Post-Treatment Assessment and Creating Imaging-Based Short- and Intermediate-Term Patient Outcomes
Faina Shtern, MD, introduces an international group to advance research and clinical strategies for focal treatment of prostate cancer.
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Topic: Focal Therapy
Point Counterpoint: Is Focal Therapy Ready for Prime Time (No)
Michael Rothberg, MD, critically examines whether focal therapy for prostate cancer is ready for widespread clinical adoption, emphasizing the need for rigorous evaluation. The 10-minute discussion highlights prostate cancer’s biological complexity, including its multifocal and heterogeneous nature, which challenges the premise of focal therapy targeting the “index lesion.”
Dr. Rothberg underscores significant limitations in current diagnostic tools, particularly MRI and biopsy techniques. Imaging inconsistencies and operator variability reduce the reliability of identifying clinically significant lesions.
Current guidelines from leading organizations like NCCN and AUA do not endorse focal therapy as a standard treatment due to insufficient high-level evidence. Dr. Rothberg cites the lack of randomized controlled trials comparing focal therapy to whole-gland treatments, which leaves gaps in understanding survival and recurrence rates beyond medium-term follow-ups.
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Point Counterpoint: Is Focal Therapy Ready for Prime Time (Yes)
Ruben Olivares, MD, emphasizes the growing momentum of focal therapy in prostate cancer management, urging clinicians to embrace its evolving philosophy. The 9-minute discussion highlights a shift from whole-gland treatment to strategies aimed at cancer control, progression delay, and preserving quality of life.
Dr. Olivares underscores the importance of tailored approaches, utilizing advanced imaging like MRI to localize aggressive lesions. Enhanced biopsy techniques and energy-based modalities offer new avenues for precise and effective treatments. Emphasizing the balance between oncological control and functional preservation, his talk highlights the need for proficiency and sufficient patient volumes to optimize outcomes. Focal therapy is presented as a safe, feasible, and effective strategy with excellent functional and medium-term oncological outcomes, marking it as a critical component of the evolving prostate cancer treatment paradigm.
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Energy Selection Ablative Technologies for Focal Therapy
Andre Abreu, MD, delves into energy modalities for focal therapy in prostate cancer, presented with a comprehensive and practical approach. This 16-minute presentation explores multiple energy options, including cryoablation, high-intensity focused ultrasound (HIFU), irreversible electroporation (IRE), laser ablation, and microwave ablation. Dr. Abreu emphasizes the importance of aligning energy selection with institutional expertise and patient-specific factors.
Patient-specific considerations guide technology selection, including rectal wall thickness and proximity to critical structures. Transition zone lesions benefit from tools like aqua ablation, while anterior lesions present challenges for certain devices. The speaker emphasizes the need for personalized management, integrating oncologic characteristics with procedural capabilities.
Dr. Abreu optimistically frames the future of focal therapy, with ongoing trials like vapor ablation and the potential for low-dose radiation therapy combined with IRE promising advancements. He calls for practical recommendations and an invitation for ongoing exploration in the evolving field of prostate cancer management.
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Complications of Focal Therapy – Risk Factors, Timepoints, Management
Amir Lebastchi, MD, explores complications associated with focal therapy for prostate cancer, emphasizing the variability influenced by patient characteristics, disease features, treatment factors, and operator experience.
In this 14-minute keynote presentation, Dr. Lebastchi highlights studies reporting a 13-32% overall complication rate. Bleeding complications, sensory changes like penile numbness, and functional impacts such as erectile dysfunction and transient urinary incontinence are discussed.
To minimize risks, operator expertise and careful patient selection are emphasized. Strategies for prevention and management include tailored ablation templates, urethra-sparing techniques, and post-procedure interventions like alpha-blockers and antibiotics. Advanced techniques such as hydro-dissection and real-time monitoring with temperature probes further mitigate risks.
Dr. Lebastchi stresses the safety profile of focal therapy, noting its significantly lower morbidity compared to radical treatments like prostatectomy or radiation. Close postoperative monitoring is recommended to ensure patient recovery and address complications promptly.
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KEYNOTE LECTURE – Introduction of Disruptive Technologies The Lessons From the Minimally Invasive Surgery
Ralph V. Clayman, MD, offers an inspiring and pragmatic perspective on fostering innovation and navigating the challenges of medical advancements. He begins this 34-minute keynote presentation by emphasizing the importance of curiosity and intellectual humility.
Dr. Clayman underscores how disruptive technologies have evolved in urology by presenting historical examples. He traces the creative and collaborative processes that turned initial skepticism into groundbreaking techniques, emphasizing the philosophical, practical, and personal factors required to drive innovation. These include having a clear vision, protected time, effective partnerships, and a multidisciplinary team.
Clayman discusses the future intersection of robotics and artificial intelligence, foreseeing advancements like automated anastomoses and enhanced focal therapies. He stresses that meaningful progress will require collaboration, resourcefulness, and a willingness to challenge conventional norms. He offers practical advice for aspiring innovators and recommends building diverse teams with complementary strengths, as innovation is inherently collaborative.
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Mechanisms and Management of Recurrences
Abhinav Sidana, MD, MPH, delves into the mechanisms and management of recurrences in patients undergoing focal therapy. This 17-minute presentation underscores the absence of a consistent surveillance strategy and advocates for a standardized approach, combining PSA tests, MRI, and biopsies to detect clinically significant cancer.
Dr. Sidana identifies factors such as patient selection, multifocal disease, and tumor biology as primary contributors to failures. His talk also addresses the challenges of inadequate margins and the spatial localization of lesions. Management strategies for recurrences focus on returning to foundational clinical assessments, considering patient life expectancy, comorbidities, cancer grade, and preferences. Cases illustrating success and challenges in treatment strategies reinforce the need for individualized patient care.
Dr. Sidana advocates for integrating biopsies and MRIs into surveillance protocols and highlights patient selection as pivotal to reducing therapy failures. This comprehensive analysis aims to refine focal therapy practices and improve patient outcomes.
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Oral Abstracts – Spacial Characterization and AI-Driven Prevention of Residual Cancer Following Focal Therapy
Substituting for Wayne Brisbane, MD, Preston Sprenkle, MD, highlights the evaluation of AI-driven cancer risk mapping in guiding focal therapy for prostate cancer. This 7-minute presentation shares results related to Unfold AI, a tool cleared by the FDA in December 2022 for generating 3D cancer risk maps.
The primary focus of the presentation is determining whether AI mapping could predict marginal treatment failures. The AI model demonstrated high precision, significantly reducing necessary treatment margins and potentially enhancing patient outcomes while minimizing treatment invasiveness.
Dr. Sprenkle discusses future directions, including the prospective use of AI-defined margins in treatment planning, which could potentially reduce focal therapy failures. This retrospective study underscores the transformative potential of AI in improving prostate cancer treatment precision.
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Outcomes of Recent Clinical Trials for Focal Therapy
Derek Lomas, MD, provides an extensive overview of recent clinical trials and emerging technologies in focal therapy for prostate cancer. In this 13-minute presentation, Dr. Lomas showcases studies which illustrate focal therapy’s potential as safe, effective, and minimally invasive options for prostate cancer management.
The first study highlights nanoparticle-directed photothermal ablation using gold nanoparticles and MRI-ultrasound fusion guidance. Preliminary results show promising safety and efficacy.
The HIFI trial evaluates focal therapy with high-intensity focused ultrasound (HIFU) versus radical prostatectomy. Findings reveal that HIFU achieves non-inferior outcomes regarding salvage therapy-free survival and demonstrates better urinary and erectile function preservation.
Further insights come from randomized trials comparing focal ablation with radical prostatectomy. These studies consistently show non-inferior treatment failure rates and a reduced impact on functional outcomes with focal therapy.
The PRESERVE trial on irreversible electroporation provides preliminary safety data, with final oncologic outcomes pending. Early results indicate significant reductions in PSA and low adverse effect rates.
The FOSTINE1b trial explores targeted microwave ablation, demonstrating complete necrosis in treated areas with no severe adverse effects.
Two-year data from the ExAblate system, utilizing MRI-guided transrectal HIFU, report high cancer-free rates within treatment zones and overall glands while preserving functional outcomes.
Dr. Lomas shares that ongoing research promises to further refine these technologies. This dynamic field continues to offer exciting prospects for individualized prostate cancer treatment.
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Interpretation of Post Focal Therapy Imaging Target and Pifab
Sadhna Verma, MD, MBA, FSAR, explores advancements in imaging and reporting for post-focal therapy in prostate cancer, highlighting the emergence of two scoring systems, TARGET and PI-FAB. This 16-minute presentation provides an overview of expected multiparametric MRI findings at different post-treatment intervals, describing immediate changes like coagulative necrosis and late findings such as fibrosis and scarring.
Dr. Verma introduces TARGET, a consensus-based system focusing on MRI timing, technical parameters, and interpretation. The PI-FAB system, developed from expert opinion, similarly prioritizes dynamic contrast imaging. Comparative examples illustrate their application.
Preliminary studies reveal moderate inter-reader agreement for both systems, though sensitivity and specificity vary, underscoring the importance of experience in interpretation. Despite promising results, the presenter stresses the need for validation through large, multicenter cohorts and integration with molecular imaging to enhance diagnostic accuracy.
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Optimal Surveillance Algorithm Following Focal Therapy of Prostate Cancer
In this 13-minute presentation, Herbert Lepor, MD, focuses on the development and implementation of an evidence-based surveillance algorithm following focal therapy for prostate cancer. Dr. Lepor highlights the fundamental role of longitudinal PSA testing, imaging, and biopsy in monitoring patients. Key findings from his cohort of over 500 patients include:
PSA Trends as Predictors: Longitudinal consecutive PSA rises are the strongest predictors of clinically significant recurrence.
MRI Utility: Positive MRIs are associated with a 30-40% likelihood of detecting cancer, but the overall frequency of positive MRIs remains low, justifying their use selectively.
Biopsy Strategies: The cohort’s data indicate that systematically performing biopsies on patients with negative MRIs yields low detection rates, and most findings represent low-volume or less concerning disease.
Dr. Lepor concludes that the current algorithm incorporates PSA testing, selective MRI, and biopsy based on imaging or PSA trends, reducing unnecessary procedures while maintaining effective cancer surveillance. However, further data, especially at the five-year mark, are needed to refine this approach further. This pragmatic and evolving strategy balances oncologic safety with patient quality of life.
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The Changing Landscape of Focal Therapy for Prostate Cancer
In this 20-minute presentation, Herbert Lepor, MD, reflects on a 40-year journey in prostate cancer management and emphasizes the evolving role of focal therapy. Having performed over 5,000 radical prostatectomies, outcomes like continence, potency, and complications are critically evaluated. Challenges such as climacturia, penile shortening, and recurrence prompt the exploration of focal therapy as a patient-centered alternative. The shift towards minimally invasive options like cryoablation reflects efforts to balance cancer control with improved quality of life.
Early studies demonstrate that focal therapy effectively ablates targeted lesions with minimal in-field recurrence. MRI is a cornerstone in lesion identification and treatment planning, ensuring precision in disease localization and minimizing overtreatment. Functional outcomes from focal therapy show marked improvements, particularly in preserving sexual function and reducing urinary symptoms. Focal therapy’s growing adoption, bolstered by robust evidence and improved techniques, positions it as a transformative approach in prostate cancer care. This evolution marks a paradigm shift, with patients increasingly opting for therapies prioritizing oncologic control and quality of life.
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