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Focal therapy: A treatment option for localised prostate cancer?

Aisling Glynn ()
Elizabeth Forde ()
Laure Marignol ()


Therapeutic options for localised prostate cancer (PCa) include active surveillance or radical whole-gland therapy. Men with localised PCa and the physicians who advise them are posed with a difficult therapeutic dilemma: which one? The former requires intensive surveillance causing possible psychological distress. The latter maximises chance of cure but with near certainty of genitourinary toxicity. Focal therapy (FT) is a technique by which only the known disease is targeted while preserving normal tissue. Early reports of FT outcomes are encouraging; however apprehension still exists over its standardised use in localised PCa. This review discusses the evidence regarding the oncologic and functional outcomes of focal therapies for localised prostate cancer.


prostate cancer, focal therapy,

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Epstein J, Walsh P, Carmichael M, Brendler C. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage t1 c) prostate cancer. JAMA 1994; 271(5): 368–74.

Lu-Yao G, Yao S. Population-based study of long-term survival in patients with clinically localised prostate cancer. The Lancet 1997; 349(9056): 906–910. doi: 10.1016/S0140-6736(96)09380-4.

Sanda M, Dunn R, Michaliski J Sandler HM, Northouse L, et al., Quality of life and satisfaction with outcome among prostate-cancer survivors. New Eng J Med 2008; 358(12): 1250–1261. doi: 10.1056/NEJMoa074311.

Eifler J, Carter H. Patient selection for active surveillance. In: Active surveillance for localized prostate cancer: A new paradigm for clinical management. L. Klotz (editor). New York: Humana Press. 2012. p. 9–21.

Karavitakis M, Winkler M, Abel PD, Hazell S, Ahmend HU. Focal therapy for prostate cancer: Opportunities and uncertainties. Discov Med 2011; 12(64): 245–255.

Mearini L, Porena M. Pros and cons of focal therapy for localised prostate cancer. Prostate Cancer 2011; 2011: 584784. doi:10.1155/2011/584784.

Heidenreich A, Bastian P, Bellmunt J Bolla M, Jonuau S, et al. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent-update 2013. Eur Urol 2014; 65(1): 124–137. doi: 10.1016/j.eururo.2013.09.046.

Jácome-Pita F, Sánchez-Salas R, Barret E, Amaruch N, Gonzalez-Enguita C, et al. Focal therapy in prostate cancer: The current situation. Ecancermedicalscience, 2014; 8: 435. doi: 10.3332/ecancer.2014.435.

Rees J, Patel B, MacDonagh R, Persad R. Cryosurgery for prostate cancer. BJU Int 2004; 93(6): 710–714.

Madersbacher S, Pedevilla M, Vingers L, Susani M, Marberger M. Effect of high-intensity focused ultrasound on human prostate cancer in vivo. Cancer Res 1995; 55(15): 3346–3351.

Bozzini G, Colin P, Nevoux P, Villers A, Mordon S, et al. Focal therapy of prostate cancer: Energies and procedures. Ural Oncol-Semin Ori 2013; 31(2): 155–167. doi: 10.1016/j.urolonc.2012.05.011.

Langley S, Ahmed H, Al-Qaisieh B, Bostwick D, Dickinson L, et al. Report of a consensus meeting on focal low dose rate brachytherapy for prostate cancer. BJU Int 2012; 109: 7–16. doi: 10.1111/j.1464-410X.2011.10825.x.

Cosset J-M, Cathelineau X, Wakil G, Pierrat N, Quenzer O, et al. Focal brachytherapy for selected low-risk prostate cancers: A pilot study. Brachytherapy 2013; 12(4): 331–337. doi: 10.1016/j.brachy.2013.02.002.

Nguyen P, Chen MH, Zhang Y, Tempany CM, Cormack RA, et al. Updated results of magnetic resonance imaging guided partial prostate brachytherapy for favorable risk prostate cancer: Implications for focal therapy. J Urology 2012; 188(4): 1151–1156. doi: 10.1016/j.juro.2012.06.010.

Kamrava M, Chung M, Kayode O, Wang J, Marks L, et al. Focal high-dose-rate brachytherapy: A dosimetric comparison of hemigland vs. conventional whole-gland treatment. Brachytherapy 2013; 12(5): 434–441. doi: 10.1016/j.brachy.2012.09.002.

Mason J, Al-Qaisieh B, Bownes P, Thwaites D, Henry A. Dosimetry modeling for focal high-dose-rate prostate brachytherapy. Brachytherapy 2014; 13(6): 611–617. doi: 10.1016/j.brachy.2014.06.007.

Morris W. Focal therapy for prostate cancer: A pilot study of focal low dose rate brachytherapy (FTPC) [Internet]. Available from:

Downs S, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Commun H 1998; 52(6): 377–348. doi: 10.1136/jech.52.6.377.

Rischmann P, Hoquetis L, Crouzet S, Pasticier G, Villers A, et al. 358 Focal therapy with HIFU for localized prostate cancer: A prospective multicentric study. Eur Urol Supplements 2014; 13(1): e358. doi: 10.1016/S1569-9056(14)60353-5.

Mendez M, Passoni N, Pow-Sang J, Jones S, Polasick T. Comparison of outcomes between preoperatively potent men treated with focal versus whole gland cryotherapy in a matched population. J Endourol 2015; 29(10): 1193–1198. doi: 10.1089/end.2014.0881.

Feijoo E, Sivaraman A, Barret E, Sanchez-Salas R, Galiano M, et al. Focal high-intensity focused ultrasound targeted hemiablation for unilateral prostate cancer: A prospective evaluation of oncologic and functional outcomes. Eur Urol 2016; 69(2): 214–220. doi: 10.1016/j.eururo.2015.06.018.

Van Velthoven R, Aoun F, Limani K, Narahari K, Lemort M, et al. Primary zonal high intensity focused ultrasound for prostate cancer: Results of a prospective phase IIa feasibility study. Prostate Cancer 2014; 2014: 756189. doi: 10.1155/2014/756189.

Hale Z, Miyake M, Palacios DA, Rosser CJ. Focal cryosurgical ablation of the prostate: A single institute’s perspective. BMC Urol 2013; 13(1): 1–6. doi: 10.1186/1471-2490-13-39.

Dickinson L, Ahmed HU, Kirkham AP, Allen C, Freeman A, et al. A multi-centre prospective development study evaluating focal therapy using high intensity focused ultrasound for localised prostate cancer: The INDEX study. Contemp Clin Trials 2013; 36(1): 68–80. doi: 10.1016/j.cct.2013.06.005.

Ward J, Jones J. Focal cryotherapy for localized prostate cancer: A report from the national Cryo On-Line Database (COLD) Registry. BJU Int. 2012; 109(11): 1648–1654. doi: 10.1111/j.1464-410X.2011.10578.x.

Truesdale M, Cheetham P, Hruby G Wenske S, Conforto A, et al. An evaluation of patient selection criteria on predicting progression-free survival after primary focal unilateral nerve-sparing cryoablation for prostate cancer: Recommendations for follow up. Cancer J 2010; 16(5): 544–549. doi: 10.1097/PPO.0b013e3181f84639.

Ellis D, Manny Jr T, Rewcastle J. Focal cryosurgery followed by penile rehabilitation as primary treatment for localized prostate cancer: Initial results. Urology 2007; 70(6): 9–15. doi: 10.1016/j.urology.2007.07.036.

Lambert E, Bolte K, Masson P, Katz A. Focal cryosurgery: Encouraging health outcomes for unifocal prostate cancer. Urology 2007; 69(6): 1117–1120. doi: 10.1016/j.urology.2007.02.047.

Onik G, Vaughan D, Lotenfoe R, Dineen M, Brady J. “Male Lumpectomy”: Focal therapy for prostate cancer using cryoablation. Urology 2007; 70(6): S16–S21. doi: 10.1016/j.urology.2007.06.001.

Bahn D, Silverman P, Lee F, Badalament R, Bahn E, Rewcastle J. Focal prostate cryoablation: Initial results show cancer control and potency preservation. J Endourol 2006; 20(9): 688–692. doi: 10.1089/end.2006.20.688.

Ghai S, Louis A, Van Vliet M Lindner U, Haider M, et al. Real-time MRI-guided focused ultrasound for focal therapy of locally confined low-risk prostate cancer: Feasibility and preliminary outcomes. Am J Roentgenol 2015; 205(2): 177–84. doi: 10.2214/AJR.14.13098.

Gelet A, Crouzet S, Rouviere O, Bratan F, Chapelon JY. Focal treatment of prostate cancer using focal one device: Pilot study results. J Therapeutic Ultrasound 2015; 3: O54–O54. doi: 10.1186/2050-5736-3-S1-O54.

Ahmed H, Dickinson L, Charman S Weir S, McCartan N et al., Focal ablation targeted to the index lesion in multifocal localised prostate cancer: A prospective development study. Eur Urol 2015; 68(6): 927–936. doi: 10.1016/j.eururo.2015.01.030.

Del Monte M, Napoli A, Anzidei M, Cartocci G, Caliolo G, et al. Non-invasive focal therapy of organ confined prostate cancer: Phase I study using MrgFus and excision pathology for efficacy assessment. EPOS 2015. doi: 10.1594/ecr2015/C-1899.

Barqawi A, Stoimenova D, Krughoff K, Eid K, O’Donnell C, et al. Targeted focal therapy for the management of organ confined prostate cancer. J Urology 2014; 192(3): 749–753. doi: 10.1016/j.juro.2014.03.033.

Durand M, Barret E, Galiano M, Rozet F, Sanchez-Salas R, et al. Focal cryoablation: A treatment option for unilateral low-risk prostate cancer. BJU Int 2014; 113(1): 56–64. doi: 10.1111/bju.12370.

Bahn D, de Castro Abreu AL, Gill I, Inderbir S, Hung A, et al. Focal cryotherapy for clinically unilateral, low-intermediate risk prostate cancer in 73 men with a median follow-up of 3.7 years. Eur Urol 2012; 62(1): 55–63. doi: 10.1016/j.eururo.2012.03.006.

Lindner U, Weersink RA, Haider MA, Gertner MR, Davidson SR, et al. Image guided photothermal focal therapy for localized prostate cancer: Phase I trial. J Urol 2009; 182(4): 1371–1377. doi: 10.1016/j.juro.2009.06.035.

Ahmed H, Hindley R, Dickinson L, Freeman A, Kirkham A, et al. Focal therapy for localised unifocal and multifocal prostate cancer: A prospective development study. Lancet Oncol 2012; 13(6): 622–632. doi: 10.1016/S1470-2045(12)70121-3.

Dickinson L, Ahmed H, McCartan N, Freeman A, Kirkham A, et al. Medium term outcomes following primary focal therapy using HIFU for localised prostate cancer. BJU Int 2012; 109(S7): 6.

Ahmed H, Freeman A, Kirkman A, Sahu M, Scott R, et al. Focal therapy for localized prostate cancer: A phase I/II trial. J Urology 2011; 185(4): 1246–1255. doi: 10.1016/j.juro.2010.11.079.

Mendez M, Passoni N, Pow-Sang J, Jones J, Polascik T. Comparison of outcomes between preoperatively potent men treated with focal versus whole gland cryotherapy in a matched population. J Endourol 2015; 29(10): 1193–1198. doi: 10.1089/end.2014.0881.

Napoli A, Anzidei M, De Nunzio C, Cartocci G, Panebianco V, et al. Real-time magnetic resonance-guided high-intensity focused ultrasound focal therapy for localised prostate cancer: Preliminary experience. Eur Urol 2013; 63(2): 395–398. doi: 10.1016/j.eururo.2012.11.002.

Chopra R, Colquhoun A, Burtnyk M, N’djin W, Kobelevskiy I, et al. MR imaging–controlled transurethral ultrasound therapy for conformal treatment of prostate tissue: Initial feasibility in humans. Radiology 2012; 265(1): 303–313. doi: 10.1148/radiol.12112263.

Tareen B, Godoy G, Taneja SS. Focal therapy: A new paradigm for the treatment of prostate cancer. Rev Urol 2009; 11(4): 203–212. doi: 10.3909/riu0475.

Klotz L, Zhang L, Lam A, Nam R, Mamedov A, et al. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol 2010; 28(1): 126–131. doi: 10.1016/j.eururo.2010.04.015.

Ahmed H, Pendse D, Illing R, Allen C, van der Meulen J, et al. Will focal therapy become a standard of care for men with localized prostate cancer? Nat Clin Prac Oncol 2007; 4(11): 632–642. doi: 10.1038/ncponc0959.

van den Bergh R, Essink-Bot M, Roobol M, Wolters T, Shroder F, et al. Anxiety and distress during active surveillance for early prostate cancer. Cancer 2009; 115(17): 3868–3878. doi: 10.1002/cncr.24446.

Harlan S, Cooperberg M, Elkin E Lubeck D, Meng M, et al. Time trends and characteristics of men choosing watchful waiting for initial treatment of localized prostate cancer: Results from CaPSURE. J Urol 2003; 170(5): 1804–1807. doi: 10.1097/01.ju.0000091641.34674.11.

Stephenson A, Kattan M, Eastham J, Bianco F, Yossepowitch O, et al. Prostate cancer – Specific mortality after radical prostatectomy for patients treated in the prostate-specific antigen era. J Clin Oncol 2009; 27(26): 4300–4305. doi: 10.1200/JCO.2008.18.2501.

Alicikus Z, Yamada Y, Zhang Z, Pei X, Hunt M, et al. Ten-year outcomes of high-dose, intensity-modulated radiotherapy for localized prostate cancer. Cancer 2011; 117(7): 1429–1437. doi: 10.1002/cncr.25467.

Sylvester J, Grimm P, Wong J, Galbreath R, Merrick G, et al. Fifteen-year biochemical relapse-free survival, cause-specific survival, and overall survival following I125 prostate brachytherapy in clinically localized prostate cancer: Seattle experience. Int J Rad Oncol Biol Phys 2011; 81(2): 376–381. doi: 10.1016/j.ijrobp.2010.05.042.

Wilt T, Brawer M. The prostate cancer intervention versus observation trial: A randomized trial comparing radical prostatectomy versus expectant management for the treatment of clinically localized prostate cancer. J Urol 1994; 152(5): 1910–1914. doi: 10.1016/S0022-5347(17)32413-8.

Gore J, Kwan L, Lee S, Reiter R, Litwin M. Survivorship beyond convalescence: 48-Month quality-of-life outcomes after treatment for localized prostate cancer. J Natl Cancer Inst 2009; 101(12): 888–892. doi: 10.1093/jnci/djp114.

Rice K, Hudak J, Peay K, Elsamanoudi S, Travis J, et al. Comprehensive quality-of-life outcomes in the setting of a multidisciplinary, equal access prostate cancer clinic. Urology 2010; 76(5): 1231–1238. doi: 10.1016/j.urology.2010.03.087.

Huang G, Sadetsky N, Penson D. Health related quality of life for men treated for localized prostate cancer with long-term followup. J Urol 2010; 183(6): 2206–2212. doi: 10.1016/j.juro.2010.02.013.

Pardo Y, Gueda F, Aguilo F, Ferran F, Macias V, et al. Quality-of-life impact of primary treatments for localized prostate cancer in patients without hormonal treatment. J Clin Oncol 2010; 28: 4687–4696. doi: 10.1200/JCO.2009.25.3245.

Humphrey P. Complete histologic serial sectioning of a prostate gland with adenocarcinoma. Am J Surg Pathol 1993; 17(5): 468–472.doi: 10.1097/00000478-199305000-00005.

Liu W, Laitinen S, Khan S, Vihinen M, Kowalski J, et al. Copy number analysis indicates monoclonal origin of lethal metastatic prostate cancer. Nat Med 2009; 15(5): 559–565. doi: 10.1038/nm.1944.

Haffner M, Mosbruger T, Esopi D, Fedor H, Heaphy C, et al. Tracking the clonal origin of lethal prostate cancer. J Clin Invest 2013; 123(11): 4918–4922. doi: 10.1172/JCI70354.

Giannarini G, Gangaglia G, Montorsi F, Briganti A. Will focal therapy remain only an attractive illusion for the primary treatment of prostate cancer? J Clin Oncol 2014; 32(13): 1299–1301. doi: 10.1200/JCO.2013.54.8214.

Fütterer J, Briganti A, De Visschere P, Emberton M, Giannarini G, et al. Can clinically significant prostate cancer be dpetected with multiparametric magnetic resonance imaging? A systematic review of the literature. Eur Urol 2015; 68(6): 1045–1053.

Le J, Tan N, Shkolyar E, Lu D, Kwan L, et al. Multifocality and prostate cancer detection by multiparametric magnetic resonance imaging: Correlation with whole-mount histopathology. Eur Urol 2015; 67(3): 569–576. doi: 10.1016/j.eururo.2014.08.079.

Muller BG, van den Bos W, Brausi M, Futterer J, Ghai S, et al. Follow-up modalities in focal therapy for prostate cancer: Results from a Delphi consensus project. World J Urol 2015; 33(10): 1503–1509. doi: 10.1007/s00345-014-1475-2.

Ahmed H, Akin O, Coleman J, Crane S, Emberton M, et al. Transatlantic consensus group on active surveillance and focal therapy for prostate cancer. BJU Int 2012; 109(11): 1636–1647. doi: 10.1111/j.1464-410X.2011.10633.x.

Taira A, Merrick G, Galbreath R, Andreini H, Taubenslag W, et al. Performance of transperineal template-guided mapping biopsy in detecting prostate cancer in the initial and repeat biopsy setting. Prostate Cancer P D 2010 13(1): 71–77. doi: 10.1038/pcan.2009.42.

Ahmed H, Hu Y, Carter T, Arumainayagam N, Lecornet E, et al. Characterizing clinically significant prostate cancer using template prostate mapping biopsy. J Urology 2011; 186(2): 458–464. doi: 10.1016/j.juro.2011.03.147.

Ward JF III, Rewcastle J, Ukimura O, Gill I. Focal therapy for the treatment of localized prostate cancer: A potential therapeutic paradigm shift awaiting better imaging. Curr Opin Urol 2012; 22(2): 104–108. doi: 10.1097/MOU.0b013e3283501813.

Buskirk S, Pinkstaff D, Petrou S, Wehle M, Broderick G, et al. Acute urinary retention after transperineal template-guided prostate biopsy. Int J Rad Oncol Biol Phys 2004; 59(5): 1360–1366. doi: 10.1016/j.ijrobp.2004.01.045.

Eggener S, Scardino P, Carroll P, Zelefsky M, Sartor O, et al. Focal therapy for localized prostate cancer: A critical appraisal of rationale and modalities. J Urology 2007; 178(6): 2260–2267. doi: 10.1016/j.juro.2007.08.072.

Dickinson L, Ahmed HU, Allen C, Barentsz J, Carey B, et al. Magnetic resonance imaging for the detection, localisation, and characterisation of prostate cancer: Recommendations from a European consensus meeting. Eur Urol 2011; 59(4): 477–494. doi: 10.1016/j.eururo.2010.12.009.

Bantema-Joppe E, de Munck L, Visser O, Willemse P, Langendijk J, et al. Early-stage young breast cancer patients: Impact of local treatment on survival. Int J Rad Oncol Biol Phys 2011; 81(4): e553–e559. doi: 10.1016/j.ijrobp.2011.02.060.

Valerio M, Ahmed H, Emberton M, Lawrenstschuk N, Lazzeri M, et al. The role of focal therapy in the management of localised prostate cancer: A systematic review. Eur Urol 2014; 66(4): 732–751. doi: 10.1016/j.eururo.2013.05.048.

Gradishar W, Anderson B, Balassanian R, Blair S, Burnstein H, et al. Invasive breast cancer version 1.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2016; 14(3): 324–354. doi: 10.6004/jnccn.2016.0037.

Veronesi U, Luini A, Del Vecchio M, Greco M, Galimberti V, et al. Radiotherapy after breast preserving surgery in women with localised cancer of the breast. N Eng J Med 1992; 328(22): 1587–1591. doi: 10.1056/NEJM199306033282202.

Peeters S, Heemsbergen W, Koper P, van Putten W, Slot A, et al. Dose-response in radiotherapy for localized

prostate cancer: Results of the dutch multicenter randomized phase III trial comparing 68 Gy of radiotherapy with 78 Gy. J Clin Oncol 2006; 24(13): 1990–1996. doi: 10.1200/JCO.2005.05.2530.

Mouraviev V, Nosnik I, Sun L, Robertson C, Walther P, et al. Financial comparative analysis of minimally invasive surgery to open surgery for localized prostate cancer: A single-institution experience. Urology 2007; 69(2): 311–314. doi: 10.1016/j.urology.2006.10.025.

Bortfeld T, Marks L. Hype cycle in radiation oncology. Int J Rad Oncol Biol Phys 2013; 86(5): 819–821. doi: 10.1016/j.ijrobp.2013.03.027.

Novara G, Ficarra V, Rosen R, Artibani W, Costello A, et al. Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol 2012; 62(3): 431–452. doi: 10.1016/j.eururo.2012.05.044.

McCulloch P. The IDEAL recommendations and urological innovation. World J Urol 2011; 29(3): 331–336. doi: 10.1007/s00345-011-0647-6.



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