Elsevier

Urology

Volume 70, Issue 6, Supplement 1, December 2007, Pages S3-S8
Urology

Preoperative Prediction of Multifocal Prostate Cancer and Application of Focal Therapy: Review 2007

https://doi.org/10.1016/j.urology.2007.06.1129Get rights and content

Prostate cancer is a leading malignancy among men. Early prostate cancer is most commonly treated with radical surgery and radiotherapy. In the era of prostate-specific antigen and newly emerging highly specific screening tests, a greater number of men are given a diagnosis earlier in life, and disease is more often confined. Less-invasive treatments, such as focal therapy, are becoming increasingly popular, yielding shorter hospital stays, faster recovery, and fewer complications. Potential drawbacks to focal therapy include the risk of incomplete treatment, which may result from missed cancer foci and inadequate ablation to target tissues. Furthermore, this approach is not universally applicable to all patients—for example, those who have periurethral and extraprostatic extension of the tumor may not benefit from focal treatment. This article reviews the importance of multifocal prostate cancer and the application of focal treatment.

Section snippets

Unifocal versus multifocal disease

Prostate cancer is identified in 3 different settings: (1) clinically diagnosed by physical examination, laboratory tests, or symptoms; (2) discovered when the prostate is removed incidentally (eg, during cystoprostatectomy for bladder cancer); and (3) discovered latently at autopsy without ever having caused symptoms during the person’s lifetime. The incidence of prostate cancer in each of these settings is different.

Multifocal prostate cancer has been reported in 67% to 87% of all cases of

Tumor volume

The prediction of tumor volume is among the central issues involved in assessing the clinical relevance of prostate cancer. The inability to accurately determine prostate cancer volume and tumor doubling time through existing diagnostic means poses a great challenge for clinicians in identifying patients with life-threatening cancers.

Current staging of palpable organ-confined adenocarcinoma relies on digital rectal examination to separate unilateral from bilateral tumors or small from large

Tumor location

The location of cancer within the prostate influences prognosis. Adenocarcinoma that arises in the transition zone of the prostate appears to be less aggressive than typical acinar adenocarcinoma that occurs in the peripheral zone.46, 47, 48 Most cases of transition zone adenocarcinoma arise adjacent to nodules of hyperplasia, with one third actually originating within nodules. These adenocarcinomas are better differentiated than those in the peripheral zone, accounting for a majority of

Tumor grade

Accurate determination of patient prognosis is important when one is treating patients with unifocal prostate cancer. Gleason score has been shown to be an important prognostic factor for predicting biochemical failure (PSA progression), systemic recurrence, and overall patient survival.52 Patients with well-differentiated tumors (Gleason score 2 to 6) generally have a favorable prognosis, while those with high-grade tumors (Gleason score 7 to 10) experience higher rates of progression.53

Potential advantages and disadvantages of the focal therapy approach

Potential advantages of focal therapy in the treatment of patients with localized prostate cancer include the maintenance of curative and survival rates that are comparable with those of conventional primary surgical and radiation therapy and the lack of increase in complications (eg, erectile dysfunction, urinary incontinence, rectal injury). This approach is cost-effective because the procedure is performed within a shorter time and a briefer inpatient hospital stay is required. In addition,

Conclusion

The use of focal therapy for prostate cancer may result in complete destruction of all significant cancer foci within the prostate in an effective and cost-effective manner. The recent emergence of high-resolution imaging tools coupled with advances in computerized modeling software should lead to alternative treatment options in the near future for men with localized, early-stage cancer. This approach represents an important step in our quest to find better ways of treating the disease while

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    Dr. Meiers has no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this supplement. Dr. Waters has no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this supplement. Dr. Bostwick is a study investigator for Bioniche, Dendreon, DiagnoCure, Endocare, Genotherapeutics, GlaxoSmithKline, and Health Tronics; and is the founder and majority shareholder in Bostwick Laboratories.

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