Index Lesion Only. Prof. Phillip D Stricker

Transcription

1 Index Lesion Only Prof. Phillip D Stricker

2 Financial and Other Disclosures Off-label use of drugs, devices, or other agents: None Data from IRB-approved human research is presented I have the following financial interests or relationships to disclose: No financial relationships Disclosure code N 2

3 Focal Therapy Options Van den Bos W et al. Focal therapy in prostate cancer: international multidisciplinary consensus on trial design. Eur Urol 2014;13:2 7

4 NEED A MARGIN NOT A REGION 4

5 Safety margin Assessment of Pca extent on MRI and RP using detailed software-assisted co-registration n = 46 cancer lesions A 9mm treatment margin around an MRI-visible lesion ensures complete Tumour Rx 9 mm MRI underestimates histologically determined tumor boundaries A 9 mm treatment margin around a lesion visible on MRI would consistently ensure treatment of the entire histological tumor volume Le Nobin et al, J Urol 2015; ( )

6 Focal Therapy Always more than you can see Need 1cm margin Biopsy and Prostatectomy Gl 3 Gl 3 Gl 4

7 Genetic phylogeny Three recent studies identified multiple foci of differing clonal origin in each case (Cooper et al. 2015, Gundem et al Hong et al. 2015)

8 Primary Oncological control Comparison of peri-operative parameters of patients free of in-field significant PCa compared with patients with in-field significant cancer on FU biopsy Median, IQR No significant PCa on biopsy (n = 34) Significant in-field on biopsy (n = 7) P-value Minimum (mm) interelectrode distance Maximum (mm) interelectrode distance 9 (8-10) 8.5 (8-9) (17-19) 18 (16-20) 1.0 Minimum voltage 1500 ( ) 1480 ( ) 0.4 Maximum voltage 2550 ( )_ 2550 ( ) 0.6 Minimum amperage 23 (20-28) 20 (17-26) 0.3 Average amperage of lowest pulse set 26 (22-30) 21 (17-28) 0.2 Maximum amperage 41 (37-47) 39 (35-50) 0.6 Safety margin (mm) 10 (10-10) 5 (5-10) <0.05 System errors 8.8% (3/34) 57% (4/7) <0.05

9 Safety Margin Makes a Difference Our IRE Data In-field Oncological Control Whole Gland Free of Clinically Significant PCa In-field and Adjacent Failure Out-field Failure All Primary Patients 90% (90/100) 77% (77/100) 10% (10/100) 13% (13/100) 10 mm minimal margin 97.3% (70/72) 84.7% (61/72) 2.7% (2/72) 12.5% (9/72)

10 Key Factors for Infield Clearance 1cm safety margin Confidence to identify area Thorough Initial Evaluation ( High quality MRI & Thorough Template and targeted TPTMBx If > 1 lesion or index lesion may require Hemi or quadrant depending on prostate size If Anterior need a wider safety margin If Pericapsular go extracapsular 10

11 NEED A THOROUGH EVALUATION 11

12 mpmri plus TTMB

13 Can we Accurately Select Pts? MRI 90-97% NPV esp on AS TTPMB is accurate (Crawford Prostate 2013 ) &PROMIS Combined MRI + TTPB accurate ( Tranh) PSAD < 0.2 Combine Image Guided Bx To TRUB (Siddiqui JAMA 2015 ) BUT Some Gl 3+4 missed (3-4%)

14 PSMA Pet Scanning and Fusion to MRI

15 Epigenetic Prediction of Failure CIA-Pidsley/CIB-Clark/AIKorbie, bioinformatician AI-Luu, PCa biologists AI-Risbridger/AI-Lawrence, CIC-Stricker and AIs Scheltema/Chang and pathologist AI-Delprado

16 NEED GOOD PATIENT SELECTION 16

17 Who is the Ideal Candidate Selective Alternative To WGT ( Not AS ) Unifocal OR Single Index lesion Refuses or Unsuitable for WGT >60 years and >10 life expectancy Intermediate Risk Disease New Lesions on AS Consensus PSA<15, T1c, T2a, Gl 7

18 NOT ALL LESIONS ARE SUITABLE FOR QUADRANT OR HEMIABLATION Midline lesions Anterior Lesions Crossing Midline Lesions 18

19 Case Study - Lesionectomy Age 76 Clinical Stage T2a PSA 4.99 Prostate Volume 30 Gleason Score 3+4=7 Transperineal biopsy: 2/22 cores positive Right posterior apex 3+3; 15% Right anterior 3+4; 75%

20 Pre-op mp-mri

21 6 month mp-mri

22 6 month mp-mri Nodule in midline anteriorly: 4-5mm in size. Suspicious for residual tumour.

23 Follow up Transperineal follow up biopsy: 14 cores, all negative PSA PSA Baseline month

24 Not one fits all Small Pz Tumour ( well assessed ) --- Lesionectomy & 1cm margin Anterior Tumour ---- Lesionectomy & Wide Margin 2-3 areas on one side of prostate ---- Hemiablation &? Cross midline ( Multiple lesionectomies with overlap! 24

25 Less Rx = Less S/Es Partial ablation results in better posttreatment sexual function compared with whole-gland ablation in men with intermediaterisk prostate cancer. We did not observe a difference in early BPFS between the two groups. J Endourol Jun;31(6): doi: /end Propensity Score-Matched Comparison of Partial to Whole-Gland Cryotherapy for Intermediate-Risk Prostate Cancer: An Analysis of the Cryo On-Line Data Registry Data. Tay KJ 1, Polascik TJ 1, Elshafei A 2,3, Tsivian E 1, Jones JS 2. 25

26 CONCLUSION How to decide extent of Ablation Initial thorough evaluation Depends on which energy source If in doubt do more For Trials Hemiablation For Individuals Lesionectomy + Margin. This may require quadrantectomy 26

27 Future Trials Hemi vs Lesion IRE De la Rosette 27