Dr. Orczyk started by highlighting that Gleason 3+4 disease is truly a multidisciplinary process, even in the focal therapy platform where patients may be candidates for cryosurgery or high-intensity focused ultrasound (HIFU). Dr. Orczyk considers a “target lesion” as having to have the following criteria:
- Unilateral significant disease – intermediate risk Gleason 3+4
- Concordant lesion with mpMRI
- Insignificant contralateral disease -- ≤ Gleason 6 disease
Dr. Orczyk notes that the choice of energy to use is based on the amenability of the lesion. For example, a patient with a posterior peripheral zone lesion, away from the urinary sphincter, in the field of HIFU, and ability to deliver complete ablation – this patient is a candidate for focal HIFU. Focal HIFU is preferable if feasible as this technique has excellent functional outcomes.
A recent systematic review assessed the current focal ablation literature, identifying 37 articles reporting on 3,230 patients1. High-intensity focused ultrasound, cryotherapy, photodynamic therapy, and brachytherapy have been assessed in up to Stage 2b studies. Median follow-up varied between 4 mo and 61 mo, and the median rate of serious adverse events ranged between 0% and 10.6%. Pad-free leak-free continence and potency were obtained in 83.3-100% and 81.5-100%, respectively. The median rate of significant and insignificant disease at control biopsy varied between 0% and 13.4% and 5.1% and 45.9%, respectively.
Unquestionably the most important focal therapy paper was published a few months ago, assessing 5-year outcomes in a multi-center study2. Among 625 consecutive patients with nonmetastatic clinically significant PCa undergoing focal HIFU therapy, over a median follow-up of 56 months (IQR 35-70) the following results were reported:
- FFS: 99% (95%CI 98-100%) at 1 year
- FFS: 92% (95%CI 90-95%) at 3 years
- FFS: 88% (95%CI 85-91%) at 5 years
- 5-year metastasis-free survival: 98% (95%CI 97-99%)
- 5-year cancer-specific survival: 100%
- 5-year overall survival: 99% (95%CI 97-100%)
Presented by: Clement Orczyk, MD, Ph.D., DESC (Urol) FRCS, Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic
- Valerio M, Cerantola Y, Eggener SE, et al. New and Established Technology in Focal Ablation of the Prostate: A Systematic Review. Eur Urol 2017 Jan;71(1):17-34.
- Guillaumier S, Peters M, Arya M, et al. A Multicentre Study of 5-year Outcomes Following Focal Therapy in Treating Clinically Significant Nonmetastatic Prostate Cancer. Eur Urol 2018 Oct;74(4):422-429.
- Muller BG, van den Bos W, Brausi M, et al. Follow-up modalities in focal therapy for prostate cancer: Results from a Delphi consensus project. World J Urol 2015 Oct;33(10):1503-1509.
Further Related Content:
Treatment of Gleason 3+4 in a Multidisciplinary Scenario: Active Surveillance
Treatment of Gleason 3+4 in a Multidisciplinary Scenario: Hypofractionation Radiation Therapy
Treatment of Gleason 3+4 in a Multidisciplinary Scenario: Surgery