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The “Ideal” Biopsy in Advanced Prostate Cancer - Axel Merseburger and Maria Ribal at PC Debate, Baveno, April 2016
Professor Axel Merseburger, Professor and Chairman of the Department of Urology Campus Lübeck,
University Hospital Schleswig-Holstein, Lübeck, Germany,
Dr Maria José Ribal Caparròs, Head of Uro-Oncology Unit, Urology Department, Barcelona, Spain
Prostate Cancer Debates, Baveno, April 2016
Optimizing biopsy in advance prostate cancer patients is essential for decision making and diagnosis. In the talk Dr Capparrós, Barcelona, Spain, explains to Professor Merseburger, Lübeck, Germany, that an image-based targeted biopsy combined with a random biopsy would be the “perfect” procedure at present. Furthermore she states that the new Epstein grading system is a validated alternative to the Gleason system and that focal therapy could be a future approach.
Axel Merseburger: My name is Axel Merseburger and I am a urologist and Head of the Urology Department at Lűbeck University in Northern Germany. I am pleased to be sitting here together with Professor Maria Ribal, from Barcelona: we are here in Italy, in Baveno by the beautiful Lake Maggiore, at the prostate cancer debate meeting in 2016. We are debating prostate cancer, advanced prostate cancer, and we have had a workshop on the biopsy of the prostate – initial biopsy, the pros and cons. We have extensively discussed this topic but, first of all, Maria, could you introduce yourself to the audience.
Maria Ribal: Thank you very much, Axel. I am Maria Ribal and I come from Barcelona. I work at the Hospital Clinic: it is a university hospital and I am in charge of the multidisciplinary team and unit in uro-oncology that comprises a team of urologists, medical oncologists, radiation oncologists, pathologists and radiologists. We all work together, practising uro-oncology.
Image-guided targeted prostate biopsy
Merseburger: Thank you. According to the couple of hours of discussion that we have just had, what do you think would be the ideal biopsy? What would you recommend to your friends? Transrectal, transperineal, in narcotic, with antibiotics or not?
Ribal: That is a difficult question. Right now, if we lived in an ideal world, I would say that the perfect biopsy is first, that based on image. I would say we should not biopsy any longer without imaging test before, so that would probably be the first message – that it should be based on an imaging test.
Regardless of which kind of biopsy I would recommend between the transperineal or transrectal, the truth is that nowadays we use transrectal biopsy upfront, as a first manoeuvre, when we decide that it should be biopsied. The truth is that transperineal is used as a second-round biopsy. Probably, in some cases, transperineal should be the first approach but I am not sure about that. Probably, as a first step, I would say, image guy, target biopsy, use ultrasound, transrectal, and obviously use a prophylactic antibiotic – this is not a discussion about the use of prophylactic antibiotic.
Merseburger: When performing biopsies, could you comment on the cores? How many cores of prostatic tissue should be received?
Ribal: If you are thinking about a random biopsy, that probably is almost dying, as we discussed in the workshop today. I would you say that you need to do at least 10 or 12 cores. The truth is that, the more we base our biopsy on the imaging test, we will go more to target biopsies. We should combine the target biopsy to the lesion that is a suspicious one, with a random biopsy. I would say that this is the ideal way to proceed now.
Merseburger: Yes, but knowing that you are heavily involved in EAU guidelines work, you recommend what the EAU guidelines 2016 version recommends right now. It is not standard to do two or three target biopsies, but it is still standard that you do a randomise biopsy, and 10 to 12, according to EAU guidelines. Would you go back over that, or - ?
Ribal: The truth is that the EAU guidelines are already based on the work that has demonstrated a level of evidence. The truth is that the level of evidence that we have now for target biopsies is not strong enough to recommend in level 1. Why? Because we need to improve our MRI technique and we need to improve the way we do evaluation. It will probably be recommended with a level 1, in a very, very few months.
Epstein prostate grading system
Merseburger: Okay. We have also touched on, once you have the biopsy, the new grade groups by Epstein, just published recently in European Urology. I personally think that those five groups are very handy to use, and to explain to the patient. Do you agree, or do you have another feeling about those new – will it replace Gleason, or will it just incorporate Gleason?
Ribal: Well, I think it is not replacing Gleason, because they are based on Gleason. I think it is a more rationale use of the Gleason score. Probably, what we are trying to improve is the way we have used Gleason until now. There are many things that are already delivered from the way we classify our patients, which is therapy, which is non-therapy, what kind of approach? I think these new groups from Epstein will help us to decide which patient is at very low risk of the disease, and those who are at very high risk. I am not sure whether this could be the last classification. We should probably wait for years and perhaps it could be improved. At the moment, however, I think it is better than the Gleason by itself.
Focal therapy in prostate cancer
Merseburger: I agree. As you mentioned, it helps cueing in the biopsy result into patients who might undergo active surveillance, for example. Also – and this is a trend in Germany and also performed at our centre in Lűbeck – is focal therapy already a topic which is already worldwide, Europe-wide, under discussion, following EAU at the beginning at this year? What is your perspective on focal therapy? Is it here to stay, or to come, or is it something in the future?
Ribal: This is really controversial. The truth is that we are moving in a moment where we are completely aware that there is over-diagnosis and over-treatment. We are trying to avoid the over-diagnosis with a better diagnosis schedule, and we are trying to overcome the over-treatment.
Focal therapy could be included there, but not competing with active surveillance. I think we don’t need to treat patients who don’t deserve therapy. Active surveillance is for very, very low-risk disease, and it should maintain that, so we cannot replace this with focal therapy. It could be in those intermediate-risk prostate cancers, at low risk of progression, but the truth is that there are many things that are not solved by focal therapy, such as multiplicity and how to follow the patients, and which technique we should use. I would say that, by now, focal therapy could only be applied in clinical trials or in an experimental setting, because there are many things we need to learn. I would say that it could be an option in the future but we need to learn a little more.
Merseburger: Maria, I have really learned a great deal from having the interactive discussion with you at the workshop and now. Do you have anything in mind about our workshop, that we haven’t covered now? Otherwise, I would really like to thank you for the opportunity to interview you here in Baveno. Are there any other aspects on focal therapy or biopsy, which you would like to share with the audience?
Ribal: No, I would say that we have covered everything. The first and principal message is that we need to improve our way of biopsying patients, because there are many decisions that depend on the way that we do the diagnosis. It is really useful, and I would like to thank you very much for this interview.
Merseburger: Thank you very much. Good-bye.