ESOU18: Treatment Modalities for Intermediate Risk Prostate Cancer

Amsterdam, The Netherlands (UroToday.com) Focal therapy (FT) is as an anatomy-based (zonal) or lesion-based treatment strategy. It is an emerging field of localized prostate cancer (PC) treatment, which will eventually be incorporated into guidelines, based on its mid to long-term oncological results. Intermediate risk PC (IRPC) is currently the only indication for FT, according to Dr. Villers. FT requires knowledge of the precise extent of the disease and grade assessment, for which MRI with targeted biopsies are necessary^1,2. The frequent multi-focality of PC and the fact that MRI does not capture all IRPCs, might serve as potential arguments against FT usage. However, studies using radical prostatectomy specimens have showed that acceptable oncologic control can be achieved in appropriately selected patients, with the untreated part of the prostate being monitored in an AS protocol, after FT.

Follow-up includes MRI with subsequent 12-core random biopsies and targeted biopsies to any suspicious lesion at MRI 6–12 months after treatment. PSA kinetics is based on 6 months PSA tests. In case of a suspicious PSA rise (> 0.5ng/ml/yr) a biopsy is performed. Functional Results of the AFU study (HIFU hemi-ablation) (Figure 1) in 111 patients at 2 years of follow-up showed grade 3 adverse events in 13%⁴. At 12 months continence and erectile functions were preserved in 97% and 78% of patients. No significant decrease in quality of life score was observed at 12 months follow-up. FT failure may be reported in one of the following definitions⁵: 1-ablation failure : treatment failure due to the ablative energy inadequately destroying treated tissue, 2- targeting failure : the energy is not adequately applied to the tumor spatially, 3- selection failure occurs when a patient was wrongfully selected for FT.

Ablative techniques demonstrate acceptable short-term oncologic outcomes but will require longer follow-up to determine their true oncologic efficacy. To date, there are no randomized controlled trials comparing FT to conventional radical prostatectomy or radiotherapy, and there is limited oncologic follow-up beyond 5 years. There is a real need for long-term results from several centers.

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Speaker: Arnauld Villers, MD, PhD Department of Urology Lille University, France

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands

References:

1. Villers A, Puech P, Mouton D, Leroy X, Ballereau C, Lemaitre L. Dynamic contrast enhanced, pelvic phased array magnetic resonance imaging of localized prostate cancer for predicting tumor volume: correlation with radical prostatectomy findings. J Urol. 2006, 2432-7.

2. Ahmed HU, Hindley RG, Dickinson L, Freeman A, Kirkham AP, Sahu M, Scott R, Allen C, Van der Meulen J, Emberton M Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study. Lancet Oncol. 2012 (6):622-32.

3. Valerio M, Donaldson I, Emberton M, Ehdaie B, Hadaschik BA, Marks LS, Mozer P, Rastinehad AR, Ahmed HU. Detection of Clinically Significant Prostate Cancer Using Magnetic Resonance Imaging-Ultrasound Fusion Targeted Biopsy: A Systematic Review. Eur Urol. 2015 (1):8-19.

4. Rischmann P, Gelet A, Riche B, Villers A, Pasticier G, Bondil P, Jung JL, Bugel H, Petit J, Toledano H, Mallick S, Rouvière O, Rabilloud M, Tonoli-Catez H, Crouzet S. Focal High Intensity Focused Ultrasound of Unilateral Localized Prostate Cancer: A Prospective Multicentric Hemiablation Study of 111 Patients. Eur Urol. 2017 (2):267-273.

5. Postema AW, De Reijke TM, Ukimura O, Van den Bos W, Azzouzi AR, Barret E, Baumunk D, Blana A, Bossi A, Brausi M, Coleman JA, et al. Standardization of definitions in focal therapy of prostate cancer: report from a Delphi consensus project. World J Urol. 2016 (10):1373-82.

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