image guided focal prostate cancer therapy · 2018. 5. 1. · image guided focal prostate cancer...
TRANSCRIPT
![Page 1: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/1.jpg)
Image Guided Focal Prostate
Cancer Therapy
Peter A. Pinto, M.D.
28th Annual Conference
Advances in Urology - USF Health
April 14, 2018
Head, Prostate Section
Fellowship Director
Urologic Oncology Branch
National Cancer Institute
National Institutes of Health
Bethesda, Maryland
![Page 2: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/2.jpg)
Financial Disclosures
• Research lab @ National Institutes of Health and Philips have a CRADA (Cooperative Research and Development Agreement) which resulted in the development of UroNav (MRI - TRUS prostate fusion biopsy system)
![Page 3: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/3.jpg)
NIH Research Team
• Molecular Imaging– Peter Choyke, M.D.
– Baris Turkbey, M.D.
– Marcelino Bernado, PhD
– Vijay Shah, PhD
– Tom Pohida, PhD
– Dagane Daar
• Interventional Radiology– Bradford Wood, M.D.
– Jochen Krueker, Ph.D*
– Pingkun Yang, Ph.D.*
– Sheng Xu, Ph.D
• Pathology– Maria Merino, M.D.
*In Vivo, Philips Healthcare
• Biometric Research Branch– Richard Simon, D.Sc.
![Page 4: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/4.jpg)
Current State of Focal Therapy
![Page 5: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/5.jpg)
![Page 6: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/6.jpg)
Current State of Focal Therapy
• Prostate cancer focal therapy is like the Wild Wild West
– No rules govern it’s use regarding patient selection
– FDA approved devices for whole gland prostate or “tissue” ablation are being used
– Urology struggles to “police” focal tx since other medical disciplines are offering this to patients
![Page 7: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/7.jpg)
Treatment Methods for Localized Prostate Cancer
• Surgery– Retropubic Prostatectomy
– Perineal Prostatectomy
– Laparoscopic Prostatectomy
– Robotic Assisted Prostatectomy
• Radiation Therapy– External Beam
– Proton Beam
– Interstitial Seed Implantation
• Ablation (Cryo / Heat, HIFU, Laser, PDT)
• Active Surveillance
![Page 8: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/8.jpg)
Prostate Cancer Treatment
• Radical treatment (surgery or radiation)– Results in known harms that may not outweigh
the potential benefit
• Concern is overtreatment
• Patients and physicians seeking less morbid treatment modalities today such as focal therapy
• Fear is standard TRUS biopsy underestimates tumor volume and grade
![Page 9: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/9.jpg)
9
RATIONALE FOR FOCAL THERAPY
• Middleground for patients faced with AS or radical therapy
• Tissue preserving strategy employed in renal, thyroid, breast, liver, and pancreatic Ca
• Though PCa is multifocal, natural history driven by index lesion
Marshall et al. Prostate International 2015
Ahmed et al. European Urology 2015
![Page 10: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/10.jpg)
10
PATIENT SELECTION
• In 2015, an expert consensus panel agreed patients with low and intermediate risk PCa are candidates
• Multifocality does not preclude focal therapy– Index lesion is targeted since it drives the natural
history of the disease
Donaldson et al. European Urology 2015
![Page 11: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/11.jpg)
11
CANCER LOCALIZATION
• Standard TRUS biopsy inadequate for estimating cancer focus
• Lesions may be localized by:– Multiparametric MRI
– MRI-TRUS fusion guided biopsy
– Transperineal template-mapping biopsy
Donaldson et al. European Urology 2015
![Page 12: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/12.jpg)
• 25 men had 1,403 needle cores taken
• Results correlated with computer models of 3D whole
mounted RRP specimens
• Total of 64 tumors identified
• 18/64 tumors missed by TPMB but only 1 was
clinically significant
![Page 13: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/13.jpg)
59 y.o. PSA=6 ng/mL, with prior negative TRUS biopsy
Gleason 3+4
![Page 14: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/14.jpg)
Prostate Cancer is Multifocal
• 83% of patients exhibit multifocality
• Index cancers much larger than secondary tumors
Wise et al. Urology 2002
![Page 15: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/15.jpg)
Insignificant Minimal Moderate Advanced
Size < 0.2 cm3 0.2 - 0.5
> 0.5 or caps
penetration > 0.5
Gleason <7 <7 <7 >7
Extent confined confined
capsular
penetration
caps penetration,
lymph nodes,
seminal vesicles
Insignificant
Significant but
curable Advanced
< 0.5 cm3 > 0.5 cm3 >0.5cm3
Gleason 1-3 Gleason 4-5 Gleason ≥6
confined
microscopic
extracapsular
extension
extensive extracapsular,
seminal vesicles, lymph
nodes
Epstein JAMA. 1994
Ohori J Urol. 1994
Does size matter ?
![Page 16: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/16.jpg)
Image Guided Focal Therapy for
Prostate Cancer
• Localized prostate cancer is the new challenge of the PSA era
• Requires rethinking of diagnostic and treatment strategies
• What about focal therapy ?
– Can we identify tumor(s) within the prostate
in order to treat ONLY the cancer ?
![Page 17: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/17.jpg)
• Evaluated 135 patients at the NCI who had multi-
parametric 3T endorectal coil prostate MRI followed
by radical prostatectomy
• The index tumor volume was determined
prospectively and independently by MRI and
confirmed by histopathology
![Page 18: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/18.jpg)
23
FOCAL ABLATION STRATEGIES
• Margin ≤3mm around the edge of the lesion is an acceptable error for center of lesion delivered therapy
• Circumferential margin of treatment is 5mm around the lesion
• This allows a targeting error of 2-3mm to prove a positive hit rate of 90-95%
Hu et al. Medical Image Analysis 2012
Cornud et al. Journal of Urology 2014
![Page 19: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/19.jpg)
Treatment Template
![Page 20: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/20.jpg)
Energy Delivery
• High Intensity focused Ultrasound
• Cryotherapy
• Photodynamic Therapy
• Laser Interstitial Thermal Therapy
• Irreversible electroporation
• Radiation
• Nanopartilces
• Radiofrequency Ablation
• More to come
![Page 21: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/21.jpg)
• Multiple focal therapies available– Commonly used: Cryotherapy, HIFU, laser
ablation, and radiofrequency ablation
• Insufficient evidence to support one
modality over another
• Best modality is the one the clinician
is most experienced with
Energy Delivery
![Page 22: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/22.jpg)
FOCAL ABLATION STRATEGIES
Pereza et al. Nature Reviews Urology 2016
![Page 23: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/23.jpg)
Focal Brachytherapy
• No long term data from large clinical
trials
• Approx 5 trials listed as cancer.gov
website
• More likely to follow as this will be a
future direction of research by radiation
oncology
![Page 24: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/24.jpg)
Long-term results of MRI-guided partial
prostate brachytherapy for favorable-risk
prostate cancer: Implications for focal therapy.
(Anthony D’Amico)
• 318 men with cT1c, PSA < 15, Gleason ≤ 3 + 4 received
MRI-guided brachytherapy in which only the PZ was
targeted. PSA failure was defined as nadir + 2 with PSA
velocity >0.75 ng/mL/yr.
• Median follow-up of 5.1 yrs 26 men failed. PSA failure-
free survival at 5 and 8 years was 95.6% and 90.0% for
low risk, and was 73.0% and 66.4% for intermediate risk.
J Clin Oncol. 2012 Feb 10;30(5_suppl)
![Page 25: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/25.jpg)
Focal application of low-dose-rate
brachytherapy for prostate cancer:
a pilot study.
• 17 men screened with mpMRI, 14
proceeded to TTMB, 5 received focal
LDR-PB. Follow-up included PSA, mpMRI
and TTMB.
J Contemp Brachytherapy. 2017 Jun;9(3):197-208.
![Page 26: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/26.jpg)
J Contemp Brachytherapy. 2017 Jun;9(3):197-208.
![Page 27: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/27.jpg)
J Contemp Brachytherapy. 2017 Jun;9(3):197-208.
![Page 28: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/28.jpg)
Focal application of low-dose-rate
brachytherapy for prostate cancer:
a pilot study. • 17 men screened with mpMRI, 14 proceeded to TTMB, 5
received focal LDR-PB. Follow-up included PSA, mpMRI
and TTMB.
• Of the 5 treated pts 3 had repeat mpMRI with no residual
cancer seen and 2 have had repeat TTMB at 24 months
with no residual cancer detected.
J Contemp Brachytherapy. 2017 Jun;9(3):197-208.
![Page 29: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/29.jpg)
Focal Therapy Modalities
![Page 30: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/30.jpg)
Focal Therapy Modalities
![Page 31: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/31.jpg)
![Page 32: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/32.jpg)
FOLLOW UP• Long term oncologic data unavailable
• One year follow up targeted biopsy is
recommended–Often used to determine efficacy
–Residual Gleason 3+3 of ≤3mm is acceptable
–Residual Gleason ≥3+4 disease represents
failure of treatment
![Page 33: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/33.jpg)
FOCAL THERAPY APPROACH
• Cryotherapy Coagulative necrosis as a result of freezing and thawing cycles
• Focal laser ablation
• HIFU Coagulative necrosis as a result of high temperature thermoablation
![Page 34: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/34.jpg)
NIH FOCAL LASER ABLATION CLINICAL TRIAL TEAM
![Page 35: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/35.jpg)
NIH FOCAL LASER ABLATION CLINICAL TRIAL
• Transmission of laser energy into the tumor tissue via optical fiber
• Coagulative necrosis as a result of thermoablation
• MRI guidance at 1.5T or 3T
• Transperineal approach - coaxial
• Brachytherapy grid system
• Endorectal coil
• Foley catheter
![Page 36: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/36.jpg)
Oto and
Eggener et
al. Current
Opinion
Urology
2014
![Page 37: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/37.jpg)
74-year-old man, PSA=7.33ng/dl, 2 prior negative TRUS guided bx
Gleason 3+4 (60% core involvement)
![Page 38: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/38.jpg)
Pre-FLA
![Page 39: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/39.jpg)
Pre-FLA
1 Day Post FLA
![Page 40: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/40.jpg)
Pre-FLA (PSA=7.33ng/ml)
6 months post-FLA (PSA=2.43ng/ml)
![Page 41: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/41.jpg)
12 months post-FLA (PSA=2.59ng/ml)/targeted bx neg
24 months post-FLA (PSA=5.58ng/ml)/targeted bx neg
![Page 42: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/42.jpg)
58-year-old man, PSA=6.65ng/dl, 1 prior negative TRUS guided bx
Gleason 3+4 (50% core involvement)
TRUS guided hydrodissectionof the rectum
and nerve
![Page 43: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/43.jpg)
Pre-FLA
Immediate post-FLA
![Page 44: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/44.jpg)
1 day post-FLA
6 months post-FLA (4.49ng/ml)
![Page 45: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/45.jpg)
12 months post-FLA (PSA=4.09) targeted bx neg
24 months post-FLA (PSA=4.7) targeted bx neg
![Page 46: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/46.jpg)
• 12 patients
• Low risk disease
• 75% patients home same day
• 100% catheter removed by 24hours
• Adverse events:• G1 – perineal discomfort (4), hematuria (2), hemospermia (1), fatigue (1)- No high grade AEs
• No significant changes in IIEF or IPSS at 6 months
• 8 patients with no tumor at ablation site (2pts with contralateral G6)
• 4 patients (33% of cohort) with residual cancer
Lindner et al. J Urol 2009;182:1371-77
![Page 47: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/47.jpg)
PHASE 1 TRIAL RESULTS• University of Chicago
– 9 cases: 8 Gleason 6, 1 Gleason 3+4
– No major complications
– Minor perineal injury in 1 case
– Transient glans penis paresthesia in 1 case
– IPSS and SHIM scores are stable
– 6 months follow up / MRI and biopsy
– Oncologic outcomes: 2/9 case residual cancer
Oto et al. Radiology
2013
Before treatment After treatment
![Page 48: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/48.jpg)
PHASE 1 TRIAL RESULTS• NIH
– 15 cases: low-intermediate risk PCa
• 7 cases Gleason 3+3
• 8 cases Gleason 3+4
– No major complications
– Hematuria in 4 cases
– 1 case of epididymitis
– IPSS and SHIM scores are stable
– 1 year follow-up / MRI and TRUS / MRI fusion
biopsy
– Oncologic outcomes: 3/15 case residual cancerGeorge A, Pinto P et al 2016.
![Page 49: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/49.jpg)
TRANSURETHRAL MR-GUIDED HIGH
INTENSITY ULTRASOUND SYSTEM FOR
FOCAL ABLATION OF PROSTATE
CANCER
Nitin Yerram, Ari Partanen, Hari Trivedi, Dmitry Volkin, Jeffrey
Nix, An Hoang, Baris Turkbey, Marcelino Bernardo, Matthew
Dreher, Peter Choyke, Bradford Wood, Aradhana Venkatesan,
Peter Pinto.
National Cancer Institute, National Institutes of Health
Bethesda, Maryland
BJU International Vol 112, Issue 4, pages 508–516, August 2013
![Page 50: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/50.jpg)
Transurethral Applicator
-Axially rotating applicator under robotic control
-Eight colinear 0.5cm elements (f= 3 or 6 Mhz, max Pac= 4W)
-Cooling via circulating degassed water
![Page 51: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/51.jpg)
planning Transducer localization Burn 1-temperature map with dose overlay
Post HIFU raw contrast enhanced MRI
Burn 2-temperature map with dose overlay
HE stain of necrotic areas
Partanen BJUI 2014
![Page 52: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/52.jpg)
ADVANTAGES• Effective detection of target lesion
• Relatively efficient navigation
• Simultaneous thermometer of ablation and
protection of critical adjacent structures
![Page 53: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/53.jpg)
DISADVANTAGES• Expensive procedure
– MRI compatible equipment needed
– Long MRI time block: 3-4 hours
processing time
– Urologist, interventional radiologist and
diagnostic radiologist
–Multicenter trials and oncologic follow up
are necessary
![Page 54: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/54.jpg)
CONCLUSIONS• Role of focal therapy is evident for
selected low and intermediate risk
prostate cancer
• Prospective trials will provide morbidity
and functional outcomes of each
treatment modality
• Long term follow up data will be
necessary for oncologic outcomes
![Page 55: Image Guided Focal Prostate Cancer Therapy · 2018. 5. 1. · Image Guided Focal Prostate Cancer Therapy Peter A. Pinto, M.D. 28th Annual Conference Advances in Urology - USF Health](https://reader033.vdocuments.net/reader033/viewer/2022053021/6049f1df0ce6a209bd60c6f8/html5/thumbnails/55.jpg)
NIH Clinical Center