Focal Therapy of Prostate Cancer

Nicolai Hübner; Shahrokh F. Shariat; Mesut Remzi

Disclosures

Curr Opin Urol. 2018;28(6):550-554. 

In This Article

Laser Ablation

Focal laser ablation (FLA) is another new method of focal therapy. It consists of a laser-fibre being inserted into the tumour and heating up the tissue to cause damage (coagulated necrosis). Both transrectal and transperineal approaches have been used.

Overall, many Phase I trials have been published establishing the safety of FLA. The largest cohort consisted of 12 patients with low-risk cancer and was published by Lindner et al.[24] in 2009. In their study continence, erectile function was not affected by therapy, and 67% of patients had a negative biopsy at 6 months. Thermal sensors and real-time contrast-enhanced ultrasound were used to monitor the treatment.[24]

A more recent cohort of 11 patients with intermediate risk cancer by Natarajan et al.[25] also used MRI-ultrasound fusion technology to guide the laser towards the tumour in local anaesthesia. Again, no changes in continence and potency were observed at 6 months. An MRI-ultrasound fusion biopsy performed at 6 months revealed no cancer in 3, micro-focal Gleason 3+3 and persistent intermediate risk cancer in 4 patients.[25] In this case, patients underwent the procedure in local anaesthesia, which is not possible for other thermal ablative techniques such as HIFU. This might be an important advantage in the future, yet at the moment, it is questionable if this is actually desirable, as even small movement of the patient can have an effect on treatment. This might be partially responsible for the relatively low negative biopsy rate at 6 months, and in conjunction with the intermediate-risk population, a general anaesthesia might have shown better results. However, with only very short follow-up, conclusions regarding oncologic outcome should not be dawn at this point.

Another advantage of FLA is the option of real-time MRI treatment and heat monitoring. The largest study published about in-bore FLA was done by Eggener et al.[26] in 2016, including 27 low-risk and intermediate-risk patients. The procedure was performed within the MRI unit under conscious sedation and added local anaesthesia. There were no statistically significant differences in I-PSS and sexual health inventory for men at 12 months. At repeat MRI-guided biopsy at 12 months, cancer was present in 37% of patients, 11 of whom were inside the ablation zone.[26]

With better technology and understanding to improve outcomes and more data, FLA might become a more widely used method, due its simplicity, which might even allow it to be used in the clinic. This could make it an attractive alternative for practitioners and patients alike.

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