Laser Ablation

Just read an article about MRI guided laser ablation of prostate cancer developed at UTMB, Texas. Round 2 trials being conducted in Chicago. Any opinions or info on this?

With the success of Active Surveillance for low risk, there really isn't much justification for the use of focal therapy for low risk anymore, imho. After all, one remains on AS after focal therapy anyway, so what would the point be?

On a recent talk show, Mark Emberton made what I thought was a very good case for focal therapy for favorable intermediate risk (GS3+4) with low volume (1 or 2 cores, <50%). It then becomes a way to stay on AS even after G4 is detected.

One needs very good image location and guidance (mpMRI or CDUS) and an excellent radiologist. I think the most promising ablative technique is irreversible electroporation (IRE)/NanoKnife because of its pinpoint accuracy and the fact that it doesn't use heat to destroy the cancer cells. All other ablative techniques (like laser, HIFU, cryo, PDT, RF, MW), generate heat or cold. The problem is that heat travels, and although efforts are made to protect organs, nerves and blood vessels, there is inevitably some damage.

Another non-thermal ablative technique is focal radiation (SBRT or HDR brachy). I'm going to a lecture tonight about it, and will report back if there is anything interesting.

Dr. Kamrava said he expects he will have his clinical trial of HDR brachy (w/ mpMRI/US fusion guidance) focal therapy up and running in about 3 months.

• He shares many of my concerns about the necessity of any treatment other than AS for low risk, but will probably open it to them if they want it.
• He points out that mpMRI/US fusion may miss some of the smaller Gleason 3+3 lesions, and he is "happy to exclude them, since they probably shouldn't be treated anyway."
• He is equivocal about the index lesion hypothesis (as am I).
• Exactly what and how much of the prostate will be treated will vary on a case-by-case basis.
• If he can, he will avoid seminal vesicles and neurovascular bundles to prevent ED and preserve ejaculation.
• If he can, he will avoid as much of the urethra as possible to avoid irritative urinary symptoms.
• Large prostates, colitis, prostatitis and a history of urinary retention will not necessarily exclude one.
• Defining biochemical failure will be based on PSA kinetics rather than nadir+2.
• Salvage therapies will probably include additional HDR brachy, depending on where the recurrence is.

- Allen