EAU 2017: Controversies - Focal therapy and the concept of the index lesion: Sense

London, England (UroToday.com) Dr. De La Rosette debated why focal therapy is a good and viable option for treating the index lesion in prostate cancer. Focal therapy should be incorporated into the armamentarium being used by the urologist treating prostate cancer. Reasons to us focal therapy include the increasing diagnosis of prostate cancer in early stages, the growing evidence showing that over-diagnosis can lead to over treatment (with classical radical treatment options), the substantial reduction of side effects proposed by the option of focal therapy and the ability to contain costs with it.

Focal therapy aims to maintain oncological benefit of an active treatment and preserve genitourinary function. It can eradicate clinically significant disease and can potentially cure aggressive cancer with minimal side effects, according to Dr. De La Rosette.

Dr. De Rosette continued and showed published evidence of prostate cancer is being unifocal and multifocal in 15% and 78% of cases. Additionally, in 86% there is a bilateral disease and 99% of cancers have satellite lesions of Gleason 6, the majority of which (87%) are smaller than 0.5 ml. Due to the multifocality of the disease, it is important to figure out which lesion to treat with focal therapy. This dilemma resulted in the development of the concept of the ‘index (dominant) lesion’, which is defined as the largest or most aggressive lesion that drives cancer progression. It is therefore critical to define where the index lesion lies before embarking on the quest of focal therapy.

Transperineal template guided mapping biopsy (TTMB) is the preferred approach to identify the index lesion. It entails 5 mm sampling frame to “rule in” foci of 0.5 cc and “rule out” foci of 0.2 cm (with 90% certainty). Another option is the multiparamteric MRI guided fusion biopsy with an 82% sensitivity identification of the index lesion. One of these options must be used before consideration of focal therapy as a means to reach good oncological and functional outcomes.
Dr. De La Rosette concluded with the statement that: “Focal therapy for prostate cancer is an ‘A la carte’ approach in an era of ‘personalized medicine’”.

Presented by: Jena De La Rosette, Amsterdam (NL)

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto
Twitter: @GoldbergHanan

at the #EAU17 -March 24-28, 2017- London, England