Wilma, 69 years old, still cooks traditional Dutch meals every Sunday, but she always ends dessert with ‘stroopwafels’ warmed over tea for her grandchildren. She says it is a small tradition that keeps everyone at the table a little longer. 

She recently underwent cystoscopy for painless haematuria, revealing a papillary bladder tumour. Her past medical history includes stable coronary artery disease, hypertension and borderline diabetes. She quit smoking 25 years ago.

Assessment summary: 

• Diagnostic TURBT, pathological review:
  • At least pT2 urothelial carcinoma (UCa)
  • Unifocal, no concomitant carcinoma in situ (CIS)
• Imaging: suggestive for cT3N0M0
• Ultrasound: no hydronephrosis
• CrCl: 66 ml/min
• No peripheral neuropathy
• No hearing impairment
• ECOG PS: 0
• Cardiac ejection fraction: 62%

The multidisciplinary tumour board assessed that the patient is a candidate for RC + PLND.

Regulatory approval and local restrictions aside, which option would you suggest for Wilma?

(click on the option you would recommend & scroll down to compare your answer with Dr. Thomas Powles)

A. Neoadjuvant dd-MVAC

B. Neoadjuvant full dose gemcitabine + cisplatin (GC)

C. Neoadjuvant full dose GC + perioperative durvalumab

D. Neoadjuvant split dose GC + perioperative durvalumab

E. Perioperative enfortumab vedotin + pembrolizumab

F. No neoadjuvant treatment

Piet, 76 years old, lives close to the museum district and often visits the Rijksmuseum. He looks forward to taking his grandchildren there. He can’t wait to show them the work of his favourite, famous painters: Rembrandt van Rijn and Vermeer.

After a recent cystoscopy, Piet was told he has a papillary tumour.  

Assesment summary:

• Assessment summary:

• Medical history: former smoker (50 pack years), hypertension
• Diagnostic TURBT, pathological review:
  o   At least pT2 UCa
  o   Unifocal, no concomitant CIS
• Imaging: suggestive for cT2N0M0
• Ultrasound: no hydronephrosis
• CrCl: 40 ml/min
• No peripheral neuropathy
• No hearing impairment
• ECOG PS: 1
• Cardiac ejection fraction: 55%

The multidisciplinary tumour board assessed that the patient is a candidate for RC + PLND.

Regulatory approval and local restrictions aside, which of the following treatment options would you choose for this patient?

(click on the option you would recommend & scroll down to compare your answer with Dr. Thomas Powles)

A. Neoadjuvant dd-MVAC

B. Neoadjuvant full dose gemcitabine + cisplatin (GC)

C. Neoadjuvant full dose GC + perioperative durvalumab

D. Neoadjuvant split dose GC + perioperative durvalumab

E. Perioperative enfortumab vedotin + pembrolizumab

F. No neoadjuvant treatment

Hendrik, 72 years old, used to work as a canal guide. He preferred the quieter early morning tours, when the water was calm and the city felt like it belonged to him again for a short moment. Now, his son sometimes takes him along on his own boat for a tour through the canals. 

Assessment summary: 

Hendrik has a history of PCa:

• 8 years ago: RP + ePLND for high-risk PCa (pT3aN0M0), ISUP grade group 4, undetectable postoperative PSA 
• 6 years ago: salvage EBRT to the prostate bed without ADT for rising PSA (0.24 ng/ml) 
• 4 years ago: ADT + abiraterone/prednisone for low-volume mHSPC (PSA 0.7 ng/ml, 2 bone metastases on the spine)
• 1.5 years ago: docetaxel for oligoprogressive mCRPC (PSA: 9.8 ng/ml, testosterone: 12 ng/dl (0.42 nmol/l), 4 metastases on the spine, 1 on the pelvis, small pelvic LNs), ADT continued throughout treatment

Current situation: 

• Medical history: controlled hyperlipidaemia (on statin therapy)
• ECOG PS: 0
• Symptoms: back pain (under control with NSAIDs) and mild fatigue
• Lab values: normal
• PSMA PET/CT: progression in bone only with multiple PSMA-avid bone metastases (4 on spine, 2 on pelvis, 1 on left rib), stable small pelvic LNs, no visceral metastases

Which genomic alteration would you prioritise testing for in this patient (not taking into account regulatory approval and local restrictions)?

(click on the option you would recommend & scroll down to compare your answer with Dr. Alice Bernard-Tessier)

A. AR amplification and AR ligand-binding domain mutations

B. HRR alterations

C. Microsatellite instability

D. PTEN loss

Theo, 72 years old, regularly takes the train to Amsterdam to visit small galleries and second-hand bookshops. He enjoys browsing without a plan and often returns home with an old photography book or a vintage map. Each time, his wife wonders what treasure he will bring home next. 

Assessment summary: 

3 years ago, Theo was diagnosed with high-risk PCa:

• cT3N0M0, ISUP grade 4, PSA: 17 ng/ml
• He was treated with EBRT + 24 months of ADT
• PSA nadir was 0.25 ng/ml

1 year ago: 

• PSA 2.9 ng/ml; serum testosterone 315 ng/dl (10.9 nmol/l)
• Bone and CT scan: 2 enlarged pelvic lymph nodes, no bone or visceral metastases
• ADT was restarted continuously
• PSA nadir was 0.9 ng/ml

Now, Theo has mCRPC:

• Medical history: well-controlled hypertension
• ECOG PS: 0, G8 score: 15/17
• Asymptomatic
• PSA: 18.6 ng/ml, serum testosterone: 14 ng/dl (0.49 nmol/l)
• Lab values: normal
• Bone scan: 5 bone metastases (3 on vertebrae, 1 on the pelvis, 1 on the left femur), not present on conventional imaging 6 months ago
• CT scan: stable lymph nodes, no signs of visceral metastasis
• No actionable germline or somatic mutations identified

Treatment with denosumab was started.

Which of the following treatment options would you suggest for this patient? (not taking into account regulatory approval and local restrictions)?

(click on the option you would recommend & scroll down to compare your answer with Dr. Fabio Turco)

A. Abiraterone

B. Enzalutamide

C. Docetaxel

D. Radium-223

E. Enzalutamide + radium-223

F. ARPI + PARPi

Anton, 69 years old, spends 3 days a week volunteering at a local museum. He cycles there and welcomes visitors, bringing Amsterdam's history to life through his stories. He enjoys the sense of purpose the role provides and appreciates the chance to interact with people from all walks of life. It helps him stay active and engaged, which is important to him.

Assessment summary: 

Recently, Anton was diagnosed with mHSPC. His baseline PSA was 18.8 ng/ml and ADT was started. Now, a few weeks later, he visits the clinic to discuss further management.

• Medical history: type 2 diabetes (on metformin) and well-controlled hypercholesterolaemia (on simvastatin)
• ECOG PS: 0
• PSA: 10.1 ng/ml
• Lab values: normal
• Prostate biopsy: ISUP grade group 4 (Gleason score 4+4)
• Bone scan: 3 bone metastases (1 lesion in the left iliac bone, 1 in the lumbar spine and 1 in the right rib)
• CT: locally advanced prostatic mass; 3 sclerotic bone lesions, no enlarged pelvic or retroperitoneal lymph nodes, no evidence of visceral metastases
• No actionable germline or somatic mutations detected

Which systemic treatment option would you suggest for Anton (not taking into account regulatory approval and local restrictions)?

(click on the option you would recommend & scroll down to compare your answer with Dr. Fabio Turco)

A. ADT + 6 cycles of docetaxel

B. ADT + abiraterone

C. ADT + apalutamide

D. ADT + darolutamide

E. ADT + enzalutamide

F. ADT + 6 cycles of docetaxel + abiraterone

G. ADT + 6 cycles of docetaxel + darolutamide