Preoperative Prediction of Multifocal Prostate Cancer and Application of Focal Therapy: Review 2007
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
References (64)
- et al.
Sexual dysfunction after radical prostatectomy: prevalence, treatments, restricted use of treatments and distress
J Urol
(2005) - et al.
Minimally invasive approaches to localized prostate carcinoma
Hematol Oncol Clin North Am
(2006) - et al.
Expectant management of nonpalpable prostate cancer with curative intent: preliminary results
J Urol
(2002) - et al.
Morphology of prostate cancer: the effects of multifocality on histological grade, tumor volume and capsule penetration
J Urol
(1994) - et al.
Prognostic factors for multifocal prostate cancer in radical prostatectomy specimens: lack of significance of secondary cancers
J Urol
(2003) - et al.
Perineural invasion in radical prostatectomy specimens: lack of prognostic significance
J Urol
(2004) - et al.
Anatomic distribution and pathologic characterization of small-volume prostate cancer (<0.5 ml) in whole-mount prostatectomy specimens
Mod Pathol
(2005) - et al.
Stage A versus stage B adenocarcinoma of the prostate: morphological comparison and biological significance
J Urol
(1988) - et al.
Nonpalpable stage T1c prostate cancer: prediction of insignificant disease using free/total prostate specific antigen levels and needle biopsy findings
J Urol
(1998) - et al.
Distinguishing clinically important from unimportant prostate cancers before treatment: value of systematic biopsies
J Urol
(1996)
Identification of insignificant prostate cancers: analysis of preoperative parameters
Urology
Does increased needle biopsy sampling of the prostate detect a higher number of potentially insignificant tumors?
J Urol
Impalpable invisible stage T1c prostate cancer: characteristics and clinical relevance in 100 radical prostatectomy specimens—a different view
J Urol
Insignificant prostate cancer in radical prostatectomy specimen: time trends and preoperative prediction
Eur Urol
Identification of isolated and early prostatic adenocarcinoma in radical prostatectomy specimens with correlation to biopsy cores: clinical and pathogenetic significance
Pathol Res Pract
Combining prostate specific antigen with cancer and gland volume to predict more reliably pathological stage: the influence of prostate specific antigen cancer density
J Urol
Prostate specific antigen in the staging of localized prostate cancer: influence of tumor differentiation, tumor volume, and benign hyperplasia
J Urol
Is tumor volume an independent prognostic factor in clinically localized prostate cancer?
J Urol
The volume of prostate cancer in the biopsy specimen cannot reliably predict the quantity of cancer in the radical prostatectomy specimen on an individual basis
J Urol
Detection of clinically significant prostate cancer by transrectal ultrasound–guided systematic biopsies
J Urol
Patterns of progression in prostate cancer
Lancet
Long-term impact of conservative management on localized prostate cancer: a twenty-year experience in Japan
Urology
Tumour grade, proliferation, apoptosis, microvessel density, p53, and bcl-2 in prostate cancers: differences between tumours located in the transition zone and in the peripheral zone
Eur Urol
Individualization of the biopsy protocol according to the prostate gland volume for prostate cancer detection
J Urol
Proximity of prostate cancer to the urethra: implications for minimally invasive ablative therapies
Urology
Temperature-correlated histopathologic changes following microwave thermoablation of obstructive tissue in patients with benign prostatic hyperplasia
Urology
Analysis of risk factors for progression in patients with pathologically confined prostate cancers after radical retropubic prostatectomy
J Urol
Use of Gleason score, prostate specific antigen, seminal vesicle and margin status to predict biochemical failure after radical prostatectomy
J Urol
Clinical significance of biopsy-derived primary Gleason score among radical prostatectomy candidates with Gleason 7 tumors
Urology
Gleason score 7 prostate cancer on needle biopsy: is the prognostic difference in Gleason scores 4 + 3 and 3 + 4 independent of the number of involved cores?
J Urol
Impact of the percentage of positive biopsy cores on the further stratification of primary grade 3 and grade 4 Gleason score 7 tumors in radical prostatectomy patients
J Urol
Long-term prognostic significance of primary Gleason pattern in patients with Gleason score 7 prostate cancer: impact on prostate cancer specific survival
J Urol
Cited by (93)
A statistical, voxelised model of prostate cancer for biologically optimised radiotherapy
2022, Physics and Imaging in Radiation OncologyCitation Excerpt :Although increasing the radiation dose to the entire prostate volume would likely improve rates of tumour control, this is not possible with existing technology due to risks of exceeding tolerance doses to nearby healthy tissue. Considering this, a potential approach to improve RT efficacy is to deliver higher boost doses of radiation to small subvolumes of the prostate identified as cancerous [7–10], typically using mpMRI to define these subvolumes [11–15]. A number of clinical trials have investigated this MRI-based focal boost RT [16,5,17,18], with at least one modern study reporting improvements in disease-free survival [19].
The Genomics of Prostate Cancer: emerging understanding with technologic advances
2018, Modern PathologyIndications and limits of ablative therapies in prostate cancer
2017, Progres en UrologieQuestions and answers on prostate multiparameter magnetic resonance imaging: Everything a urologist should know
2016, Actas Urologicas EspanolasHigh-Intensity Focused Ultrasound
2016, Prostate Cancer: Science and Clinical Practice: Second Edition
- 1
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.