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When to use imaging and imaging-guided therapies

Presented by
Dr Lorenzo Bianchi, Dr Carlo Andrea Bravi
EAU 2019
A clinical tool to guide physicians before suggesting 68Ga-PSMA PET/CT.

Which patient with biochemical recurrence after primary treatment for prostate cancer would result in a positive 68 Ga-PSMA PET/CT? The 2019 EAU Guideline panel recommends performing 68 Ga-PSMA PET/CT if the PSA level is >0.2 ng/mL, providing the results will influence treatment decisions, but it is unclear if this is cost-effective. Dr Lorenzo Bianchi (University of Bologna, Italy) built a prediction model to assess the risk of individual patients to have a positive PET/CT. Prostate cancer patients (n=703) with confirmed biochemical recurrence were stratified according to different clinical settings of recurrence: first PSA relapse (detection rate 40%), biochemical relapse after salvage therapy (detection rate 54%), PSA persistence after primary therapy (detection rate 60%), and disease progression before starting systemic therapies (detection rate 87%). The prediction model thus showed some promise, but will need to learn from this validation process in order to achieve better detection.

Dr Carlo Andrea Bravi et al. (Ospedale San Raffaele, Italy) reported a multicentre study looking at 605 patients treated with salvage lymph node dissection (SLND) for nodal recurrence of prostate cancer at 11 tertiary referral centres between 2002-2018. Outcomes were biochemical recurrence, clinical recurrence-free survival, cancer-specific and other-cause mortality at 8, 10, and 12 years from SLND. The long-term outcomes of these patients are not good; at 10 years post-SLND follow-up, only 15% of patients were free of clinical recurrence; cancer-specific mortality at 10 years was 34%. In a multivariate analysis of these data it became evident that the patients in this study that had a better outcome had been treated with concomitant hormonal/androgen deprivation therapy or a combination of concomitant hormonal therapy plus radiation therapy. This data points to the hypothesis that the combination treatment leads to the best outcomes, not the SLND alone.

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