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Benefit of upfront use of PET-CT still unclear

“Nobody knows yet if using PET-CT upfront is beneficial, or if picking up small traces of the disease can lead to patient improvement in survival and outcomes. We know from some series that there might be a place for such imaging techniques, but certainly not for all patients. It can be a waste of money and time,” Prof. Alberto Briganti (IT) cautioned following Plenary Session 3.

The third day of EAU18 started with a well-attended Plenary Session on Prostate Cancer. The session included several case-based debates, an overview of the most important PCa-related posters and the ESMO lecture. The main session was preceded by a short “Game-changing session”, which featured an update on immunotherapy in renal cell and bladder cancer, and a talk on the new standard of care for hormone-sensitive PCa.

Case-based debate on PET-CT

The majority of Plenary Session 3 was dedicated to a multidisciplinary case-based debate on PET-CT-detected oligometastatic disease, moderated by Briganti. It featured contributions from Prof. Silke Gillessen Sommer (CH) from the perspective of an oncologist, Prof. Steven Joniau (BE) as a urologist, Prof. Gert De Meerleer (BE) as a radiation therapist and finally Prof. Nicolas Mottet for the EAU Guidelines perspective.

The case as presented to the panel by Briganti concerned a 61 year-old patient who was classified as cN0, M0 through conventional imaging, but where the use of a PSMA PET-CT revealed a spread to a lymph node in the pre-sacral area and two bone lesions, both smaller than 1cm. This raised the patient’s status to cN1 and cM1.

Profs. Gillessen Sommer, Joniau and De Meerleer each argued treatment options from their perspective, leaving Prof. Mottet to give the audience of the eURO Auditorium the perspective of the most current EAU Guidelines. The Guidelines considers PET PSMA ‘of interest’, despite the lack of evidence of effectiveness for upfront staging. Targeting the metastases, as De Meerleer advocated for, is considered ‘experimental’, and interesting to evaluate.

“We saw a nice multidisciplinary discussion, which allowed the audience to see possible treatment options from different perspectives,” Briganti summarised. “Of course we always need evidence first, but there is certainly a role for expert opinion. We are waiting for strong evidence yet to come.”

On the timeframe of possible strong evidence for the advantage of upfront use of PET-CT: “we might never even see it. We are currently using PSMA, but in a few years or even months, we might have a better tracer. It’s a constantly evolving field.”

Article by Loek Keizer