3D Prostate 3D Prostate Mapping BiopsiesMapping BiopsiesHAS A SIGNIFICANT IMPACT ON HAS A SIGNIFICANT IMPACT ON

PROSTATE CANCER MANAGEMENTPROSTATE CANCER MANAGEMENT

GARY ONIK MDGARY ONIK MD

MATTHEW MIESSAU MATTHEW MIESSAU

DAVID BOSTWICK MDDAVID BOSTWICK MD

TRUS BX-Gold StandardTRUS BX-Gold StandardStaging of PCaStaging of PCa

• TRUS Bx highly inaccurate for stagingTRUS Bx highly inaccurate for staging

• Accurate stage and grade, effects therapeutic Accurate stage and grade, effects therapeutic decisionsdecisions• Watchful waitingWatchful waiting• Choice of radiation therapy/brachytherapy aloneChoice of radiation therapy/brachytherapy alone• Addition of CHT to radiationAddition of CHT to radiation• Suitability for RPSuitability for RP• Appropriateness of focal therapy “lumpectomy”Appropriateness of focal therapy “lumpectomy”

3D Mapping Biopsies/Technique

CD-US false negativeCD-US false negative

54 yr oldGleason 6, 1mm, Rt sideOne year WW

Normal CD-US

Bilateral Gleason 8

Increasing StageIncreasing Stage

• 60 yr old60 yr old

• PSA 5.3, T1cPSA 5.3, T1c

• TRUS bx, TRUS bx, • 1.3 mm, 1 core, 1.3 mm, 1 core, leftleft• Gleason 6Gleason 6

• Considering WWConsidering WW

• 3D PMB3D PMB• 78 cores78 cores• 14 cores positive bilat14 cores positive bilat• I one, cancer into fatI one, cancer into fat

• T3T3

3D Mapping-Results3D Mapping-Results• N=180 all previous TRUS bx,N=180 all previous TRUS bx,• ALL positive only one side TRUS BXALL positive only one side TRUS BX• 3D-PMB shows that:3D-PMB shows that:•Bilateral cancer, (55%)Bilateral cancer, (55%)•Increased Gleason score (22%)Increased Gleason score (22%)•Over 70% would have Over 70% would have

management changedmanagement changed•Morbidity- Morbidity-

•hematuria (1.2%),hematuria (1.2%),•retention (7%) retention (7%)

Focal Therapy for Focal Therapy for Prostate CancerProstate Cancer

The Male LumpectomyThe Male Lumpectomy

Local Control of PCa Matters!!!!Local Control of PCa Matters!!!!

• Accepted Theory-Mets already presentAccepted Theory-Mets already present– LOCAL CONTROL DOES NOT CHANGE SURVIVALLOCAL CONTROL DOES NOT CHANGE SURVIVAL

• Recent evidence to the contraryRecent evidence to the contrary– Zelefsky MJ et al. “Higher radiation dose levels Zelefsky MJ et al. “Higher radiation dose levels (better (better

local control)local control) improved biochemical tumor control and improved biochemical tumor control and decreased risk of distant metastases.” Int J Radiat decreased risk of distant metastases.” Int J Radiat Oncol Biol Phys. 2008 Jul 15;71(4):1028-33.Oncol Biol Phys. 2008 Jul 15;71(4):1028-33.

– Trock et al. “Salvage radiotherapy Trock et al. “Salvage radiotherapy (better local control)(better local control) administered within 2 years of biochemical recurrence administered within 2 years of biochemical recurrence was associated with a significant increase in prostate was associated with a significant increase in prostate cancer-specific survival.”cancer-specific survival.”

Focal Therapy and Local Focal Therapy and Local ControlControl

Hypothesis: Focal Therapy with Hypothesis: Focal Therapy with Cryo Provides better local Cryo Provides better local control than RP or Radcontrol than RP or Rad• Superior treatment of ECESuperior treatment of ECE• Only treatment that can be repeatedOnly treatment that can be repeated• Treatment rad failuresTreatment rad failures• Achieved with significantly lower Achieved with significantly lower

morbidity.morbidity.

Superiority of Local Control-ECESuperiority of Local Control-ECE

74 yr old 74 yr old

PSA=200 ng/mlPSA=200 ng/ml

Gleason 10Gleason 10

12 months, CHT resistant12 months, CHT resistant

4 yrs Post op4 yrs Post op

PSA undetectable off CHTPSA undetectable off CHT

3 yrs P/O

Superiority of focal Therapy/RetreatmentSuperiority of focal Therapy/Retreatment

52 yr old, 6/2002, PSA 6.3, G6 left gland, Re TRUS bx rt side negative, left hemi cryo, PSA stable 6 years then rise, Mapping bx +, retreat, PSA .4 stable

Risk level Risk level N=120 1-13 year F/UN=120 1-13 year F/U

Focal Therapy ResultsFocal Therapy Results

Risk Level

N= ASTRO Pheonix

Rad failure

11 2 (81%) 2 (81%)

Total 120 8 (93%) 7 (94%)

100% local control, 8 patients retreated

Male Lumpectomy Male Lumpectomy ResultsResults

high RP/45%Lodde M, et al

FOCAL THERAPY MORBIDITYFOCAL THERAPY MORBIDITYN=120N=120

•CONTINENCE 100%CONTINENCE 100%

•POTENCY 85%POTENCY 85%

•Reproduced 2 published Reproduced 2 published studiesstudies

CONCLUSIONCONCLUSION

In the patients who need treatment the In the patients who need treatment the most Focal therapy provides better most Focal therapy provides better local control of prostate cancer. This local control of prostate cancer. This will translate into improved survivalwill translate into improved survival

Focal therapy, promises better cancer Focal therapy, promises better cancer results with lower morbidityresults with lower morbidity

It is now an obligation of the medical It is now an obligation of the medical community to produce a randomized community to produce a randomized trial comparing focal ablation to trial comparing focal ablation to Robotic RPRobotic RP