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Tumor focality in prostate cancer: implications for focal therapy

Nature Reviews Clinical Oncology volume 8, pages 48–55 (2011)Cite this article

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Abstract

In recent years, there has been a growing interest in focal treatment for prostate cancer. Although widely used for the treatment of tumors of the breast and kidney, focal treatment for prostate cancer remains a controversial area. Criticism of focal prostate therapy has been based on the fact that prostate cancer is a multifocal disease. Until now, little attention has been paid to distinguishing between men with unifocal and those with multifocal disease because such information has little clinical relevance when treatment is aimed at the whole gland irrespective of the volume or number of cancers in the prostate. In this Review, we summarize existing knowledge and examine the issue of prostate cancer focality in the context of focal treatment.

Key Points

  • Early studies on focal therapy for prostate cancer demonstrate encouraging health outcome; the primary argument against the application of focal therapy is that prostate cancer is a multifocal and bilateral disease

  • Multiple prostate cancers arise independently and are probably secondary to numerous independent mutations; however, intra-glandular spread of a single malignant transformed cell cannot be excluded in some cases

  • Neither tumor laterality nor tumor focality per se are associated with worse pathological findings in prostatectomy specimens or worse clinical outcome following radical treatment

  • In multifocal tumors, the dominant index lesion (as measured by tumor volume focus) may represent the only lesion in the prostate with truly relevant malignant potential

  • Ablation of the index lesion alone and close monitoring of the secondary tumors for early signs of progression might be the cornerstone of successful focal treatment

  • Further studies in which only the index lesion is ablated and other untreated lesions are followed are necessary

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Figure 1: Radical prostatectomy step section: Multifocal prostate cancer.

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Acknowledgements

H. U. Ahmed receives funding from the Medical Research Council, Pelican Cancer Foundation, Prostate UK, Prostate Cancer Research Centre, Prostate Cancer Research Foundation and St Peters Trust for work on focal therapy and imaging of prostate cancer.

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Authors and Affiliations

  1. Department of Urology, “St. Panteleimon” General Hospital of Nikaia, Dim. Mantouvalou 3, 18454, Nikaia Piraeus, Greece

    Markos Karavitakis

  2. Division of Surgery and Interventional Science, University College London, 67 Riding House Street, London, W1P 7NN, UK

    Hashim U. Ahmed

  3. Department of Surgery and Cancer, Imperial College, B Block, Hammersmith Campus, DuCane Road, London, W12 0NN, UK

    Paul D. Abel

  4. Department of Histopathology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK

    Steven Hazell

  5. Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK

    Mathias H. Winkler

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Contributions

M. Karavitakis, H. U. Ahmed, P. Abel and M. Winkler researched the data for the article. All the authors provided a substantial contribution to discussions of the content. M. Karavitakis contributed to writing the article, and all authors reviewed and/or edited the manuscript before submission.

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Correspondence to Markos Karavitakis.

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Competing interests

Dr. H. U. Ahmed is a consultant for Steba Biotech and receives grant and research support from Focus Surgery, Medical Research Council, Misonix, Pelican Cancer Foundation, Prostate Cancer Research Centre, Prostate Cancer Research Foundation, Prostate UK, St. Peters Trust, UKHIFU and USHIFU. Dr. P. D. Abel and Dr. M. H. Winkler are collaborators in the multicenter focal therapy HIFU study. M. Karavitakis and S. Hazell declare no competing interests.

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Karavitakis, M., Ahmed, H., Abel, P. et al. Tumor focality in prostate cancer: implications for focal therapy. Nat Rev Clin Oncol 8, 48–55 (2011). https://doi.org/10.1038/nrclinonc.2010.190

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