Focal therapy for localized prostate cancer in the era of routine multi-parametric MRI

Abstract

Background

Prostate cancer focal therapy aims to minimize the side-effects of whole gland treatments, such as radical prostatectomy and radiotherapy without compromising oncological efficacy. However, concerns exist regarding the multifocal nature of prostate cancer and the lack of long-term oncological data for this form of treatment. In recent years, the routine adoption of multi-parametric magnetic resonance imaging (mpMRI) of the prostate has improved our ability to select candidates for focal therapy and to accurately deliver this form of prostate cancer treatment.

Methods

We performed a review of the literature to provide a summary of the oncological and functional outcomes of men receiving primary prostate focal therapy. Furthermore, we discuss the impact of the routine implementation of mpMRI as part of the initial prostate cancer diagnostic pathway on the selection of candidates and delivery of focal therapy. Finally, we summarize knowledge gaps in the field and highlight active clinical trials in this arena.

Results

Primary focal therapy involves the application of one of a number of energies that ablate tissue, such as cryotherapy and high intensity focused ultrasound (HIFU). Success is principally dependent on highly accurate patient selection and disease localization underpinned in large part by the routine integration of pre-biopsy mpMRI. Prospective medium-term follow-up data for primary HIFU and cryotherapy for men with intermediate-risk disease have shown acceptable cancer control with low risk of side effects and complications. Additional research is needed to clearly define an appropriate follow-up approach and to guide the management of in- and out-of-field recurrences. Multiple comparative trials with randomization against standard care are currently underway in men with intermediate- and high-risk prostate cancer.

Conclusion

The widespread adoption of prostate mpMRI has led to improved disease localization, enabling the performance of focal therapy as a viable treatment strategy for men with low volume intermediate-risk prostate cancer.

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MJC, RN, HUA, and MAG conceived the idea of the article. MJC and MAG wrote the first version and all authors contributed significant editing to the final version.

Corresponding author

Correspondence to M. J. Connor.

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Conflict of interest

MJC is funded by the Wellcome Trust and University College London Hospital (UCLH) Charity. MAG: None. HUA's research is supported by core funding from the United Kingdom’s National Institute of Health Research (NIHR) Imperial Biomedical Research Centre. HUA currently receives funding from the Wellcome Trust, Medical Research Council (UK), Prostate Cancer UK, Cancer Research UK, The BMA Foundation, The Urology Foundation, The Imperial Health Charity, University College London Hospital (UCLH) Charity Sonacare Inc., Trod Medical and Sophiris Biocorp for trials and studies in prostate cancer. HUA is a paid medical consultant for Sophiris Biocorp, Sonacare Inc. and BTG/Galil. HUA is a paid proctor for HIFU, cryotherapy and Rezum water vapor therapy. RN: None.

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Connor, M.J., Gorin, M.A., Ahmed, H.U. et al. Focal therapy for localized prostate cancer in the era of routine multi-parametric MRI. Prostate Cancer Prostatic Dis 23, 232–243 (2020). https://doi.org/10.1038/s41391-020-0206-6

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