Abstract
BackgroundFocal therapy is being offered as a viable alternative for men with localised prostate cancer (PCa), but it is unclear which men may be suitable. ObjectiveTo determine the proportion of men with localised PCa who are potentially suitable for focal therapy. Design, setting, and participantsOur institutional transperineal template prostate-mapping (TTPM) biopsy registry of 377 men from 2006 to 2010 identified 291 consecutive men with no prior treatment. InterventionTTPM biopsies using a 5-mm sampling frame. Outcome measurements and statistical analysisSuitability for focal therapy required the cancer to be (1) unifocal, (2) unilateral, (3) bilateral/bifocal with at least one neurovascular bundle avoided, or (4) bilateral/multifocal with one dominant index lesion and secondary lesions with Gleason ≤3+3 and cancer core involvement ≤3mm. Binary logistic regression modelling was used to determine variables predictive for focal therapy suitability. Results and limitationsThe median age was 61 yr, and the median prostate-specific antigen was 6.8 ng/ml. The median total was 29 cores, with a median of 8 positive cores. Of 239 of 291 men with cancer, 29% (70 men), 60% (144 men), and 8% (20 men) had low-, intermediate-, and high-risk PCa, respectively. Ninety-two percent (220 men) were suitable for one form of focal therapy: hemiablation (22%, 53 men), unifocal ablation (31%, 73 men), bilateral/bifocal ablation (14%, 33 men), and index lesion ablation (26%, 61 men). Binary logistic regression modelling incorporating transrectal biopsy parameters showed no statistically significant predictive variable. When incorporating TTPM parameters, only T stage was a significant negative predictor for suitability (p=0.001) (odds ratio: 0.001 [95% confidence interval, 0.000–0.048]). Limitations of the study include potential selection bias caused by tertiary referral practise and lack of long-term results on focal therapy efficacy. ConclusionsFocal therapy requires an accurate tool to localise individual cancer lesions. When such a test, TTPM biopsy, was applied to men with low- and intermediate-risk PCa, most of the men were suitable for a tissue preservation strategy.
Highlights
In this month’s issue of European Urology, Singh and colleagues report an interesting and important study that retrospectively looked at all patients who had undergone transperineal template prostate-mapping biopsies over a 4-yr period [2]
Multifocality is highly prevalent and many urologists would question the use of focal therapy where multifocal, intermediate- to high-risk disease has been detected
Singh’s group and others rely on the index theory to advocate focal therapy in these groups [2]. This is the belief that a dominant, index lesion drives malignant and metastatic potential and that eradication of this results in effective treatment [5]. This is supported by the idea of the monoclonal origin of prostatic metastases [6]
Summary
In this month’s issue of European Urology, Singh and colleagues report an interesting and important study that retrospectively looked at all patients who had undergone transperineal template prostate-mapping biopsies over a 4-yr period [2]. Multifocality is highly prevalent (up to 87% in radical prostatectomy series [4]) and many urologists would question the use of focal therapy where multifocal, intermediate- to high-risk disease has been detected. It is perhaps too early to surmise that all of these men identified by Singh et al are suitable for focal therapy [2]. Pending robust validation, it is difficult to counsel patients regarding the effectiveness of focal treatment.
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