ESOU 2019: Treatment of Gleason 3+4 in a Multidisciplinary Scenario: Focal Therapy

Prague, Czech Republic (UroToday.com) Dr. Clement Orczyk made the case for considering focal therapy among men with Gleason 3+4 disease at today’s multidisciplinary prostate cancer session at ESOU 2019.

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
When performing focal therapy, it is necessary to be able to see an image-guided margin for optimal oncological control:
ESOU2019 UroToday Treatment of Gleason 34 in a Multidisciplinary Scenario focal
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%)
Follow up after focal therapy should be a minimum of 5 years3. The following modalities should be included in assessing post-treatment outcomes: mpMRI, biopsies, assessment of ED, quality of life, urinary symptoms and incontinence. A systematic 12-core TRUS biopsy combined with 4-6 targeted biopsy cores of the treated area and any suspicious lesion(s) should be performed after 1 year, and thereafter only when there is suspicion of imaging. In patients that fail HIFU, retreatment is possible, although patients may opt for more definitive treatment. In limited case series experience, patients undergoing a robotic prostatectomy after HIFU have no difference in continence rates.


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

References:
  1. 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.
  2. 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.
  3. 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
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