Focal therapy of prostate and kidney cancer

The evolving management of small renal masses

Small renal masses (SRMs) are a heterogeneous group of tumours with varying metastatic potential. The increasing use and improving quality of abdominal imaging have led to increasingly early diagnosis of incidental SRMs that are asymptomatic and organ confined. Despite improvements in imaging and the growing use of renal mass biopsy, diagnosis of malignancy before treatment remains challenging. Management of SRMs has shifted away from radical nephrectomy, with active surveillance and nephron-sparing surgery taking over as the primary modalities of treatment. The optimal treatment strategy for SRMs continues to evolve as factors affecting short-term and long-term outcomes in this patient cohort are elucidated through studies from prospective data registries. Evidence from rapidly evolving research in biomarkers, imaging modalities, and machine learning shows promise in improving understanding of the biology and management of this patient cohort.

Oncological and Functional Outcomes of Patients Undergoing Individualized Partial Gland Cryoablation of the Prostate: A Single-Institution Experience

Objectives: We aim at reporting the functional and oncological outcomes in men with localized prostate cancer who underwent individualized partial gland cryoablation of the prostate by using validated quality-of-life instruments. Methods: We retrospectively reviewed our cryosurgery database between July 2003 and September 2019 for men who were treated with individualized partial gland cryoablation of the prostate at our tertiary care center. Baseline and periodic urinary and sexual function surveys were administered throughout the post-treatment period. Results: A total of 82 men were included in the study. Median follow-up was 28 months (interquartile range: 10.5-59.3 months). A total of 71 men underwent primary individualized partial gland cryoablation, whereas 11 men underwent salvage partial gland ablation. Failure-free survival at 1 to 5 years was 98%, 89%, 84%, 75%, and 75% in the primary therapy group, and 100%, 80%, and 40% in the salvage group at 1 to 3 years, respectively. In the primary therapy group, all 71 patients remained free of pads at 3 months and throughout the follow-up period. Men who had undergone primary focal cryoablation had a higher post-treatment International Index of Erectile Function (IIEF) score, followed by men treated with primary hemi-cryoablation and primary subtotal cryoablation. The American Urological Association (AUA) symptom scores decreased regardless of the type of partial gland ablation performed, with subtotal ablation having the lowest score compared with hemiablation and focal cryoablation. No patient developed a fistula in the primary group, and 1 (9%) patient developed a fistula in the salvage group. Conclusion: Individualized partial gland cryoablation of the prostate is able to achieve excellent oncological and functional outcomes in select men with localized prostate cancer.

Utilization of focal therapy for patients discontinuing active surveillance of prostate cancer: Recommendations of an international Delphi consensus

BACKGROUND

With the advancement of imaging technology, focal therapy (FT) has been gaining acceptance for the treatment of select patients with localized prostate cancer (CaP). We aim to provide details of a formal physician consensus on the utilization of FT for patients with CaP who are discontinuing active surveillance (AS).

METHODS

A 3-stage Delphi consensus on CaP and FT was conducted. Consensus was defined as agreement by ≥80% of physicians. An in-person meeting was attended by 17 panelists to formulate the consensus statement.

RESULTS

Fifty-six respondents participated in this interdisciplinary consensus study (82% urologist, 16% radiologist, 2% radiation oncology). The participants confirmed that there is a role for FT in men discontinuing AS (48% strongly agree, 39% agree). The benefit of FT over radical therapy for men coming off AS is: less invasive (91%), has a greater likelihood to preserve erectile function (91%), has a greater likelihood to preserve urinary continence (91%), has fewer side effects (86%), and has early recovery post-treatment (80%). Patients will need to undergo mpMRI of the prostate and/or a saturation biopsy to determine if they are potential candidates for FT. Our limitations include respondent's biases and that the participants of this consensus may not represent the larger medical community.

CONCLUSIONS

FT can be offered to men coming off AS between the age of 60 to 80 with grade group 2 localized cancer. This consensus from a multidisciplinary, multi-institutional, international expert panel provides a contemporary insight utilizing FT for CaP in select patients who are discontinuing AS.