IO treatments for localized prostate cancer

Three things you will learn at my lecture

1. Targeted treatment: Focal therapy offers a minimally invasive approach, targeting only cancerous areas in the prostate while preserving healthy tissue.
2. Reduced side effects: Compared to traditional treatments, focal therapy typically results in fewer side effects like incontinence and erectile dysfunction.
3. Potential for recurrence: While effective for localized prostate cancer, focal therapy may carry a higher risk of recurrence and often requires careful patient selection and monitoring.

Prof. Jurgen Fütterer
Speaker bio

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Current evidence for prostate cancer

Prostate cancer is one of the most common malignancies in men, characterized by significant morbidity due to its variable aggressiveness and potential for progression if untreated. While radical treatments, such as prostatectomy or radiation therapy, offer curative potential, they are associated with substantial side effects, including urinary incontinence and erectile dysfunction [1,2]. Therefore, less invasive options, including focal therapy, are gaining attention as alternatives for carefully selected patients. Focal therapy aims to control localized disease while minimizing the adverse effects associated with radical treatments [3,4].

Ablation for prostate cancer – Current insights

Focal therapy, particularly image-guided ablation techniques, is being actively explored as a treatment option for localized intermediate-grade prostate cancer. These therapies are especially relevant for patients with well-confined lesions, who may benefit from organ-preserving approaches. Emerging evidence suggests that focal therapy offers similar oncological outcomes to more invasive treatments while significantly reducing the risk of treatment-related side effects.

The rationale for focal therapy is rooted in the index lesion theory. Prostate cancer is frequently multifocal. According to the index lesion theory, the largest and most aggressive lesion within the gland drives the clinical behavior and progression of the disease. At the same time, the secondary foci have less potential to do so.

Focal therapy targets the lesion plus a margin of normal tissue while sparing the rest of the prostate gland. Minimizing the treatment volume may optimize the risk of adverse events and the chance of functional preservation. Currently, focal therapy is being carried out with different energy sources: ultrasound ablation, either transrectal high-intensity focused ultrasound (HIFU) or MRI-guided transurethral ultrasound ablation (TULSA), cryoablation, laser ablation, and irreversible electroporation (IRE) [5-7]. All modalities leverage different mechanisms to eradicate localized prostate cancer

A benefit of focal therapy is the possibility of re-treatment with radical therapy in case of recurrence or a new lesion elsewhere in the prostate. Despite current research towards focal therapies in prostate cancer, there is a lack of evidence regarding randomized controlled trials. Another factor that might make focal therapies an interesting approach for the treatment of intermediate-risk prostate cancer is a reduction of complication-related costs.

Future directions and conclusion

Technological advancements, such as robotic-assisted ablation systems, bolster focal therapy in prostate cancer treatment. These innovations enhance treatment precision, reduce variability, and improve outcomes. Coupled with advances in molecular profiling, AI-driven predictive tools, and combination therapies, interventional oncology holds the potential to revolutionize prostate cancer care by offering tailored, patient-specific treatments.

With ongoing research and technological innovation, focal therapy is likely to become an increasingly important part of the prostate cancer treatment paradigm, offering a balanced approach that prioritizes both oncological control and quality of life.

Jurgen Fütterer

Radboudumc, Nijmegen/NL

Jurgen Fütterer is an interventional radiologist, full professor at the Department of Medical Imaging, Radboudumc, and at the Robotics and Mechatronics group, University of Twente. Prof. Fütterer is the founder and Research Group Leader of the Minimally Invasive Image-Guided Interventions Center (MAGIC) research group at the Radboudumc. The group has played a key role in establishing and extending the Radboudumc’s Imaging department’s role as an internationally recognized center of excellence in MRI-guided prostate cancer diagnosis and minimally invasive treatment.

References

E. Haglind et al., “Urinary Incontinence and Erectile Dysfunction After Robotic Versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial,” Eur Urol, vol. 68, no. 2, pp. 216-25, Aug 2015, doi: 10.1016/j.eururo.2015.02.029.
S. Guillaumier et al., “A Multicentre Study of 5-year Outcomes Following Focal Therapy in Treating Clinically Significant Nonmetastatic Prostate Cancer,” Eur Urol, vol. 74, no. 4, pp. 422-429, Oct 2018, doi: 10.1016/j.eururo.2018.06.006.
J. S. Hopstaken, J. G. R. Bomers, M. J. P. Sedelaar, M. Valerio, J. J. Futterer, and M. M. Rovers, “An Updated Systematic Review on Focal Therapy in Localized Prostate Cancer: What Has Changed over the Past 5 Years?,” Eur Urol, vol. 81, no. 1, pp. 5-33, Jan 2022, doi: 10.1016/j.eururo.2021.08.005.
T. D. McClure, D. J. Margolis, and J. C. Hu, “Partial gland ablation in the management of prostate cancer: a review,” Curr Opin Urol, vol. 27, no. 2, pp. 156-160, Mar 2017, doi: 10.1097/MOU.0000000000000376.
A. Blazevski et al., “Oncological and Quality-of-life Outcomes Following Focal Irreversible Electroporation as Primary Treatment for Localised Prostate Cancer: A Biopsy-monitored Prospective Cohort,” Eur Urol Oncol, vol. 3, no. 3, pp. 283-290, Jun 2020, doi: 10.1016/j.euo.2019.04.008.
L. Klotz et al., “Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Cancer,” J Urol, vol. 205, no. 3, pp. 769-779, Mar 2021, doi: 10.1097/JU.0000000000001362.
Bomers JGR, et al. “Focal Salvage MR Imaging-Guided Cryoablation for Localized Prostate Cancer Recurrence after Radiotherapy: 12-Month Follow-up.” J Vasc Interv Radiol, vol. 31, pp. 35-41, Jan 2020, doi: 10.1016/j.jvir.2019.07.001.