Novel Focal Therapy Treatment Options for Prostate Cancer

Ryan P. Werntz; Scott E. Eggener

Disclosures

Curr Opin Urol. 2018;28(2):178-183. 

In This Article

Abstract and Introduction

Abstract

Purpose of review: Examine and discuss novel focal therapy treatment options for prostate cancer.

Recent findings: With the widespread adoption of mpMRI-guided biopsies for prostate cancer, use of image-guided treatment of prostate cancer has increased. Focal therapies leading to partial gland ablation such as partial prostatectomy, focal laser ablation, irreversible electroporation, vascular targeted photodynamic therapy, and focal radiofrequency ablation have emerged and begun to be properly evaluated. This review covers published phase 1 and 2 trials of each treatment and discusses potential limitations of each modality.

Summary: Focal therapy of prostate cancer is being actively investigated. On the basis of limited published data, the treatments appear to be well tolerated and have an acceptable side effect profile. Importantly, short-term oncologic control has been mixed and there are no long-term outcomes. The acquisition of more data is essential to evaluate these novel technology platforms.

Introduction

Prostate cancer (PCa) screening, diagnosis and management continues to evolve in an effort to treat men likely to benefit and minimize treatment-related side effects. However, whole gland therapy with surgery or radiation has placed a significant proportion of men, with an otherwise low risk of cancer-specific mortality, at increased risk for treatment-related side effects.[1] Although whole gland therapy remains the treatment of choice for men with high-risk or high-volume intermediate-risk PCa, efforts have been made to reduce the burden of treatment while still maximizing oncologic control by initiating active surveillance programs and image-guided focal therapy specifically for men with low-risk cancer or lower volume intermediate-risk cancers.

Abundant data suggests multiparametric MRI (mpMRI) is currently the optimal modality for visualizing clinically significant PCa.[2–4] This has sparked interest in the use of mpMRI to guide treatment of prostate lesions focally, known as focal therapy or partial gland ablation. Focal treatment of cancers is an evidence-based, standard-of-care management strategy in many other solid-organ malignancies including renal cell, urothelial, thyroid, liver, breast, and pancreas. There are unique features of PCa that warrant consideration whenever discussing focal therapy: the high prevalence, typical multifocal nature, diagnostic and imaging challenges, and proximity to important structures such as the rectum, erectile nerves, and urinary continence mechanism. Although the potential merits and controversies of PCa focal therapy are not the focus of our review, it is our opinion that the concept is worthy of prospective investigation to better understand whether it has an appropriate role for select patients.

Our review presents available cancer-specific and functional data on novel PCa focal therapy strategies. We have chosen not to discuss high intensity focused ultrasound (HIFU) or cryoablation as they have been available for decades and there is relatively abundant peer-reviewed literature.

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