PSMA-GUIDED SURGERY

Maurer et al., Eur Urol 2018

slide-27
SLIDE 27

PSMA-radioguided surgery for LN detection

  • Injection of 110-150MBq 111In-labeled PSMA-

ligand 24h prior to surgery

  • Intraoperative detection by gamma probe with

acoustic and visual feedback

Maurer et al., Eur Urol 2018

slide-28
SLIDE 28

Maurer et al., Eur Urol 2018

PSMA-radioguided surgery for LN detection

slide-29
SLIDE 29

Maurer et al., Eur Urol 2018

Excellent correlation between RGS and histopathology

83.6% sensitivity 100% specificity

slide-30
SLIDE 30

Take home messages 2 |Novel imaging

  • Self-evident that PSMA PET/CT has superior sensitivity and

specificity in higher-risk prostate cancer

– proPSMA will provide objective evidence

  • Disruptive technology
  • The management impact needs to be evaluated
  • Also offers radio-guided surgery possibility
slide-31
SLIDE 31

Conclusions | Surgery for cN1 prostate cancer

  • Strong evidence for local therapy in cN1 MO prostate cancer

(by conventional imaging)

  • Surgery is an option as part of multi-modal therapy
  • Novel imaging provides much more accurate picture of

disease extent

  • Management impact needs to be evaluated
  • Surgery role likely better defined
slide-32
SLIDE 32

w: petermac.org e: declan.murphy@petermac.org @declangmurphy #APCCC19

Thank you