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Which technology to select for primary focal treatment of prostate cancer?—European Section of Urotechnology (ESUT) position statement

Prostate Cancer and Prostatic Diseases volume 21, pages 175–186 (2018)Cite this article

Subjects

Abstract

Background

With growing interest in focal therapy (FT) of prostate cancer (PCa) there is an increasing armamentarium of treatment modalities including high-intensity focused ultrasound (HIFU), cryotherapy, focal laser ablation (FLA), irreversible electroporation (IRE), vascular targeted photodynamic therapy (VTP), focal brachytherapy (FBT) and stereotactic ablative radiotherapy (SABR). Currently there are no clear recommendations as to which of these technologies are appropriate for individual patient characteristics. Our intention was to review the literature for special aspects of the different technologies that might be of advantage depending on individual patient and tumour characteristics.

Methods

The current literature on FT was screened for the following factors: morbidity, repeatability, tumour risk category, tumour location, tumour size and prostate volume and anatomical issues. The ESUT expert panel arrived at consensus regarding a position statement on a structured pathway for available FT technologies based on a combination of the literature and expert opinion.

Results

Side effects were low across different studies and FT modalities with urinary continence rates of 90–100% and erectile dysfunction between 5 and 52%. Short to medium cancer control based on post-treatment biopsies were variable between ablative modalities. Expert consensus suggested that posterior lesions are better amenable to FT using HIFU. Cryotherapy provides best possible outcomes for anterior tumours. Apical lesions, when treated with FBT, may yield the least urethral morbidity.

Conclusions

Further prospective trials are required to assess medium to long term disease control of different ablative modalities for FT. Amongst different available FT modalities our ESUT expert consensus suggests that some may be better for diffe`rent tumour locations. Tumour risk, tumour size, tumour location, and prostate volume are all important factors to consider and might aid in designing future FT trials.

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References

  1. Abern MR, Tsivian M, Polascik TJ. Focal therapy of prostate cancer: evidence-based analysis for modern selection criteria. Curr Urol Rep. 2012;13:160–9.

    Article  Google Scholar 

  2. Polascik TJ, Mouraviev V. Focal therapy for prostate cancer is a reasonable treatment option in properly selected patients. Urology. 2009;74:726–30.

    Article  Google Scholar 

  3. Murphy DG, Loeb S. Prostate cancer: growth of AS in the USA signals reduction in overtreatment. Nat Rev Urol. 2015;12:604–5.

    Article  Google Scholar 

  4. Welty CJ, Cooperberg MR, Carroll PR. Meaningful end points and outcomes in men on active surveillance for early-stage prostate cancer. Curr Opin Urol. 2014;24:288–92.

    Article  Google Scholar 

  5. van den Bergh RC, Murphy DG, Costello AJ. Identification of candidates for observation. Curr Opin Urol. 2015;25:252–7.

    Article  Google Scholar 

  6. Tsivian M, Abern MR, Polascik TJ. Evolution of the concept of focal therapy for prostate cancer. Oncology (Williston Park). 2013;27:64–68. 70

    Google Scholar 

  7. van der Poel H, Klotz L, Andriole G, Azzouzi AR, Bjartell A, Cussenot O, et al. Role of active surveillance and focal therapy in low- and intermediate-risk prostate cancers. World J Urol. 2015;33:907–16.

    Article  Google Scholar 

  8. Ahmed HU, Emberton M. Active surveillance and radical therapy in prostate cancer: can focal therapy offer the middle way? World J Urol. 2008;26:457–67.

    Article  Google Scholar 

  9. Bahn D, Silverman P, Lee F, Badalament R, Bahn ED, Rewcastle JC. Focal prostate cryoablation: initial results show cancer control and potency preservation. J Endourol. 2006;20:688–92.

    Article  Google Scholar 

  10. Mouraviev V, Johansen TE, Polascik TJ. Contemporary results of focal therapy for prostate cancer using cryoablation. J Endourol. 2010;24:827–34.

    Article  Google Scholar 

  11. Eggener SE, Scardino PT, Carroll PR, Zelefsky MJ, Sartor O, Hricak H, et al. Focal therapy for localized prostate cancer: a critical appraisal of rationale and modalities. J Urol. 2007;178:2260–7.

    Article  Google Scholar 

  12. de la Rosette J, Ahmed H, Barentsz J, Johansen TB, Brausi M, Emberton M, et al. Focal therapy in prostate cancer-report from a consensus panel. J Endourol. 2010;24:775–80.

    Article  Google Scholar 

  13. Ahmed HU, Akin O, Coleman JA, Crane S, Emberton M, Goldenberg L, et al. Transatlantic Consensus Group on active surveillance and focal therapy for prostate cancer. BJU Int. 2012;109:1636–47.

    Article  Google Scholar 

  14. Donaldson IA, Alonzi R, Barratt D, Barret E, Berge V, Bott S, et al. Focal therapy: patients, interventions, and outcomes--a report from a consensus meeting. Eur Urol. 2015;67:771–7.

    Article  Google Scholar 

  15. Ahmed HU, Berge V, Bottomley D, Cross W, Heer R, Kaplan R, et al. Can we deliver randomized trials of focal therapy in prostate cancer? Nat Rev Clin Oncol. 2014;11:482–91.

    Article  CAS  Google Scholar 

  16. van den Bos W, Muller BG, Ahmed H, Bangma CH, Barret E, Crouzet S, et al. Focal therapy in prostate cancer: international multidisciplinary consensus on trial design. Eur Urol. 2014;65:1078–83.

    Article  Google Scholar 

  17. Postema AW, De Reijke TM, Ukimura O, Van den Bos W, Azzouzi AR, Barret E, et al. Standardization of definitions in focal therapy of prostate cancer: report from a Delphi consensus project. World J Urol. 2016;34:1373–82.

    Article  CAS  Google Scholar 

  18. Coleman JA, Scardino PT. Targeted prostate cancer ablation: energy options. Curr Opin Urol. 2013;23:123–8.

    Article  Google Scholar 

  19. Salgaonkar VA, Prakash P, Rieke V, Ozhinsky E, Plata J, Kurhanewicz J, et al. Model-based feasibility assessment and evaluation of prostate hyperthermia with a commercial MR-guided endorectal HIFU ablation array. Med Phys. 2014;41:033301.

    Article  Google Scholar 

  20. Ahmed HU, Moore C, Emberton M. Minimally-invasive technologies in uro-oncology: the role of cryotherapy, HIFU and photodynamic therapy in whole gland and focal therapy of localised prostate cancer. Surg Oncol. 2009;18:219–32.

    Article  Google Scholar 

  21. Rischmann P, Gelet A, Riche B, Villers A, Pasticier G, Bondil P, et al. Focal high intensity focused ultrasound of unilateral localized prostate cancer: a prospective multicentric hemiablation study of 111 patients. Eur Urol. 2016;71:267–73.

    Article  Google Scholar 

  22. Ganzer R,Hadaschik B,Pahernik S,Koch D,Baumunk D,Kuru T, et al. Prospective multicenter phase II-study on focal therapy (hemiablation) of the prostate with High Intensity focused ultrasound (HIFU). J Urol. 2017;199:983–989.

    Article  Google Scholar 

  23. Babaian RJ, Donnelly B, Bahn D, Baust JG, Dineen M, Ellis D, et al. Best practice statement on cryosurgery for the treatment of localized prostate cancer. J Urol. 2008;180:1993–2004.

    Article  Google Scholar 

  24. Ward JF, Jones JS. Focal cryotherapy for localized prostate cancer: a report from the national Cryo On-Line Database (COLD) registry. BJU Int. 2012;109:1648–54.

    Article  Google Scholar 

  25. Truesdale MD, Cheetham PJ, Hruby GW, Wenske S, Conforto AK, Cooper AB. An evaluation of patient selection criteria on predicting progression-free survival after primary focal unilateral nerve-sparing cryoablation for prostate cancer: recommendations for follow up. Cancer J. 2010;16:544–9.

    Article  Google Scholar 

  26. Onik G,Vaughan D,Lotenfoe R,Dineen M,Brady J, “Male lumpectomy”: focal therapy for prostate cancer using cryoablation. Urology. 2008;70:16–21.

    Article  Google Scholar 

  27. Lindner U, Lawrentschuk N, Weersink RA, Davidson SR, Raz O, Hlasny E, et al. Focal laser ablation for prostate cancer followed by radical prostatectomy: validation of focal therapy and imaging accuracy. Eur Urol. 2010;57:1111–4.

    Article  Google Scholar 

  28. Lindner U, Weersink RA, Haider MA, Gertner MR, Davidson SRH, Atri M. Image guided photothermal focal therapy for localized prostate cancer: Phase I trial. J Urol. 2009;182:1371–7.

    Article  CAS  Google Scholar 

  29. Oto A, Sethi I, Karczmar G, McNichols R, Ivancevic MK, Stadler WM, et al. MR imaging-guided focal laser ablation for prostate cancer: Phase I trial. Radiology. 2013;267:932–40.

    Article  Google Scholar 

  30. Raz O, Haider MA, Davidson SR, Lindner U, Hlasny E, Weersink R, et al. Real-time magnetic resonance imaging-guided focal laser therapy in patients with low-risk prostate cancer. Eur Urol. 2010;58:173–7.

    Article  Google Scholar 

  31. Eggener SE, Yousuf A, Watson S, Wang S, Oto A. Phase II evaluation of magnetic resonance imaging guided focal laser ablation of prostate cancer. J Urol. 2016;196:1670–5.

    Article  Google Scholar 

  32. Lepor H, Llukani E, Sperling D, Futterer JJ. Complications, recovery, and early functional outcomes and oncologic control following in-bore focal laser ablation of prostate cancer. Eur Urol. 2015;68:924–6.

    Article  Google Scholar 

  33. Natarajan S, Jones TA, Priester AM, Geoghegan R, Lieu P, Delfin M, et al. Focal laser ablation of prostate cancer: feasibility of magnetic resonance imaging-ultrasound fusion for guidance. J Urol. 2017;198:839–47.

    Article  Google Scholar 

  34. Taneja SS,Bennett J,Coleman J,Grubb R,Andriole G,Reiter RE, et al. Final results of a Phase I/II Multicenter Trial of WST11 vascular targeted photodynamic therapy for hemi-ablation of the prostate in men with unilateral low risk prostate cancer performed in the United States. J Urol. 2016;196:1096–104.

    Article  Google Scholar 

  35. Azzouzi AR,Barret E,Moore CM,Villers A,Allen C,Scherz A, et al. TOOKAD((R)) soluble vascular-targeted photodynamic (VTP) therapy: determination of optimal treatment conditions and assessment of effects in patients with localised prostate cancer. BJU Int. 2013;112:766–74.

    Article  CAS  Google Scholar 

  36. Moore CM, Azzouzi AR, Barret E, Villers A, Muir GH, Barber NJ, et al. Determination of optimal drug dose and light dose index to achieve minimally invasive focal ablation of localised prostate cancer using WST11-vascular-targeted photodynamic (VTP) therapy. BJU Int. 2015;116:888–96.

    Article  CAS  Google Scholar 

  37. Azzouzi A-R, Vincendeau S, Barret E, Cicco A, Kleinclauss F, van der Poel HG, et al. Padeliporfin vascular-targeted photodynamic therapy versus active surveillance in men with low-risk prostate cancer (CLIN1001 PCM301): an open-label, phase 3, randomised controlled trial. Lancet Oncol. 2016;18:181–91.

    Article  Google Scholar 

  38. Cosset JM, Cathelineau X, Wakil G, Pierrat N, Quenzer O, Prapotnich D, et al. Focal brachytherapy for selected low-risk prostate cancers: a pilot study. Brachytherapy. 2013;12:331–7.

    Article  Google Scholar 

  39. Barret E, Ahallal Y, Sanchez-Salas R, Galiano M, Cosset JM, Validire P, et al. Morbidity of focal therapy in the treatment of localized prostate cancer. Eur Urol. 2013;63:618–22.

    Article  CAS  Google Scholar 

  40. Kamrava M, Chung MP, Kayode O, Wang J, Marks L, Kupelian P, et al. Focal high-dose-rate brachytherapy: a dosimetric comparison of hemigland vs. conventional whole-gland treatment. Brachytherapy. 2013;12:434–41.

    Article  Google Scholar 

  41. Kovacs G, Cosset JM, Carey B. Focal radiotherapy as focal therapy of prostate cancer. Curr Opin Urol. 2014;24:231–5.

    Article  Google Scholar 

  42. King CR, Lehmann J, Adler JR, Hai J. CyberKnife radiotherapy for localized prostate cancer: rationale and technical feasibility. Technol Cancer Res Treat. 2003;2:25–30.

    Article  Google Scholar 

  43. Macdougall ND, Dean C, Muirhead R. Stereotactic body radiotherapy in prostate cancer: is rapidarc a better solution than cyberknife? Clin Oncol (R Coll Radiol). 2014;26:4–9.

    Article  CAS  Google Scholar 

  44. Lu DS, Kee ST, Lee EW. Irreversible electroporation: ready for prime time? Tech Vasc Interv Radiol. 2013;16:277–86.

    Article  Google Scholar 

  45. Bozzini G, Colin P, Nevoux P, Villers A, Mordon S, Betrouni N. Focal therapy of prostate cancer: energies and procedures. Urol Oncol. 2013;31:155–67.

    Article  CAS  Google Scholar 

  46. Onik G, Rubinsky B. Irreversible electroporation. Berlin, Heidelberg: Springer-Verlag; 2010. p. 235–47.

    Chapter  Google Scholar 

  47. van den Bos W, Muller BG, de la Rosette JJ. A randomized controlled trial on focal therapy for localized prostate carcinoma: hemiablation versus complete ablation with irreversible electroporation. J Endourol. 2013;27:262–4.

    PubMed  Google Scholar 

  48. Valerio M, Stricker PD, Ahmed HU, Dickinson L, Ponsky L, Shnier R, et al. Initial assessment of safety and clinical feasibility of irreversible electroporation in the focal treatment of prostate cancer. Prostate Cancer Prostatic Dis. 2014;17:343–7.

    Article  CAS  Google Scholar 

  49. Valerio M, Dickinson L, Ali A, Ramachadran N, Donaldson I, Mccartan N et al. Nanoknife Electroporation Ablation Trial (NEAT): a prospective development study investigating focal irreversible electroporation for localised prostate cancer. J Urol. 2016.

  50. TOOKAD (Padeliporfin) Vascular-Targeted Photodynamic Therapy versus Active Surveillance in men with low risk prostate cancer. A randomized phase 3 clinical trial.. Munich, Germany: European Association of Urology; 2016.

    Google Scholar 

  51. Marien A, Gill I, Ukimura O, Betrouni N, Villers A. Target ablation--image-guided therapy in prostate cancer. Urol Oncol. 2014;32:912–23.

    Article  Google Scholar 

  52. Crouzet S, Murat FJ, Pasticier G, Cassier P, Chapelon JY, Gelet A. High intensity focused ultrasound (HIFU) for prostate cancer: current clinical status, outcomes and future perspectives. Int J Hyperth. 2010;26:796–803.

    Article  Google Scholar 

  53. Shah TT, Ahmed H, Kanthabalan A, Lau B, Ghei M, Maraj B, et al. Focal cryotherapy of localized prostate cancer a systematic review of the literature. Expert Rev Anticancer Ther. 2014;14:1337–47.

    Article  CAS  Google Scholar 

  54. Ahmed HU, Hindley RG, Dickinson L, Freeman A, Kirkham AP, Sahu M, et al. Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study. Lancet Oncol. 2012;13:622–32.

    Article  Google Scholar 

  55. Bahn D, de Castro Abreu AL, Gill IS, Hung AJ, Silverman P, Gross ME, et al. Focal cryotherapy for clinically unilateral, low-intermediate risk prostate cancer in 73 men with a median follow-up of 3.7 years. Eur Urol. 2012;62:55–63.

    Article  Google Scholar 

  56. Lambert EH, Bolte K, Masson P, Katz AE. Focal cryosurgery: encouraging health outcomes for unifocal prostate cancer. Urology. 2017;197:647–654.

    Article  Google Scholar 

  57. Ellis DS, Manny TBJ, Rewcastle JC. Focal cryosurgery followed by penile rehabilitation as primary treatment for localized prostate cancer: initial results. Urology. 2007;70:9–15. 6 Suppl

    Article  Google Scholar 

  58. Shah TT, Kasivisvanathan V, Jameson C, Freeman A, Emberton M, Ahmed HU. Histological outcomes after focal high-intensity focused ultrasound and cryotherapy. World J Urol. 2015;33:955–64.

    Article  Google Scholar 

  59. Muto S, Yoshii T, Saito K, Kamiyama Y, Ide H, Horie S. Focal therapy with high-intensity-focused ultrasound in the treatment of localized prostate cancer. Jpn J Clin Oncol. 2008;38:192–9.

    Article  Google Scholar 

  60. Orczyk C, Emberton M, Ahmed HU. What tumours should we treat with focal therapy based on risk category, grade, size and location? Curr Opin Urol. 2015;25:212–9.

    PubMed  Google Scholar 

  61. Rouvière O, Glas L, Girouin N, Mège-Lechevallier F, Gelet A, Dantony E, et al. Prostate cancer ablation with transrectal high-intensity focused ultrasound: assessment of tissue destruction with contrast-enhanced US. Radiology. 2011;259:583–91.

    Article  Google Scholar 

  62. Merrick GS, Wallner KE, Butler WM. Prostate cryotherapy: more questions than answers. Urology. 2005;66:9–15.

    Article  Google Scholar 

  63. Crouzet S, Rouviere O, Martin X, Gelet A. High-intensity focused ultrasound as focal therapy of prostate cancer. Curr Opin Urol. 2014;24:225–30.

    Article  Google Scholar 

  64. Sonacare. Sonafuse platform. 2016.

  65. Shoji S, Uchida T, Nakamoto M, Kim H, de Castro Abreu AL, Leslie S, et al. Prostate swelling and shift during high intensity focused ultrasound: implication for targeted focal therapy. J Urol. 2013;190:1224–32.

    Article  Google Scholar 

  66. Ghai S, Trachtenberg J, In-bore MRI. interventions: current status and future applications. Curr Opin Urol. 2015;25:205–11.

    Article  Google Scholar 

  67. Le Nobin J, Rosenkrantz AB, Villers A, Orczyk C, Deng FM, Melamed J, et al. Image guided focal therapy for magnetic resonance imaging visible prostate cancer: defining a 3-dimensional treatment margin based on magnetic resonance imaging histology co-registration analysis. J Urol. 2015;194:364–70.

    Article  Google Scholar 

  68. Sivaraman A, Barret E. Focal therapy for prostate cancer: an “A la Carte” approach. Eur Urol. 2016;69:973–5.

    Article  Google Scholar 

  69. Ahmed HU, Dickinson L, Charman S, Weir S, McCartan N, Hindley RG, et al. Focal ablation targeted to the index lesion in multifocal localised prostate cancer: a prospective development study. Eur Urol. 2015;68:927–36.

    Article  Google Scholar 

  70. Van Velthoven R, Aoun F, Limani K, Narahari K, Lemort M, Peltier A. Primary zonal high intensity focused ultrasound for prostate cancer: results of a prospective Phase IIa feasibility study. Prostate Cancer. 2014;2014:756189.

    PubMed  PubMed Central  Google Scholar 

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Author notes

  1. These authors contributed equally: Roman Ganzer, Vinodh Kumar Adithyaa Arthanareeswaran.

Authors and Affiliations

  1. Department of Urology, Asklepios Hospital Bad Tölz, Bad Tölz, Germany

    Roman Ganzer, Vinodh Kumar Adithyaa Arthanareeswaran & Jens-Uwe Stolzenburg

  2. Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK

    Hashim U. Ahmed

  3. Department of Urology, Imperial College Healthcare NHS Trust, London, UK

    Hashim U. Ahmed

  4. Department of Urology, Advanced Urotechnology Center, IRCCS Istituto Auxologico Italiano, Milan, Italy

    Andrea Cestari

  5. Department of Urology, Rangueil University Hospital, Toulouse, France

    Pascal Rischmann

  6. Martini Clinic, Prostate Cancer Center, Hamburg, Germany

    Georg Salomon

  7. Department of Urology, University of Heidelberg, Heidelberg, Germany

    Dogu Teber

  8. Department of Urology, University of Patras, Patras, Greece

    Evangelos Liatsikos

  9. Department of Urology, Institut Montsouris, Paris, France

    Eric Barret

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Contributions

RM: protocol development, data collection and management, manuscript writing/editing. VKAA: protocol development, data collection and management, manuscript writing/editing. HUA: data collection and management. AC: data collection and management. PR: data collection and management. GS: data collection and management. DT: data collection and management. EL: data collection and management. J-US: data collection and management. EB: protocol development, data collection and management, manuscript writing/editing

Corresponding author

Correspondence to Roman Ganzer.

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Conflict of interest

PR is a consultant for EDAP-TMS, Vaulx-en-Velin, France and stock owner of EDAP TMS shares; HUA receives funding from SonaCare Medical (previously USHIFU) for clinical trials and has received funding from SonaCare Medical for travel to conferences. RG, VKAA, AC, GS, DT, EL, J-US and EB declare that they have no conflict of interest.

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Ganzer, R., Arthanareeswaran, V.K.A., Ahmed, H.U. et al. Which technology to select for primary focal treatment of prostate cancer?—European Section of Urotechnology (ESUT) position statement. Prostate Cancer Prostatic Dis 21, 175–186 (2018). https://doi.org/10.1038/s41391-018-0042-0

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