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Focal Therapy of Prostate Cancer: Evidence-based Analysis for Modern Selection Criteria

  • Prostate Cancer (R Reiter, Section Editor)
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Abstract

Focal therapy for prostate cancer has been increasingly utilized with the goal of effective disease control while maximizing patient functional outcomes. The optimal patient selection criteria are not known and therefore are not standardized. This review compares the available expert panel consensus guidelines with the selection criteria utilized in recently published focal therapy trials. Because the data from focal trials are still maturing, the currently enrolling clinical trials are reviewed as well. In addition, the recent literature regarding technological advances in prostate biopsy and imaging strategies are added to the current guidelines to recommend a rationale for patient selection.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Screening for Prostate Cancer: A Review of the Evidence for the U.S. Preventive Services Task Force. Available at http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm. Accessed January 2012.

  2. Eggener SE, Scardino PT, Carroll PR, Zelefsky MJ, Sartor O, Hricak H, et al. Focal therapy for localized prostate cancer: a critical appraisal of rationale and modalities. J Urol. 2007;178(6):2260–7.

    Article  PubMed  Google Scholar 

  3. de la Rosette J, Ahmed H, Barentsz J, Johansen TB, Brausi M, Emberton M, et al. Focal therapy in prostate cancer-report from a consensus panel. J Endourol. 2010;24(5):775–80.

    Article  PubMed  Google Scholar 

  4. D’Amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick GA, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998;280(11):969–74.

    Article  PubMed  Google Scholar 

  5. Epstein JI, Walsh PC, Carmichael M, Brendler CB. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA. 1994;271(5):368–74.

    Article  PubMed  CAS  Google Scholar 

  6. Onik G, Vaughan D, Lotenfoe R, Dineen M, Brady J. The “male lumpectomy”: focal therapy for prostate cancer using cryoablation results in 48 patients with at least 2-year follow-up. Urol Oncol. 2008;26(5):500–5.

    Article  PubMed  Google Scholar 

  7. Lambert EH, Bolte K, Masson P, Katz AE. Focal cryosurgery: encouraging health outcomes for unifocal prostate cancer. Urology. 2007;69(6):1117–20.

    Article  PubMed  Google Scholar 

  8. Ellis DS, Manny Jr TB, Rewcastle JC. Focal cryosurgery followed by penile rehabilitation as primary treatment for localized prostate cancer: initial results. Urology. 2007;70(6 Suppl):9–15.

    Article  PubMed  Google Scholar 

  9. Bahn DK, Silverman P, Lee Sr F, Badalament R, Bahn ED, Rewcastle JC. Focal prostate cryoablation: initial results show cancer control and potency preservation. J Endourol. 2006;20(9):688–92.

    Article  PubMed  Google Scholar 

  10. Tsivian M, Moreira DM, Sun L, Mouraviev V, Kimura M, Moul JW et al. Biopsy accuracy in identifying unilateral prostate cancer depends on prostate weight. Urol Oncol 2010.

  11. Arvold ND, Chen MH, Moul JW, Moran BJ, Dosoretz DE, Banez LL, et al. Risk of death from prostate cancer after radical prostatectomy or brachytherapy in men with low or intermediate risk disease. J Urol. 2011;186(1):91–6.

    Article  PubMed  Google Scholar 

  12. Hofner T, Pfitzenmaier J, Alrabadi A, Pahernik S, Hadaschik B, Wagener N et al. PSA density lower cutoff value as a tool to exclude pathologic upstaging in initially diagnosed unilateral prostate cancer: impact on hemiablative focal therapy. World J Urol 2010.

  13. Palma D, Tyldesley S, Pickles T. Pretreatment prostate-specific antigen velocity is associated with development of distant metastases and prostate cancer mortality in men treated with radiotherapy and androgen-deprivation therapy. Cancer. 2008;112(9):1941–8.

    Article  PubMed  Google Scholar 

  14. Ketchandji M, Kuo YF, Shahinian VB, Goodwin JS. Cause of death in older men after the diagnosis of prostate cancer. J Am GeriatrSoc. 2009;57(1):24–30.

    Article  Google Scholar 

  15. Lu-Yao GL, Albertsen PC, Moore DF, Shih W, Lin Y, DiPaola RS, et al. Outcomes of localized prostate cancer following conservative management. JAMA. 2009;302(11):1202–9.

    Article  PubMed  CAS  Google Scholar 

  16. El Fegoun AB, Barret E, Prapotnich D, Soon S, Cathelineau X, Rozet F, et al. Focal therapy with high-intensity focused ultrasound for prostate cancer in the elderly. A feasibility study with 10 years follow-up. Int Braz J Urol. 2011;37(2):213–9. discussion 220–212.

    PubMed  Google Scholar 

  17. Scattoni V, Raber M, Capitanio U, Abdollah F, Roscigno M, Angiolilli D, et al. The optimal rebiopsy prostatic scheme depends on patient clinical characteristics: results of a recursive partitioning analysis based on a 24-core systematic scheme. Eur Urol. 2011;60(4):834–41.

    Article  PubMed  Google Scholar 

  18. Tsivian M, Kimura M, Sun L, Mouraviev V, Mayes JM, Polascik TJ. Predicting unilateral prostate cancer on routine diagnostic biopsy: sextant vs extended. BJU Int 2009.

  19. King AC, Livermore A, Laurila TA, Huang W, Jarrard DF. Impact of immediate TRUS rebiopsy in a patient cohort considering active surveillance for favorable risk prostate cancer. Urol Oncol 2011

  20. Berglund RK, Masterson TA, Vora KC, Eggener SE, Eastham JA, Guillonneau BD. Pathological upgrading and up staging with immediate repeat biopsy in patients eligible for active surveillance. J Urol. 2008;180(5):1964–7. discussion 1967–1968.

    Article  PubMed  Google Scholar 

  21. Tseng KS, Landis P, Brimo F, Partin AW, Epstein JI, Carter HB. Repeat prostate biopsies predict location of index cancer in an active surveillance cohort. BJU Int. 2011;108(9):1415–20.

    Article  PubMed  Google Scholar 

  22. Abdollah F, Novara G, Briganti A, Scattoni V, Raber M, Roscigno M, et al. Trans-rectal versus trans-perineal saturation rebiopsy of the prostate: is there a difference in cancer detection rate? Urology. 2011;77(4):921–5.

    Article  PubMed  Google Scholar 

  23. Taira AV, Merrick GS, Galbreath RW, Andreini H, Taubenslag W, Curtis R, et al. Performance of transperineal template-guided mapping biopsy in detecting prostate cancer in the initial and repeat biopsy setting. Prostate Cancer Prostatic Dis. 2010;13(1):71–7.

    Article  PubMed  CAS  Google Scholar 

  24. Abdollah F, Scattoni V, Raber M, Roscigno M, Briganti A, Suardi N, et al. The role of transrectal saturation biopsy in tumour localization: pathological correlation after retropubic radical prostatectomy and implication for focal ablative therapy. BJU Int. 2011;108(3):366–71.

    Article  PubMed  Google Scholar 

  25. Ahmed HU, Hu Y, Carter T, Arumainayagam N, Lecornet E, Freeman A, et al. Characterizing clinically significant prostate cancer using template prostate mapping biopsy. J Urol. 2011;186(2):458–64.

    Article  PubMed  Google Scholar 

  26. •• Barqawi AB, Rove KO, Gholizadeh S, O’Donnell CI, Koul H, Crawford ED. The role of 3-dimensional mapping biopsy in decision making for treatment of apparent early stage prostate cancer. J Urol. 2011;186(1):80–5. This series reports high upgrade and upstage rates with TPM biopsy relative to standard TRUS biopsy. Pending correlation with whole-mount pathology will be critical to quantify the accuracy for FT applications.

    Article  PubMed  Google Scholar 

  27. Ahmed HU, Freeman A, Kirkham A, Sahu M, Scott R, Allen C, et al. Focal therapy for localized prostate cancer: a phase I/II trial. J Urol. 2011;185(4):1246–54.

    Article  PubMed  CAS  Google Scholar 

  28. Tsivian M, Hruza M, Mouraviev V, Rassweiler J, Polascik TJ. Prostate biopsy in selecting candidates for hemiablative focal therapy. J Endourol. 2010;24(5):849–53.

    Article  PubMed  Google Scholar 

  29. Roethke M, Anastasiadis AG, Lichy M, Werner M, Wagner P, Kruck S, et al. MRI-guided prostate biopsy detects clinically significant cancer: analysis of a cohort of 100 patients after previous negative TRUS biopsy. World J Urol 2011.

  30. •• Ouzzane A, Puech P, Lemaitre L, Leroy X, Nevoux P, Betrouni N, et al. Combined Multi-parametric MRI and Targeted Biopsies Improve Anterior Prostate Cancer Detection, Staging, and Grading. Urology 2011. The authors describes that biopsies targeted to suspicious Mp-MRI findings in the anterior and central prostate have a high rate of accuracy.

  31. Pinto PA, Chung PH, Rastinehad AR, Baccala Jr AA, Kruecker J, Benjamin CJ, et al. Magnetic resonance imaging/ultrasound fusion guided prostate biopsy improves cancer detection following transrectal ultrasound biopsy and correlates with multi-parametric magnetic resonance imaging. J Urol. 2011;186(4):1281–5.

    Article  PubMed  Google Scholar 

  32. ClinicalTrials.gov. Pilot Study on Focal Prostate Radio-Frequency Ablation. Available at http://clinicaltrials.gov/ct2/show/NCT01423006. Accessed January 2012.

  33. Focal MR-Guided Focused Ultrasound Treatment of Localized Low-Risk Prostate Cancer: Feasibility Study [http://clinicaltrials.gov/ct2/show/NCT01226576]

  34. Assessing the Potential for Reduced Toxicity Using Focal Brachytherapy in Low-Risk Prostate Cancer [http://clinicaltrials.gov/ct2/show/NCT01354951]

  35. Lindner U, Weersink RA, Haider MA, Gertner MR, Davidson SR, Atri M, et al. Image guided photothermal focal therapy for localized prostate cancer: phase I trial. J Urol. 2009;182(4):1371–7.

    Article  PubMed  CAS  Google Scholar 

  36. • Truesdale MD, Cheetham PJ, Hruby GW, Wenske S, Conforto AK, Cooper AB, et al. An evaluation of patient selection criteria on predicting progression-free survival after primary focal unilateral nerve-sparing cryoablation for prostate cancer: recommendations for follow up. Cancer J. 2010;16(5):544–9. This report highlights the limitations of selecting patients for FT based on standard biopsy schemes and preoperative clinical parameters.

    Article  PubMed  Google Scholar 

  37. Stark JR, Perner S, Stampfer MJ, Sinnott JA, Finn S, Eisenstein AS, et al. Gleason score and lethal prostate cancer: does 3 + 4 = 4 + 3? J ClinOncol. 2009;27(21):3459–64.

    Article  Google Scholar 

  38. Turkbey B, Mani H, Shah V, Rastinehad AR, Bernardo M, Pohida T, et al. Multiparametric 3T prostate magnetic resonance imaging to detect cancer: histopathological correlation using prostatectomy specimens processed in customized magnetic resonance imaging based molds. J Urol. 2011;186(5):1818–24.

    Article  PubMed  Google Scholar 

  39. Raz O, Haider MA, Davidson SR, Lindner U, Hlasny E, Weersink R, et al. Real-time magnetic resonance imaging-guided focal laser therapy in patients with low-risk prostate cancer. Eur Urol. 2010;58(1):173–7.

    Article  PubMed  Google Scholar 

  40. Mouraviev V, Villers A, Bostwick DG, Wheeler TM, Montironi R, Polascik TJ. Understanding the pathological features of focality, grade and tumour volume of early-stage prostate cancer as a foundation for parenchyma-sparing prostate cancer therapies: active surveillance and focal targeted therapy. BJU Int. 2011;108(7):1074–85.

    Article  PubMed  Google Scholar 

  41. Onik G, Miessau M, Bostwick DG. Three-dimensional prostate mapping biopsy has a potentially significant impact on prostate cancer management. J ClinOncol. 2009;27(26):4321–6.

    Article  Google Scholar 

  42. Ahmed HU. The index lesion and the origin of prostate cancer. N Engl J Med. 2009;361(17):1704–6.

    Article  PubMed  CAS  Google Scholar 

  43. •• Karavitakis M, Winkler M, Abel P, Livni N, Beckley I, Ahmed HU. Histological characteristics of the index lesion in whole-mount radical prostatectomy specimens: implications for focal therapy. Prostate Cancer Prostatic Dis. 2011;14(1):46–52. This article describes pathological characterization of CaP foci that supports the theory that the primary or index lesion accounts for most significant disease.

    Article  PubMed  CAS  Google Scholar 

  44. Bott SR, Ahmed HU, Hindley RG, Abdul-Rahman A, Freeman A, Emberton M. The index lesion and focal therapy: an analysis of the pathological characteristics of prostate cancer. BJU Int. 2010;106(11):1607–11.

    Article  PubMed  Google Scholar 

  45. Stamey TA, Freiha FS, McNeal JE, Redwine EA, Whittemore AS, Schmid HP. Localized prostate cancer. Relationship of tumor volume to clinical significance for treatment of prostate cancer Cancer. 1993;71(3 Suppl):933–8.

    CAS  Google Scholar 

  46. ClinicalTrials.gov. Laser Based Focal Ablation of Low Grade Prostate Cancer. Available at http://clinicaltrials.gov/ct2/show/NCT01192438. Accessed January 2012.

  47. ClinicalTrials.gov. MRI Targeted Focal Laser Thermal Therapy of Prostate Cancer (FLTT 002) Available at http://clinicaltrials.gov/ct2/show/NCT01094665. Accessed January 2012.

  48. ClinicalTrials.gov. MR Image Guided Therapy in Prostate Cancer. Available at [http://clinicaltrials.gov/ct2/show/NCT01377753. Accessed January 2012.

  49. Nogueira L, Wang L, Fine SW, Pinochet R, Kurta JM, Katz D, et al. Focal treatment or observation of prostate cancer: pretreatment accuracy of transrectal ultrasound biopsy and T2-weighted MRI. Urology. 2010;75(2):472–7.

    Article  PubMed  Google Scholar 

  50. Jackson AS, Reinsberg SA, Sohaib SA, Charles-Edwards EM, Jhavar S, Christmas TJ, et al. Dynamic contrast-enhanced MRI for prostate cancer localization. Br J Radiol. 2009;82(974):148–56.

    Article  PubMed  CAS  Google Scholar 

  51. Puech P, Potiron E, Lemaitre L, Leroy X, Haber GP, Crouzet S, et al. Dynamic contrast-enhanced-magnetic resonance imaging evaluation of intraprostatic prostate cancer: correlation with radical prostatectomy specimens. Urology. 2009;74(5):1094–9.

    Article  PubMed  Google Scholar 

  52. Rouse P, Shaw G, Ahmed HU, Freeman A, Allen C, Emberton M. Multi-parametric magnetic resonance imaging to rule-in and rule-out clinically important prostate cancer in men at risk: a cohort study. Urol Int. 2011;87(1):49–53.

    Article  PubMed  Google Scholar 

  53. Wang L, Akin O, Mazaheri Y, Ishill NM, Kuroiwa K, Zhang J, et al. Are histopathological features of prostate cancer lesions associated with identification of extracapsular extension on magnetic resonance imaging? BJU Int. 2010;106(9):1303–8.

    Article  PubMed  Google Scholar 

  54. Cornud F, Rouanne M, Beuvon F, Eiss D, Flam T, Liberatore M, et al. Endorectal 3D T2-weighted 1 mm-slice thickness MRI for prostate cancer staging at 1.5Tesla: Should we reconsider the indirect signs of extracapsular extension according to the D'Amico tumor risk criteria? Eur J Radiol 2011.

  55. Woodfield CA, Tung GA, Grand DJ, Pezzullo JA, Machan JT, Renzulli 2nd JF. Diffusion-weighted MRI of peripheral zone prostate cancer: comparison of tumor apparent diffusion coefficient with Gleason score and percentage of tumor on core biopsy. AJR Am J Roentgenol. 2010;194(4):W316–22.

    Article  PubMed  Google Scholar 

  56. Nagarajan R, Margolis D, Raman S, Sheng K, King C, Reiter R, et al. Correlation of Gleason scores with diffusion-weighted imaging findings of prostate cancer. AdvUrol. 2012;2012:374805.

    Google Scholar 

  57. Nagarajan R, Margolis D, McClure T, Raman S, Thomas MA. Role of endorectal magnetic resonance spectroscopic imaging in two different Gleason scores in prostate cancer. Med PrincPract. 2011;20(5):444–8.

    Google Scholar 

  58. Kobus T, Hambrock T. Hulsbergen-van de Kaa CA, Wright AJ, Barentsz JO, Heerschap A, Scheenen TW: In vivo assessment of prostate cancer aggressiveness using magnetic resonance spectroscopic imaging at 3 T with an endorectal coil. EurUrol. 2011;60(5):1074–80.

    Google Scholar 

  59. Augustin H, Fritz GA, Ehammer T, Auprich M, Pummer K. Accuracy of 3-Tesla magnetic resonance imaging for the staging of prostate cancer in comparison to the Partin tables. Acta Radiol. 2009;50(5):562–9.

    Article  PubMed  CAS  Google Scholar 

  60. Braeckman J, Autier P, Soviany C, Nir R, Nir D, Michielsen D, et al. The accuracy of transrectal ultrasonography supplemented with computer-aided ultrasonography for detecting small prostate cancers. BJU Int. 2008;102(11):1560–5.

    Article  PubMed  Google Scholar 

  61. Xie SW, Li HL, Du J, Xia JG, Guo YF, Xin M, et al. Contrast-enhanced ultrasonography with contrast-tuned imaging technology for the detection of prostate cancer: comparison with conventional ultrasonography. BJU Int 2011.

  62. Aigner F, Pallwein L, Schocke M, Lebovici A, Junker D, Schafer G, et al. Comparison of real-time sonoelastography with T2-weighted endorectal magnetic resonance imaging for prostate cancer detection. J Ultrasound Med. 2011;30(5):643–9.

    PubMed  Google Scholar 

  63. Brock M, von Bodman C, Sommerer F, Loppenberg B, Klein T, Deix T, et al. Comparison of real-time elastography with grey-scale ultrasonography for detection of organ-confined prostate cancer and extra capsular extension: a prospective analysis using whole mount sections after radical prostatectomy. BJU Int. 2011;108(8 Pt 2):E217–22.

    Article  PubMed  Google Scholar 

  64. Walz J, Marcy M, Pianna JT, Brunelle S, Gravis G, Salem N, et al. Identification of the prostate cancer index lesion by real-time elastography: considerations for focal therapy of prostate cancer. World J Urol. 2011;29(5):589–94.

    Article  PubMed  Google Scholar 

  65. Zhai L, Madden J, Foo WC, Mouraviev V, Polascik TJ, Palmeri ML, et al. Characterizing stiffness of human prostates using acoustic radiation force. Ultrason Imaging. 2010;32(4):201–13.

    PubMed  Google Scholar 

  66. Zhai L, Madden J, Foo WC, Palmeri ML, Mouraviev V, Polascik TJ, et al. Acoustic radiation force impulse imaging of human prostates ex vivo. Ultrasound Med Biol. 2010;36(4):576–88.

    Article  PubMed  Google Scholar 

  67. Tsivian M, Polascik TJ. Focal cryotherapy for prostate cancer. CurrUrol Rep. 2010;11(3):147–51.

    Google Scholar 

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Disclosures

M. R. Abern: none; M .Tsivian: none. Dr. Thomas J. Polascik has served as a consultant and received payment for lectures (including service on speakers bureaus) for Galil Medical and AngioDynamics, and has received research support and payment for the development of educational presentations from Galil Medical.

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Abern, M.R., Tsivian, M. & Polascik, T.J. Focal Therapy of Prostate Cancer: Evidence-based Analysis for Modern Selection Criteria. Curr Urol Rep 13, 160–169 (2012). https://doi.org/10.1007/s11934-012-0241-5

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