EAU PCa 17: The Future of Focal Therapy

Vienna, Austria (UroToday.com) Dr. Mark Emberton from UCL, London, UK provided an update on the future of focal therapy at this afternoon’s EAU Update on Prostate Cancer in Vienna, Austria. Dr. Emberton started his presentation by highlighting that since the results of the PROMIS trial [1], he feels the ‘spectrum of disease will change’ when MRI is routinely utilized prior to (targeted) prostate biopsy. Specifically, he feels that we will be seeing and treating much more Gleason pattern 3+4 prostate cancer, and correspondingly less exclusive Gleason 3, dominant Gleason 4, exclusive Gleason 4, and Gleason pattern 5.

Dr. Emberton then highlighted the recently published MAPPED study [2] – the first randomized trial using change in MRI prostate cancer tumor volume as a primary endpoint. This study was a randomized, double-blind, placebo controlled trial of men (n=42) with biopsy proven low-intermediate risk prostate cancer who had a lesion of 0.2 ml or greater on T2-weighted MRI. Patients were randomized to daily Dutasteride 0.5 mg or placebo for 6 months; lesion volume was assessed at baseline, 3 and 6 months with an exit biopsy after 6 months. Men in the Dutasteride arm had a 36% reduction in prostate tumor volume from baseline to 6 months, compared to a 12% increase in tumor volume in the placebo arm (difference in reduction: 48%, 95%CI 27.4-68.3, p<0.0001).

Dr. Emberton then shifted gears and demonstrated some of the latest MRI technology, namely the 13C hyper-polarized MRI. He subsequently showed images of 13C lactate hyperpolarizing MRI images localizing to a Gleason 3+4 tumor and essentially providing a “heat map” of prostate cancer corresponding to prostate biopsy. This has the technology to further improve accuracy of detection using targeted biopsy platforms. Furthermore, he feels this will start a gradual transition from an anatomically defined treatment to MRI-lesion based therapy.

In Dr. Emberton’s opinion, who may be a candidate for focal therapy? Men with a discrete lesion on MRI, clinically significant prostate cancer, and the opportunity to apply a margin around the tumor (~5mm). Furthermore, he feels that a man may be a candidate for focal therapy if they are highly motivated to preserve genitourinary function, and are aware and willing to accept treatment uncertainties and salvage treatment strategies. Dr. Emberton concluded with a slide remarking that our therapies for prostate cancer should be complimentary and not mutually exclusive: as disease severity increases, the spectrum of treatment should move from active surveillance focal therapy whole gland treatment.

Speaker: Mark Emberton, University College London, London, UK

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre
Twitter: @zklaassen_md at the EAU - Update on Prostate Cancer  – September 15-16, 2017, Vienna, Austria


1. Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): A paired validating confirmatory study. Lancet 2017;389(10071):815-822.
2. Moore CM, Robertson NL, Jichi F, et al. The effect of dutasteride on magnetic resonance imaging defined prostate cancer: MAPPED—A randomized, placebo controlled, double-blind clinical trial. J Urol 2017;197(4):1006-1013.