Current state of image-guided focal therapy for prostate cancer.

PURPOSE: To review the current evidence regarding protocols and outcomes of image-guided focal therapy (FT) for prostate cancer (PCa). METHODS: A literature search of the latest published studies assessing primary FT for PCa was carried out in Medline and Cochrane library databases followed by a critical review. FT modalities, follow-up strategies, and oncological and toxicity outcomes were summarized and discussed in this review. RESULTS: Twenty-four studies with six different sources of energy met the inclusion criteria. A heterogeneity of patient selection, energy sources, treatment templates, and definitions of failure was found among the studies. While a third of patients may be found to have additional cancer burden over 3-5 years following FT, most patients will remain free of a radical procedure. The vast majority of patients maintain urinary continence and good erectile function after FT. Acute urinary retention is the most common complication, whilst severe complications remain rare. CONCLUSION: An increasing number of prospective studies with longer follow-up have been recently published. Acceptable cancer control and low treatment toxicity after FT have been consistently reported. Follow-up imaging and routine biopsy must be encouraged post-FT. While there is no reliable PSA threshold to predict failure after FT, reporting post-FT positive biopsies and retreatment rates appear to be standard when assessing treatment efficacy.

Ablative options for prostate cancer management.

This review provides an overview of the available ablative options for prostate cancer (PCa) management. It contemplates the ablative concepts and the role of prostate ablation in different settings, from primary treatment to repeat ablation, and as an alternative to radiorecurrent disease. Improvements in prostate imaging have allowed us to ablate prostate lesions through thermal, mechanical, and vascular-targeted sources of energy. Partial gland ablation (PGA) has an emerging role in the management of localized PCa because toxicity outcomes have been proven less harmful compared with whole-gland treatments. Although long-term oncological outcomes are yet to be consolidated in comparative studies, recent large series and prospective studies in PGA have reported encouraging results. A second ablation after disease recurrence has demonstrated low toxicity, and future studies must define its potential to avoid radical treatments. PGA is an attractive option for PCa management in different scenarios because of its low-toxicity profile. As expected, recurrence rates are higher than those seen in whole-gland procedures. Long-term oncological outcomes of primary and salvage options are required to endorse it among the standard treatments.

Focal Therapy for Localized Prostate Cancer with Either High Intensity Focused Ultrasound or Cryoablation: A Single Institution Experience.

PURPOSE: We report oncologic outcomes in patients treated with focal therapy for prostate cancer. MATERIALS AND METHODS: We retrospectively analyzed a single institution cohort of men with localized prostate cancer who received focal therapy using high intensity focused ultrasound or cryotherapy from 2009 to 2018. Focal therapy was offered for low or intermediate risk disease (prostate specific antigen less than 20 ng/ml, Gleason score 7 or less and clinical stage T2b or less). Patients with previous prostate cancer treatment or less than 6 months of followup were excluded from study. Failure was defined as local or systemic salvage treatment, a positive biopsy Gleason score of 7 or greater in-field or out-of-field in nontreated patients, prostate cancer metastasis or prostate cancer specific death. Cox regression analysis was done to identify independent predictors of failure after focal therapy. RESULTS: Of the 309 patients included in study 190 and 119 were treated with high intensity focused ultrasound and cryotherapy, respectively. Median followup was 45 months. At 1, 3 and 5 years the failure-free survival rate was 95%, 67% and 54%, and the radical treatment-free survival rate was 99%, 79% and 67%, respectively. The 5-year metastasis-free survival rate was 98% and no prostate cancer specific death was registered in this cohort. Before focal therapy a biopsy Gleason score of 7 (3 + 4) or greater (HR 2.4, p <0.001) and nadir prostate specific antigen (HR 2.2, p <0.001) were independently associated with failed focal therapy. In the salvage focal therapy setting in-field recurrence after primary focal therapy was associated with poorer failure-free survival (p=0.02). CONCLUSIONS: Almost half of the men were free of focal therapy failure 5 years after treatment. Still, a significant proportion experienced recurrence at the midterm followup. The preoperative biopsy Gleason score and nadir prostate specific antigen were significantly associated with treatment failure.

Prostate cancer multifocality, the index lesion, and the microenvironment.

PURPOSE OF REVIEW: Most of focal therapies has addressed index lesion as the targeted tumour focus to treat localized prostate cancer (PCa), a multifocal disease. The interaction between tumour foci and host cells creates a tumour microenvironment (TME) which affects tumour growth, cellular proliferation, and PCa progression. This review aims to better understand the biology of cancer foci and their interaction with the prostatic microenvironment after focal therapy. RECENT FINDINGS: Index lesions are representative of PCa grade in low-risk patients, but the other foci of tumour, the satellite lesions, gain relevance in higher risk patients. Multiparametric MRI, guided biopsies and new biomarkers in combination are important to address PCa multifocality and to adequately select patients to focal therapy. Stromal, immune, and tumoural components are integrated in tumourigenesis and modified after the inflammation induced by focal therapy. SUMMARY: TME and inflammation play an important role in PCa progression, but further researches are necessary to understand how once protective components of prostate microenvironment become protumour elements and how inflammation induced by focal therapy can affect them. Learning how to modulate TME is an exploratory molecular field that can lead us to better manage PCa in both prevention and treatment scenarios.

The Role of Robot-Assisted Radical Prostatectomy in High-Risk Prostate Cancer.

Prostate cancer (PCa) is stratified into different risk categories based on the patient's prognosis. High-risk disease was formerly characterized by an increased risk of metastasis and lethality, requiring complex treatments. Surgery was recently highlighted to have a pivotal role for the treatment of such cases, even as monotherapy. In the past, open radical prostatectomy was performed for most patients with high-risk PCa; however, robot-assisted radical prostatectomy (RARP) emerged as a reasonable option because it provided optimal outcomes for low- and intermediate-risk PCa. Robust studies are lacking to properly assess the role of RARP for high-risk PCa. We summarize this knowledge and present a literature review on the perioperative recovery and functional and oncologic outcomes of RARP for the treatment of patients with high-risk PCa.