Frontiers in Oncologic Prostate Care and Ablative Local Therapy Archives

Restriction Spectrum Imaging Guided Biopsy

Posted by Michael A. Liss, MD, PhD, MAS, FACS | May 2024

Michael A. Liss, MD, PhD, MAS, FACS, discusses how Restriction Spectrum Imaging (RSI) Guided Biopsy can aid in processing and interpreting MRIs by reducing false positives and improving MRI distortion. Dr. Liss begins by describing the top current issues with MRI sequencing: varied positive predictive values and Apparent Diffusion Coefficient (ADC) distorting MRI results.

Dr. Liss then discusses the role of RSI-guided biopsy in mitigating the weaknesses of conventional MRI. He illustrates what an MRI sequence with RSI using compartmental, nuclear volume, and geometric filtering looks like.

Dr. Liss concludes with examples of RSI-MRI results in patients with different Gleason scores and inflammation. He compares the efficacy of RSI-MRI in differentiating between inflammatory and regular lesions and presents data that supports the use of RSI-MRI in lowering the frequency of false positive biopsies due to the misclassification of inflammatory lesions.

Fusion Biopsy Technologies and Techniques

Posted by Peter A. Pinto, MD | Apr 2024

Peter A. Pinto, MD, discusses the evolution of prostate cancer biopsy and imaging techniques in the past twenty years, from blind systematic biopsies to MRI-ultrasound fusion biopsies. He begins by noting that prostate cancer was the only solid-organ tumor diagnosed without image guidance going into the 21st century.

When MRI was introduced as an imaging modality for prostate cancer diagnosis, urologists developed several different techniques for incorporating MRI into biopsy procedures. Dr. Pinto briefly covers the history and development of in-bore biopsies, cognitive fusion biopsies, and MRI-ultrasound fusion biopsies.

He concludes with reviewing the currently available devices in this space. He evaluates each system as it relates to biopsy needle targeting route, tracking and navigation, MRI-ultrasound fusion opportunities, ultrasound image acquisition, and biopsy fixation.

Transperineal Biopsy: Rationale, Outcomes, and Techniques

Posted by Arvin George, MD | Apr 2024

Arvin K. George, MD, discusses the rationale behind performing transperineal biopsies over transrectal biopsies, supporting outcome data, and actionable techniques to combat the perceived shortcomings of the procedure. Dr. George begins by providing data on the fluoroquinolone-resistant infection risks of transrectal biopsies, and that, by avoiding the issue of antibiotic-resistant rectal flora, transperineal biopsies circumvent the rising rate of infections and strengthen antibiotic stewardship during procedures.

Dr. George then addresses the issue of patient pain in transperineal biopsies. He offers techniques on ideal administration of local anesthetic for decreasing patient pain.

Dr. George concludes by providing information on patient set-up, procedure equipment, and transperineal guides, presenting multiple options and encouraging urologists to choose according to their needs. He offers several resources for urologists and their patients from the Michigan Urologic Surgery Improvement Collaborative.

Selecting the Optimal Energy Source

Posted by Samir S. Taneja, MD | Mar 2024

Samir S. Taneja, MD, compares the merits and limitations of the leading energy sources used in prostate focal ablation. The sources available for use in prostate ablation today include laser, electroporation, radiofrequency, photodynamic therapy, high-intensity focused ultrasound (HIFU), cryosurgery, drugs/toxins, radiations (focal/interstitial), surgery, steam, and gold nanoparticles.

Dr. Taneja outlines the ideal criteria for an energy source based on the individual characteristics of the patient and their disease, as well as real-world considerations like ease of use and insurance coverage. He gives examples of which energy sources are best-suited for certain cases based on disease presentation and other factors.

In a full focal therapy practice, the optimal situation would be one with multiple energy sources available so that physicians can tailor treatments to each individual patient. Since this saturation of options can be daunting to physicians just starting in a focal therapy program, Dr. Taneja advises practitioners to pick one energy source to practice at first, limiting patient selection to those with disease that is best-treated with that specific modality. After becoming proficient with that energy source, more can be added to increase candidate selection.

The Who and Why of Focal Therapies

Posted by Abhinav Sidana, MD, MPH | Mar 2024

Abhinav Sidana, MD, MPH, discusses the selection processes, objectives, and data supporting the use of focal therapy to treat prostate cancer. He begins with an overview of the state of focal therapy, and how it can be used to provide more personalized prostate cancer treatment to patients.

Dr. Sidana then compares the weaknesses of focal therapy to those of radical surgery and surveillance. He notes that while focal therapy has been criticized for its shortcomings in addressing “invisible” and multifocal cancers, radical surgery has permanent negative effects on patient QOL and that many patients on active surveillance drop out after a certain length of time.

Dr. Sidana then addresses recent advances in focal therapy which can partially mitigate some of the shortcomings of focal therapy. He focuses on advancements in MRI accuracy and specificity which makes treating multifocal and previously invisible clinically significant cancers using focal therapy effective.

Dr. Sidana concludes by outlining strategies for patient selection for focal therapy. He presents examples of ideal patient and disease characteristics for focal therapy treatment and lists relevant contraindications.