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Focal Therapy for localised prostate cancer: con

Focal Therapy for localised prostate cancer: con. Simon F Brewster Oxford , UK. Cancer Multifocality. 309 RPs reviewed (Aslam 2009): Unifocal = 70 (22%) Unilateral multifocal with >1 significant cancer = 8 (2.5%) Bilateral multifocal non-significant cancers = 105 (33%)

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Focal Therapy for localised prostate cancer: con

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  1. Focal Therapy for localised prostate cancer: con Simon F Brewster Oxford , UK

  2. Cancer Multifocality • 309 RPs reviewed (Aslam 2009): • Unifocal = 70 (22%) • Unilateral multifocal with >1 significant cancer = 8 (2.5%) • Bilateral multifocal non-significant cancers = 105 (33%) • Bilateral multifocal significant cancers = 126 (41%) • MRI not accurate enough to map small multifocal cancers; 11/14 unifocal cancers but 0/23 multifocal cancers were correctly mapped by MRI (Okamura 2006) • Dynamic contrast enhancement, diffusion-weighting and magnetic resonance spectroscopy imaging (MRSI) mapping are still evolving technologies • Transperineal template-guided saturation biopsies using general anaesthetic is time consuming, expensive, with increased morbidity: urinary retention 40% (Merrick, 2008)

  3. Genetic evidence against treating index cancer only 4/7 multifocal cancers associated with LN metastases showed chromosomal anomalies identical to one of the multifocal non-index cancer foci; concordance with index cancer was 3/7 (Qian et al 1995); similar findings subsequently by the same group 5/12 (42%) concordance (Gburek, 1997)

  4. Which Ablative Treatment? • transrectal HIFU • transperineal Cryotherapy • transperineal PDT (Tookad) • transperineal Radiofrequency ablation (RFA) • transperineal Brachytherapy None except brachytherapy has proven long-term oncological efficacy and widespread adoption even for whole-gland ablation Morbidity? BOO, obstruction, infection, ED, incontinence, prostato-rectal fistula…

  5. Uncertainty about oncological and functional outcomes in early studies • PSA changes in focally-treated prostates • Follow-up protocol & defining biochemical failure • Post-treatment biopsy: 4-40% positive (most contralaterally) following focal cryoablation (Ellis, 2007; Onik, 2002) • 17/24 (71%) patients treated by hemi-gland cryoablation remained potent, although 7 required PDE5I’s (Lambert, 2007)

  6. The “male lumpectomy” sounds good, but is it safe? Undertreatment: Prostate cancer is a multifocal heterogeneous disease, which current imaging technology cannot reliably identify; Genetic evidence suggests the most dangerous cancer may not be the largest in a majority of cases Overtreatment: Many low-risk prostate cancers can be managed long-term by active surveillance without any intervention Which treatment? Several competing focal ablation modalities, most of which remain unproven even for whole-gland treatment, with associated morbidity

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