Radical prostatectomy specimens - a voice against focal therapy

The main treatment methods of prostate carcinoma are surgery and radiation therapy, both having serious side effects. Because of these side effects, the idea of organ preserving therapy emerged. Rationale to perform focal therapy is to preserve the prostate gland, along with potency and continence, offering good cancer control with appropriate treatment. The idea of gland sparing therapy is quite controversial. Presently, EAU Guidelines propose focal therapy as experimental in the treatment of prostate carcinoma.

The aim of the study was to asses how many patients could be qualified for focal therapy, according to post prostatectomy pathological findings. 720 patients suspected of prostate cancer were biopsied. In 324 patients, prostate carcinoma was revealed, of which 81 were subjected to radical prostatectomy. Pre and post-operative pathological results were analyzed, according to possible qualification for focal treatment.

According to the clinical evaluation of all the patients referred to the treatment, 25% could be assumed to have unifocal disease and could be qualified to the focal treatment. Post-operative evaluation revealed pT2b cancer in 5%, pT2c disease in 65%, and pT3a-pT4a disease in 20% of these patients. Cancer was unilateral (pT2a-b) in only 15% of cases, and was suitable for focal treatment (small disease not extending to whole lobe- pT2a disease) in only 10%.

It seems that with the use of current methods, proper T-staging of the disease and amount of neoplasmatic tissue inside the gland can not be reached with great certainty. In our opinion, focal therapy should not be used in patients with ≤pT2b and high risk disease. For them, radical treatment (surgery or radiation therapy) should be recommended. For the rest of the patients, with low risk disease, keeping in mind the large scale of possible overtreatment, active surveillance is a valid treatment option. Focal therapy can be an interesting therapeutic proposition for a small group of patients with pT2a cancer, but it is not possible to select them with big certainty with current methods of imaging medicine.