Focal therapy for prostate cancer: seriously or seriously? Disclosures

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1 Focal therapy for prostate cancer: seriously or seriously? Mitchell Kamrava, MD Assistant Clinical Professor Department of Radiation Oncology University of California Los Angeles Disclosures Speaking honorarium from Elekta in

2 Outline What is the rationale for focal therapy? Who is a candidate? How do you identify candidates? What treatment modality should be used? What volume do you treat? Is there data to support doing this? What s wrong with whole gland therapy? Alternative to active surveillance argument Focal is compromise b/w whole gland and AS Problem: focal is still overtreatment Alternative to definitive treatment argument The whole gland is not the target 2

3 Index Lesion Hypothesis Disease progression is driven by dominant lesion Active surveillance of small insignificant satellite lesions Ahmed H. NEJM

4 4

5 Definition of clinically significant Biopsy strategies for selecting patients for focal therapy for prostate cancer. Kanthabalan, Abi; Emberton, Mark; Ahmed, Hashim Current Opinion in Urology. 24(3): , May DOI: /MOU Wolters Kluwer Health Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc. Who is a candidate? Langley S et al. BJUI Van den Bos W et al. European Urology

6 How do you identify the index lesion short of doing a prostatectomy? Template mapping biopsies Multi parametric MRI 6

7 90% sensitivity/specificity for finding disease > 0.5 ml and GS 7 Turkbey B et al. J Urol Villers A et al. J Urol Muller B et al. BJUI Importance of Lesion Score Anderson E et al. Brachytherapy

8 U/S MRI Fusion Sonn G. Journal of Urology What treatment modality? Brachytherapy?? 8

9 Cryotherapy Impotence 80% Incontinence 5% Pelvic/rectal pain 1 11% Fistula 1% Treatment Techniques Achieving the Trifecta HIFU Impotence 44% Obstruction ti 17% Urethral stricture 12% Incontinence 8% Laser Limited clinical data PDT Limited long term data Not included is electroporation Lindner U et al. Nature Reviews Urology HDR brachytherapy Stakes of treatment > 90% PSA control (low/int risk) 10% GU (Late) < 5% GI (Late) ~50% ED 9

10 What volume do you treat? Ultra Focal Therapy Hemi Focal Therapy Focused Therapy a) a) a) b) b) b) Langley S et al. BJU Int Distribution of prostate cancer based on prostatectomy specimens # of patients Disease able to be treated with HG approach Disease able to be treated with UF approach GS % 0% GS % 11% GS % 24% GS % 12% Sifuentes J et al. Manuscript in preparation. 10

11 22% 31% 14% 26% Not candidate Not candidate European Urology Whole Gland vs Hemi Gland Radiation Dose Rectum Bladder Urethra WG HG WG HG WG HG D 0.1cc (%) D 1cc (%) D 2cc (%) % 12% 26% Kamrava M et al. Brachytherapy

12 Managing Spill Dose HG Right + HG Left = Overdose Target % D V V HG Left + Partial Right = Acceptable Target % D V V Kamrava M et al. Brachytherapy Example of actual HG implant 12

13 What s ideal subvolume to treat? 1/3 Gland 1/6 Gland Banerjee R et al. Manuscript in preparation. Organ at Risk Doses for WG vs. HG vs. < HG Bladder D2cc Rectum D2cc Urethra D1cc Whole Hemi 1/3 G 1/6 G Banerjee R et al. Manuscript in preparation. 13

14 Ultrafocal Park S et al. Manuscript in preparation. PZ Brachytherapy 95% 73% 80% 66% 318 pts, median f/u 5.1 yrs, 83% low risk Nguyen PL et al. Journal of Urology

15 PSAV > 0.75 ng/ml per year Nguyen PL et al. Journal of Urology Focal LDR Brachytherapy 21 patients 34% of theprostate treated w/ I Gy At 1 year PSA decline of ~60% (6.9 >2.6) At 6 months improvement in erectile function and borderline reduction in urinary toxicity compared with whole gland treatment Cosset JM et al. Brachytherapy

16 Conclusions Index lesion concept is a hypothesis Ongoing trials will determine it s validity both from an oncologic and toxicity standpoint Ideal focal modality is not known Radiation oncology (especially brachytherapy) needs to be actively involved in this emerging area 16

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