Editorial Comment

Abstract

The study by Taneja et al. examines in a contemporary cohort of men undergoing radical prostatectomy the likelihood of the presence of unilateral disease as a surrogate marker for the incidence of men suitable for focal therapy. They found that only 21.3% had unilateral cancer, concluding that only a small minority of men would be candidates for focal therapy. What is not provided are detailed characteristics of these men's tumor on biopsy and the tumor volume and grade of the bilateral tumor. Candidates for focal therapy should have unilateral cancer on biopsy that is not high grade and not high volume. Undoubtedly, some patients in the study by Taneja et al. had on biopsy either bilateral cancer, Gleason score ≥7 disease, or cores with >50% cancer. Including such patients in their study biases the data against focal therapy, because these men would be more likely to have bilateral disease yet would be considered ideal candidates for focal therapy. Another factor that unjustifiably biases the data against focal therapy is that the presence of bilateral tumor in and of itself does not rule out the possibility that these men could still have been excellent candidates for focal therapy. In a recent study performed at our institution of men selected according to preoperative parameters to be ideal candidates for focal therapy, 65% of men had some tumor contralateral to the positive biopsy site. 1 Yoon G.S. Wang W. Osunkoya A.O. et al. Residual tumor potentially left behind after local ablation therapy in prostate adenocarcinoma. J Urol. 2008; 179: 2203-2206 Abstract Full Text Full Text PDF Scopus (58) Google Scholar However, the mean total tumor volume in the radical prostatectomy specimen contralateral to the positive biopsy side was only 0.2 cm3. Successful focal therapy need not ablate all the tumor but should treat all significant prostate cancer. Minute, lower grade, contralateral cancer left behind after focal therapy is of little consequence. Nonetheless, focal therapy is not without risk. Although in a highly selected population with limited unilateral cancer on biopsy, tumor contralateral to the positive biopsy side is typically small, 20% of radical prostatectomy specimens have some contralateral adverse pathologic features in terms of tumor size, extraprostatic extension, tumor grade, or positive surgical margins. 1 Yoon G.S. Wang W. Osunkoya A.O. et al. Residual tumor potentially left behind after local ablation therapy in prostate adenocarcinoma. J Urol. 2008; 179: 2203-2206 Abstract Full Text Full Text PDF Scopus (58) Google Scholar We agree with the authors that urologists need to be informed and that patients should be told of the risks of leaving cancer behind before undergoing focal therapy. Appropriate Candidates for Hemiablative Focal Therapy Are Infrequently Encountered Among Men Selected for Radical Prostatectomy in Contemporary CohortUrologyVol. 73Issue 2PreviewTo assess the prevalence and pathologic features of men with unilateral prostate cancer at radical prostatectomy (RP), because it has recently been proposed that men with small-volume, well-differentiated, unilateral prostate cancer can be treated with focal therapy. Full-Text PDF ReplyUrologyVol. 73Issue 2PreviewWe agree with the reviewer that if we were evaluating biopsy characteristics to select ideal candidates for focal therapy we would include only patients with unilateral cancer on biopsy and with low-volume (Damico), low-risk features. This, however, was not the purpose of our report. Rather, our goal was to identify, from an existing population of radical prostatectomy patients, which men would have been ideal candidates for focal therapy. Although evaluating biopsy information could theoretically provide this same information, our data would suggest otherwise. Full-Text PDF