Κατευθυντήριες Οδηγίες Ουρογεννητικού Καρκίνου, Πόσο κοντά – πόσο μακριά
Φωτογραφίες από το Συνέδριο
1.ΟΜΑΔΑ ΕΡΓΑΣΙΑΣ ΚΑΡΚΙΝΟΥ ΝΕΦΡΟΥ
Q Renal biopsy: Should it ever be used as an alternative to immediate surgery?
The Group concurs with the current EAU guidelines, which define the indications of renal biopsy as follows:
- For histological diagnosis of radiologically indeterminate renal masses
- To select patients with small renal masses for surveillance
- To obtain histology before ablative treatments
- To select the most suitable form of targeted therapy in M1 disease
The following advantages and limitations should be taken into consideration:
- low morbidity
- diagnostic yield of 78-97%
- high specificity (98-100%) and high sensitivity (86-100%) for the diagnosis of malignancy
- 2.5 – 22.0% of biopsies are non-diagnostic
- accuracy of Fuhrman grading is poor
- the diagnostic accuracy in cystic lesions is poor
Q Lymphadenectomy: for which patient and to what extent?
To the current EAU guidelines
the Group suggested that, based on recent data (Capitanio U et al,
BJU Int. 2014) lymphadenectomy may be beneficial in high-risk patients:
- tumor size >10 cm
- T3-T4 disease
- high Fuhrman grade
- presence of sarcomatoid features, or coagulative tumour necrosis
Q. Nephron sparing surgery in T1b tumours
“…Management of T1b and T2 renal masses is transforming with adoption of partial nephrectomy as a safe and feasible surgical option with comparable oncological and improved renal function outcomes compared to radical nephrectomy.” (Lee HJ, Curr Opin Urol 2014)
Nephron sparing surgery offers:
- Similar Overall, Cancer Specific and Recurrence-free survival (open or lap)
- Similar length of hospital stay, blood loss, complication rate
- Better renal function post-operatively compared to radical nephrectomy
- Better QoL
Specifically for clinically T1a tumors in elderly and unfit patients, the Group accepts the following
- Elderly and comorbid patients with incidentally detected small renal masses have a relatively low RCC-specific mortality and a significant competing-cause mortality.
- The growth of renal tumours is low in most cases and progression to metastatic disease is reported in a limited number of patients (1-2%).
- In selected patients with advanced age and/or comorbidities, active surveillance is an appropriate strategy to initially monitor small renal masses, followed if required, by treatment for progression.
Q. Adjuvant or neoadjuvant targeted therapy in patients with resectable renal cancer
These approaches are not recommended outside clinical studies
Q. Cytoreductive nephrectomy in metastatic disease
Retrospective suggest a benefit for nephrectomy in RCC patients with metastatic disease.
Groups likely to benefit from cytoreductive nephrectomy are ill-defined. There is level III evidence that patients with poor PS and/or poor prognosis may not benefit from this strategy.
Q. Watchful waiting
Watchful waiting can be applied in selected cases, since series from the cytokine era have shown that 10% of patients diagnosed with mRCC will not progress 1 year after diagnosis.
Specific criteria for identifying patients appropriate for watchful waiting do not exist.
Q. Metastasectomy, resection of local relapse
Metastasectomy is NOT an emergency. A reasonable time of at least 4-6 months of follow up should ensure that a widespread progression of the disease prior to metastasectomy
Similarly to the above, in case of local recurrence within a year from initial surgery, systemic therapy might be advisable. On the other hand, a long interval between nephrectomy and local recurrence, surgical resection of the recurrence could be preferred.
Q Treatment holidays
Data from retrospective series suggest that interruption of targeted therapies is safe in patients who achieve CR (with or without surgery)
Q. 3rd line therapy in metastatic disease
After the publication of the randomized study dovitinib vs. sorafenib in 3rd line setting (Motzer et al, Lancet Oncol 2014), sorafenib has been added to everolimus as a recommended treatment with LoE I for 3rd line therapy.
Lower LoE of efficacy exist for most anti-VEGFR therapies in 3rd line
2.ΟΜΑΔΑ ΕΡΓΑΣΙΑΣ ΟΥΡΟΘΗΛΙΑΚΟΥ ΚΑΡΚΙΝΟΥ
Q:Intradiverticular bladder tumours. Do they always indicate an invasive disease?
Management and follow up of intraverticular disease is potentially tricky due to lack of muscular layers. Nevertheless, the notion that it should be a priori considered as muscle-invasive disease is not founded. The presence of in situ component is an adverse prognostic factor.
Q: Maintenance schedules of intravesical chemotherapy
The Group fully concurs with the existing EAU guidelines, as shown below
The optimal timing of immediate post-op instillation is still unclear
There was consensus that the development of granulomas more common if immediately after surgery vs. “delayed” (i.e. post 18-h)
Q:The role of Radical Cystectomy in T1G3 bladder tumours
The Group concurs with the current EAU guidelines, as shown below
During the discussion the importance of the surgical “feeling” regarding the aggressiveness of the disease and it was suggested that this factor should be clearly defined and routinely quoted.
Q: The extend of lymphadenectomy in RC
Extended lymphadenectomy is the standard in the surgical management of bladder cancer
In addition to the templates of excision the number of excised and examined lymph nodes also appear to be of great importance. The higher the number of excised lymph nodes, the higher the sensitivity of detecting nodal disease. This is related to the stage of the primary tumor and is depicted in the Table below
The Working Group strongly encourages the detailed study of patterns of practice regarding lymphadenectomy among Greek Urologists
Q: Neoadjuvant chemotherapy in everyday practice
Neoadjuvant cisplatin-based chemotherapy is the standard peri-operative treatment for localized, muscle-invasive bladder cancer
Causes for non-implementation were extensively discussed
Access-delay to oncological management
Concerns for overtreatment
Significant percentage of unfit patients
Lack of selection criteria of patients likely to benefit for neoadjuvant chemotherapy
The Group re-inforced the necessity for close interaction between urologists and oncologists
Q: Adjuvant chemotherapy for MIBC: a false common practice?
The Group felt that in view of the recent data from the most recent metanalysis (Lowe et al) and the reported EORTC ….. study (Sternberg et al, 2014) the current EAU, ESMO, NCCN guidelines (shown below) may be revised.
Patients who have not undergone neoadjuvant chemotherapy and are at high risk for relapse (T3, T4, N+) should be strongly consideredfor adjuvant cisplatin-based chemotherapy(according to the recently published HGUCG guidelines)
Q: The role of radiotherapy in MIBC
Radio-chemotherapy is the standard for patients who are not candidates for cystectomy
Need to define “unfit” patient and design studies focused in this population
3.ΟΜΑΔΑ ΕΡΓΑΣΙΑΣ ΚΑΡΚΙΝΟΥ ΠΡΟΣΤΑΤΟΥ
Q. Prostate cancer nomograms: How do we use them?
At the moment there are 106 predictive tools (!!!!), which makes their application in everyday practice somewhat problematic.
The areas which nomograms have been mainly developed are:
Prediction of biochemical recurrence after external beam radiotherapy or brachytherapy
Prediction of metastatic progression
Prediction of cancer-specific survival
Prediction of life expectancy
Q. Surgical treatment of high-risk PCa
The exact definition is unclear and a consensus has not been reached. Mostly the following criteria are used:
Clinical stage T2c
PSA > 20
Gleason score 8-10
Historically surgery is not recommended in high risk disease. Nevertheless, encouraging results have been published. The role of cytoreductive prostatectomy has not been defined and is not routinely recommended
Q. Role & templates of lymphadenectomy
Extensive lymph node dissection (eLND) is the standard for intermediate and high-risk prostate cancer which is managed with prostatectomy
The number of excised lymph nodes is directly correlated with time to disease progression. The average number of excised lymph nodes in the most reliable publications is 20. In addition, the importance oflymph node density was also discussed.
Q. Robotic vs laparoscopic vs open prostatectomy
There has been no direct comparison between robotic assisted radical prostatectomy (RARP) and open or laparoscopic radical prostatectomy.
The existing data suggest:
The oncological outcome is comparable with that of the other techniques
Recovery of continence and potency appears to be faster with RARP
RARP is a well-established alternative to the existing radical prostatectomy surgical approaches
Q. Positive surgical margins
- Positive surgical margins alone are not associated with a significantly increased risk of prostate cancer-specific mortality within 15 yr of RP.
- Urologists should continue to strive to avoid PSMs, as they increase BCR risk and need for secondary therapy and may be a source of considerable patient anxiety.
Q. Biochemical recurrence
- PSA rise represents either local or distant failure or both. Differentiating between local or distant failure is critical, because men with local recurrence can undergo salvage local treatment with curative intent, whereas those with distant failure may require systemic therapy.
- PSA kinetics (PSA DT) is the strongest factor identified to help determine which men are at the greatest risk of progression.
Q. Hormone-sensitive metastatic prostate cancer: a changing paradigm?
Following the recently reported E3805 trial, NCCN guidelines have now included ADT + docetaxel as an option for high-volume metastatic hormone-sensitive prostate cancer
High-volume disease is defined by:
Presence of visceral metastases
At least 4 bone metastases with one beyond the pelvis vertebral column
The above definition is rather arbitrary and has certain limitations regarding the extend of bone disease only (i.e. the importance of one large metastasis in the pelvis vs. 5 in the vertebral column)
Q. What is the 1st line preferred option for CRPC?
The following agents are now approved for 1st-line therapy of CRPC
Docetaxel + prednisone
Certain points should be taken into consideration
Abiraterone should be used in asymptomatic or oligosymptomatic patients without visceral metastases, while enzalutamide should be used in patients with asymptomatic or oligosymptomatic disease irrespective of the presence of visceral metastases
Ra-223 should be used in patients with symptomatic bone but without visceral metastases who are unfit for docetaxel
Sipuleucel-T has shown efficacy in minimally symptomatic patients and its use is very restricted due to technical problems
Mitoxantrone has only shown symptomatic improvement and improvement in PSA responses
Q. Sequencing of novel agents and chemotherapy in CRPC
The following agents are now approved for 2nd-line therapy of CRPC following failure of docetaxel + prednisone
The optimal sequence of novel agents in 2nd and subsequent lines has not been defined. Therefore, choice should also be based on patients preferences and co-morbidities
Q. Treatment of bone disease in prostate cancer
Denosumab has shown greater reduction of skeletal events compared to zoledronic acid. It also does not need adjustment in patients with impaired renal function and is administered sc.