Candidates For Focal Therapy Research Articles

Characteristics of Cancer Progression on Serial Biopsy in Men on Active Surveillance for Early-stage Prostate Cancer: Implications for Focal Therapy

BackgroundActive surveillance (AS) is a safe and accepted option for managing men with low-risk prostate cancer. Nevertheless, some patients lack confidence in or access to AS. Focal therapy (FT) is a possible alternative to radical treatment for such patients. ObjectiveWe evaluated dominant tumor (DT) progression across serial biopsies to determine whether men on AS could be reasonable candidates for FT. Design, setting, and participantsMen enrolled in AS at University of California, San Francisco between 1996 and 2017 with low/intermediate risk were included. Outcome measurements and statistical analysisChanges in biopsy grade, volume, and focality of the DT over time were assessed. Focality (good or poor for FT) was defined by the number of cores, laterality, and contiguity of prostate sites containing tumor (based on pathology reports). Candidates (either for targeted/quadrant ablation or for hemigland ablation) were defined based on good focality, grade group (GG) ≤2, and low-volume disease. Patients were classified as favorable (GG ≤ 2 with good focality and concordant multiparametric magnetic resonance imaging [mpMRI]) or unfavorable (poor focality or high-volume disease or discordant mpMRI) for FT at surveillance biopsies. Results and limitationsA total of 1057 men met the inclusion criteria. The median number of biopsies per patient was three (interquartile range 2–4), and 196 patients (18.5%) underwent five or more biopsies. At confirmatory biopsy, 43% remained candidates for FT (67% for targeted/quadrant ablation and 33% for hemigland ablation) and 20% had a negative biopsy. Of the candidates for FT at initial biopsy, 11% had less favorable characteristics at confirmatory biopsy. Among candidates for FT based on both initial and confirmatory biopsies, 70% remained favorable for hemigland ablation at subsequent biopsies. Limitations include retrospective design and mpMRI information only at surveillance biopsy. ConclusionsSerial biopsy findings in men with early-stage cancer on AS show that tumor location remains relatively stable and significant changes in grade and/or volume occur largely in the DT. Combined diagnostic and confirmatory biopsy findings help better select patients for FT than the use of the diagnostic biopsy alone. Patient summaryIn a large cohort of patients on active surveillance for prostate cancer, we evaluated changes across serial biopsies to identify potential candidates for focal therapy (FT). Our findings showed that the dominant tumor remained stable over time and the majority of men were favorable candidates for FT.

A model for predicting focal ablation candidates in patients with prostate cancer based on MRI and biopsy criteria.

31 Background: To determine the accuracy of multiparametric MRI (mpMRI) and fusion biopsy in predicting focal therapy candidates by correlating agreement between patients’ pre-prostatectomy MRI and biopsy findings with whole mount pathology. Methods: Patients who underwent mpMRI and biopsy followed by prostatectomy between 2010-2015 were included in the study. Patients were considered good candidates for focal therapy if they had intermediate risk cancer (max Gleason 3+4 or 4+3 on biopsy) in only one hemisphere of the prostate, and if they had an mpMRI visible lesion(s) on one hemisphere that did not cross midline. Patients were considered poor candidates for focal therapy if they had either low risk cancer (Gleason 6), high risk cancer (Gleason 8, 9 and 10), intermediate risk cancer bilaterally, MRI visible lesions that cross the midline, or contained extracapsular extension or seminal vesicle invasion. Whole mounts of patients considered good candidates were then examined histologically for maximum tumor involvement. Results: 501 patients who underwent prostatectomy between 2010 and 2015 were included in the study, with mean age 60.0 (±10.0) and PSA 6.21 (±6.0). 395 patients were considered poor focal candidates, and 106 were considered good focal candidates. Of these 106, 66 patients had whole mounts available for analysis (14 random biopsy, 52 fusion biopsy). 42/66 (63.6%) patients were confirmed as candidates (6/14 (42.9%) who had random biopsy and 36/52 (68.0%) who had fusion). Candidates failed prediction due to Gleason upgrade in final histopathology in 20/24 (83.3%), and for significant Gleason detection bilaterally in 4/24 (16.7%). Conclusions: Our results suggest that application of mpMRI and biopsy criteria to predict focal therapy candidates may result in undertreatment of a large portion of patients with significant cancer. Results from mpMRI guided targeted biopsy were shown to be a more accurate tool for predicting candidates for focal therapy than results from random biopsy alone. More accurate predictive capability is needed before focal therapy can be widely accepted.

169 Pathological analysis of patients undergoing radical prostatectomy who were potential candidates for focal therapy

169 Pathological analysis of patients undergoing radical prostatectomy who were potential candidates for focal therapy

Performance of transrectal prostate biopsies in detecting tumours and implications for focal therapy

Objective. The aim of this study was to investigate the performance of transrectal biopsies in predicting pathological outcomes after radical prostatectomy (RP) and in estimating possible candidates for focal therapies. Material and methods. The study was a retrospective analysis of 96 prostate cancer patients treated by robot-assisted laparoscopic RP at Helsinki University Central Hospital in 2009–2010. Data from diagnostic biopsies were compared with data from reassessment of RP slides. At reanalysis, an index tumour was chosen for all patients and was determined as being the most dedifferentiated tumour or the largest tumour with Gleason pattern 3 in case Gleason patterns 4 or 5 were absent. The performance of prostate biopsies in predicting cancer laterality, tumour size and tumour location was analysed. Statistical methods included Spearman’s correlation, linear regression analysis and Pearson’s chi-squared test. Suitability for focal therapies was assessed based on tumour morphology and laterality. Results. The extent of cancer in biopsies correlated with tumour size in the apex and middle of the prostate [standard coefficients in linear regression for the apex 2.479–2.553, 95% confidence interval (CI) 1.952–3.056, p < 0.001–0.007; and for the middle 1.936–2.388, 95% CI 1.504–2.861, p < 0.001]. Prostate biopsies performed moderately in predicting tumour location in RP slides (positive predictive value 34.1–90.9%). Thirty-six patients (37.5%) would possibly have been candidates for focal therapy and thirty-nine (40.6%) patients for hemiablation. Conclusions. Contemporary transrectal prostate biopsies are a suboptimal tool for predicting pathological findings at RP. Approximately 40% of patients would possibly have been suitable candidates for focal or hemiablative therapies.

Focal therapy in prostate cancer: the current situation.

Prostate cancer is one of the most significant pathologies in the field of urology. The adoption of screening strategies and improvements in biopsies have resulted in an increase in early-stage tumour detection.Radical global therapies provide very good oncological results in localised prostate cancer. However, excess treatment in low- and, in some cases, intermediate-risk groups affects the quality of life of these patients.In the case of localised prostate cancer, focal therapies offer a minimally invasive option with good results with respect to established treatments. Although this is currently not a standard treatment, it represents the therapeutic approach with the greatest potential.This literature review has the following objectives: to define selection criteria for patients who are candidates for focal therapy, to assess the current situation and results of the different therapeutic options, and to define procedures in cases of recurrence and for follow-ups.We concluded that focal therapy is a viable therapeutic alternative for localised prostate cancer, specifically cryosurgery and high-intensity targeted ultrasound, which have acceptable oncologic results and a lower comorbidity compared with global treatments. Studies with a high level of scientific evidence are still needed to validate these results.Acquisition of evidenceA search was carried out on the Medline (PubMed), EMBASE, Web of Science and Cochrane databases of all papers published before 31 July 2013. We included clinical studies and literature reviews that evaluated primary focal therapy for prostate cancer confirmed by biopsy and excluded focal rescue therapy studies. The keywords used were focal therapy and prostate cancer.Initially, we found 42 articles; 15 studies were excluded because they did not meet the minimum criteria for inclusion. A total of 1350 cases were treated throughout 27 studies.

MP12-18 FOCAL THERAPY FOR PROSTATE CANCER: THE UTILITY OF A CONFIRMATORY TRANSPERINEAL TEMPLATE GUIDED PROSTATE BIOPSY TO IDENTIFY APPROPRIATE CANDIDATES

You have accessJournal of UrologyImaging/Radiology III1 Apr 2014MP12-18 FOCAL THERAPY FOR PROSTATE CANCER: THE UTILITY OF A CONFIRMATORY TRANSPERINEAL TEMPLATE GUIDED PROSTATE BIOPSY TO IDENTIFY APPROPRIATE CANDIDATES Khanh Pham, Claudio Jeldres, John Corman, Katherine Odem-Davis, Erika Wolff, and Christopher Porter Khanh PhamKhanh Pham More articles by this author , Claudio JeldresClaudio Jeldres More articles by this author , John CormanJohn Corman More articles by this author , Katherine Odem-DavisKatherine Odem-Davis More articles by this author , Erika WolffErika Wolff More articles by this author , and Christopher PorterChristopher Porter More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.453AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Focal Therapy (FT) is considered a promising potential treatment option for men with low risk prostate cancer (CAP). FT may not be suitable for men with high volume, multifocal and high Gleason (GL) grade disease. The current standard to determine low risk CAP is 12-core transrectal ultrasound prostate biopsy (TRUS BX). We had 2 aims: 1. Determine the accuracy of a confirmatory staging 24-core transperineal template guided prostate biopsy (TP BX) 2. Evaluate the efficacy of TP BX to identify candidates for FT. METHODS For both aims we used an IRB approved prospective database to evaluate 172 men who underwent 24-core TP BX between 1/2009 and 8/2013. For Aim 1: Men with CAP who underwent 24-core TP BX and were treated with RP were evaluated. For Aim 2: Men who were candidates for FT based on an initial 12-core TRUS BX that demonstrated NCCN guideline low risk (cT1-2a, GL grade 6, PSA < 10), unifocal (< 2 positive cores) CAP were evaluated. Confirmatory 24-core TP BX was performed 3 months after initial TRUS BX under anesthesia using gray scale TRUS combined with the brachy-stepper device. The template included 12 cores obtained from the anterior prostate (base, mid and apex) together with 12 posterior lateral cores (base, mid and apex). RESULTS For Aim 1: 25 men had TP BX followed by RP. GL grade at TP BX significantly agreed with RP for 21/25 men; accuracy = 0.8 (95% CI: 0.59, 0.93; p=0.004). At RP, 23/25 men had anterior tumor (AT). TP BX sensitivity to RP detection of AT = 0.57 (95% CI: 0.34, 0.77; p=0.67). For Aim 2: 46 men met inclusion criteria. Following TP BX: 16 men demonstrated upgraded pathology with an estimated risk of 0.35 (95% CI: 0.21, 0.50), 20 men had increased volume of disease with an estimated risk of 0.44 (95% CI: 0.29, 0.59) and 30 men had multifocal tumors with an estimated risk of 0.65 (95% CI: 0.50, 0.79). Table 1 lists detailed results of TP BX. All 23 men (50%) with upgraded pathology or increased volume also had multifocal tumors detected. CONCLUSIONS Our analysis of carefully performed TP BX in men eligible for FT by TRUS BX indicates that TP BX accurately indicates GL Grade (0.8), and up to 50% of patients considered for FT have more aggressive multifocal CAP. While our results require confirmation in larger series, we believe TP BX may be important in men considering FT for low risk CAP. Table 1. Grade, Volume, Multifocality and Anteriorly Located Disease Following 24-Core TP Biopsy for Men Identified with Low Risk CAP by 12-Core TRUS Biopsy (N=46) Gleason Grade N (%) Mean PSA Mean PSAD Increased Volume N (%) Multifocal Disease N (%) Anteriorly Located Disease N (%) 3+3=6 30 (65) 5.2 0.12 7 (15) 14 (30) 15 (33) 3+4=7 11 (24) 8.4 0.17 8 (19) 11 (24) 10 (22) 4+3=7 1 (2) 7.4 0.16 1 (2) 1 (2) 1 (2) 4+4=8 1 (2) 5.0 0.20 1 (2) 1 (2) 1 (2) 4+5=9 2 (4) 6.7 0.13 2 (4) 2 (4) 2 (4) 5+4=9 1 (2) 4.5 0.14 1 (2) 1 (2) 1 (2) © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e112-e113 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Khanh Pham More articles by this author Claudio Jeldres More articles by this author John Corman More articles by this author Katherine Odem-Davis More articles by this author Erika Wolff More articles by this author Christopher Porter More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Role of transrectal ultrasonography (TRUS) in focal therapy of prostate cancer: report from a Consensus Panel

What's known on the subject? and What does the study add? Focal therapy techniques are emerging in prostate cancer treatment. However, several key questions about patient selection, treatment and monitoring still have to be addressed. The concept of focal therapy is barely discussed in current urological guidelines. In the present manuscript, we report the results of a consensus meeting focused on ultrasonography, the most common used urological imaging method, in relation to focal therapy of prostate cancer. • To establish a consensus on the utility of ultrasonography (US) to select patients for focal therapy. Topics were the current status of US to determine focality of prostate cancer, to monitor and assess outcome of focal therapy and the diagnostic advantages of new US methods. In addition, the biopsy techniques required to identify focal lesions were discussed. • Urological surgeons, radiation oncologists, radiologists, and basic researchers from Europe and North America participated in a consensus meeting on the use of transrectal US (TRUS) in focal therapy of prostate cancer. The consensus process was face-to-face and specific clinical issues were raised and discussed with agreement sought when possible. • TRUS is commonly used and essential for diagnosing men with prostate cancer. It is particularly useful for targeting specific anatomical regions or visible lesions. However, it has several limitations and there is a need for improvement. Newer visualisation techniques, e.g. colour Doppler US, contrast-enhanced US and elastography, are being developed but currently there is no US technique that can accurately characterise a cancer suitable for focal therapy. Systematic biopsy is the only known procedure that allows the identification of prostate cancers suitable for focal therapy. Scarce data exist about the role of US for monitoring patients during or after ablative therapy. • Consensus was reached on all key aspects of the meeting. • US cannot reliably identify focal prostate cancer. New US methods show promising results in identifying prostate cancer focality. • Currently selecting appropriate candidates for focal therapy should be performed using dedicated protocols and biopsy schemes.

Ideal candidates for focal therapy

Despite considerable interest in focal therapy for patients with prostate cancer, no universally accepted criteria exist to identify candidates. A new study now suggests that accurate patient identification for focal therapy is not possible using conventional techniques. New tools are required to precisely characterize and localize tumors.

Focal Therapy is an Option for the Majority of Localised Prostate Cancers: A Histopathological Study of Contemporary UK Radical Prostatectomies

Objectives: Focal therapy for prostate cancer offers a management option intermediate between active surveillance and radical therapy for small volume, low grade localised prostate cancer. We studied a series of UK radical prostatectomies (RP) performed for organ-confined prostate cancer to identify the proportion of cases potentially suitable for pure lesion only focal therapy (PLFT) or focal hemi-gland ablation (FHA). Methods: The pathological features of 309 RP specimens were studied. Patients were grouped into the following categories: group A: unifocal cancer; group B: multifocal disease where only the index cancer was significant (Epstein's criteria); group C: unilateral multifocal significant disease; group D: bilateral multifocal significant disease. Results: 56% (172) patients were candidates for PLFT, including 70 group A cases plus 102 group B cases. Group C comprised 4% (11) cases who are candidates for FHA. Thus 60% (183) cases were candidates for either PLFT or FHA. Conclusions: A significant number of patients are potential candidates for focal therapy in this RP series. We encourage prospective clinical trials investigating the oncological safety and outcomes of focal therapy in treating low and intermediate risk localised prostate cancer.

Clinicopathological Strategies to Identify Contralateral Prostate Cancer Involvement in Potential Candidates for Focal Therapy

To identify the magnitude and possible predictors of contralateral lobe involvement and contralateral extraprostatic extension (EPE) in prostatic biopsy-defined localized unilateral cancers. Between January 2005 and August 2009, 1861 patients underwent robotic-assisted radical prostatectomy at the authors' institution. A total of 1114 had unilateral disease on preoperative biopsy. Final histopathology reports of these patients were reviewed. Of the 1114 patients with unilateral disease on biopsy, 867 (77.9%) had contralateral or bilateral disease on final histopathology. EPE was found in 132 patients (11.9%). Twenty patients (1.8%) had contralateral EPE involvement. High-grade prostatic intraepithelial neoplasm (HGPIN) on biopsy was the significant predictor of contralateral lobe involvement on both univariate (P = .02; odds ratio [OR] = 1.791) and multivariate analysis (P = .004; OR = 2.677). Clinical stage T2 was the significant predictor of contralateral EPE on both univariate (P = .012; OR = 5.250) and multivariate analysis (P = .007; OR = 8.656). HGPIN on biopsy significantly predicts for contralateral lobe involvement and should be considered an exclusion criterion for focal therapy in prostate cancer patients. Patients with palpable tumor on digital rectal examination should be advised in favor of radical treatment as these patients may harbor more aggressive tumors involving the contralateral side despite the biopsy findings.

Prostate Biopsy in Selecting Candidates for Hemiablative Focal Therapy

Focal therapy (FT) for the management of clinically localized prostate cancer (PCa) is growing from a concept to reality because of increased interest of both patients and physicians. Selection protocols, however, are yet to be established. We discuss the role of prostate biopsy in candidate selection for FT and highlight the different strategies and technical aspects of the use of prostate biopsy in this setting. In our opinion, prostate biopsy plays a major role in the selection process and tailoring appropriate treatment strategy to the patient. FT necessitates dedicated biopsy schemes that would reliably predict the extent, nature, and location of PCa in selected patients. Currently, there is insufficient scientific evidence to propose a specific biopsy scheme that could fit every candidate, providing accurate characterization of the disease in the individual patient. Further research is necessary to establish solid selection protocols that would reliably identify appropriate candidates for FT of PCa.

DO CANDIDATES FOR FOCAL THERAPY EXIST AMONG A CONTEMPORARY COHORT OF RADICAL PROSTATECTOMY PATIENTS?

You have accessJournal of Urology1 Apr 2008DO CANDIDATES FOR FOCAL THERAPY EXIST AMONG A CONTEMPORARY COHORT OF RADICAL PROSTATECTOMY PATIENTS? Basir Tareen, Guilherme Godoy, Alex Sankin, Steve Temkin, Herbert Lepor, and Samir S Taneja Basir TareenBasir Tareen More articles by this author , Guilherme GodoyGuilherme Godoy More articles by this author , Alex SankinAlex Sankin More articles by this author , Steve TemkinSteve Temkin More articles by this author , Herbert LeporHerbert Lepor More articles by this author , and Samir S TanejaSamir S Taneja More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)60156-1AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "DO CANDIDATES FOR FOCAL THERAPY EXIST AMONG A CONTEMPORARY COHORT OF RADICAL PROSTATECTOMY PATIENTS?." The Journal of Urology, 179(4S), p. 52 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 52 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Basir Tareen More articles by this author Guilherme Godoy More articles by this author Alex Sankin More articles by this author Steve Temkin More articles by this author Herbert Lepor More articles by this author Samir S Taneja More articles by this author Expand All Advertisement PDF downloadLoading ...

1109: An Increasing Proportion of Patients with Stage 1 Renal Cell Carcinoma May be Candidates for Focal Therapy: Analysis from the National Cancer Database, 1993-2003

You have accessJournal of UrologyDiscussed Poster, Tuesday, May 23, 2006, 9:00 am - 12:00 pm1 Apr 20061109: An Increasing Proportion of Patients with Stage 1 Renal Cell Carcinoma May be Candidates for Focal Therapy: Analysis from the National Cancer Database, 1993-2003 Christopher J. Kane, Jacqueline D. Viilalta, Jamie Ritchey, Andrew K. Stewart, and Peter R. Carroll Christopher J. KaneChristopher J. Kane More articles by this author , Jacqueline D. ViilaltaJacqueline D. Viilalta More articles by this author , Jamie RitcheyJamie Ritchey More articles by this author , Andrew K. StewartAndrew K. Stewart More articles by this author , and Peter R. CarrollPeter R. Carroll More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)33334-2AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1109: An Increasing Proportion of Patients with Stage 1 Renal Cell Carcinoma May be Candidates for Focal Therapy: Analysis from the National Cancer Database, 1993-2003." The Journal of Urology, 175(4S), p. 357 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 175Issue 4SApril 2006Page: 357 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Christopher J. Kane More articles by this author Jacqueline D. Viilalta More articles by this author Jamie Ritchey More articles by this author Andrew K. Stewart More articles by this author Peter R. Carroll More articles by this author Expand All Advertisement PDF DownloadLoading ...