Real Time MRI guided Focal Laser Ablation Therapy for Prostate Cancer

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1 Real Time MRI guided Focal Laser Ablation Therapy for Prostate Cancer A/Prof Celi Varol and Dr Orit Raz Uro-Oncologist Nepean and Macquarie Hospital Trial at Macquarie University Hospital Ethics board and TGA approved

2 Prostate Cancer in 2015 Treatment of PCa saves lives Side effects of treatment can outweigh the benefits Better understanding of NNT

3 Prostate Cancer 2015 PCa screening = increases the incidence of Indolent disease Less aggressive approach / organ preservation Active surveillance

4 Active Surveillance Low volume disease ->Disease Progression ->Anxiety >>>>> Focal Therapy <<<<< ->Radical Rx

5 In 2015 Focal Therapy Patient selection!!!

6 Ideal Focal Therapy 1.Clearly identify and localize tumour - Targeting 2.Navigate ablation energy to target 3.Completely destroy ONLY target 4.Real time monitoring of tumour destruction 5.Have NO side effects 6.Be prepared and able to repeat if necessary 7.Eligible for more radical treatment in the future.

7 Clearly identify and localize tumour - Targeting 1. mpmri of the prostate 2. MRI guided biopsy

8 The role of magnetic resonance imaging in the diagnosis and management of prostate cancer Thompson James et al. BJU international 2013,

9 In recent years, the availability of 3 Tesla magnets has led to increased use of MRI in the detection of PCa. PIRADS The combination of anatomical (T2-weighted) MRI with functional MRI parameters (DW, DCE or spectroscopy) will detect > 90% of significant Pca (2013). MRI is less reliable at detecting tumours that are: < 0.5 cc low grade, Gleason score<7 transitional zone

10 Navigate to Tumour Combined T2W and DWI MRI for tumor localization Prostate Tumour

11 Real time FLT In the bore of the MR scanner Under general anesthesia Supine or Prone Brachy-template / TR probe

12 Transrectal Transperineal

13 Localisation of Tumour with laser fiber on real time MRI

14 Laser Fiber position

15 Dr. John Trachtenberg University of Toronto, Toronto, CA January 26, 2010 Visualase System eatment temperature map Irreversible damage estim

16 Tissue temperature map measured by MR thermometry - during laser ablation Calculated actual damage

17 Ideal Focal Therapy 1.Clearly identify and localize tumour - Targeting 2.Navigate ablation energy to target 3.Completely destroy ONLY target 4.Real time monitoring of tumour destruction 5.Have NO side effects 6.Be prepared and able to repeat if necessary 7.Eligible for more radical treatment in the future.

18 Prostate Cancer Patient PSA 6.0 ng/ml DRE normal MRI guided biopsy ¾ cores Gleason 3+4= % of cores Random biopsy x12 normal IPSS and IIEF normal

19 MRI guided Bx Gleas 7 Pca PSA 6ng/ml 63yo

20 6 months post FLT MRI guided Bx

21 Fibrosis No Prostate Cancer

22 60 years old PSA 5.8 mpmri : 0.4 cc, PIRADS 3/5 Left posterior lateral TP biopsy matched Gleason s (3+4), in 1/24 cores

23 FLT Nov 2014

24

25 Post FLT contrast enhanced MRI

26 6 months post FLT mpmri new lesion

27 MRI GBx from post FLT lesion Area of fibrosis and chronic inflamation

28 MRI GB from new lesion right Apex: Gleason s score (4+3)

29 Robotic radical Prostatectomy Uneventful RALRP Bilateral nerve spare pt2 Gleason s (4+3), 60% HG 0.2 cc tumor volume No residual tumor at treated area

30 Results February patients Average age 59.6y Pre treatment PSA 4.5 ng/ml ( ) lesion size 25mm (5-56)

31 Complications: 2 Urinary retention 2 Perineal discomfort Patients discharged home within < 2 hours No major complications Preservation of urethra, rectum, and NVBs IPSS and IIEF at 1 month = normal PSA

32 CONCLUSION In Selective patients Outpatient procedure No technical issues GA / Sedation More studies should be done, with larger number of patients and long-term follow-up, to confirm the disease and biochemical free survival benefit of this technique.

33 Who needs radical Rx Vs Surveillance? NNT is high grade NNT is intermediate grade

34 1. MRI guided FLT treats PCa 2. Assists in guiding/tailoring who will benefit from Radical Rx