1. 3D Prostate Mapping Biopsies
HAS A SIGNIFICANT IMPACT ON PROSTATE CANCER MANAGEMENT
GARY ONIK MD
MATTHEW MIESSAU
DAVID BOSTWICK MD

2. TRUS BX-Gold Standard Staging of PCa
TRUS Bx highly inaccurate for staging
Accurate stage and grade, effects therapeutic decisions
Watchful waiting
Choice of radiation therapy/brachytherapy alone
Addition of CHT to radiation
Suitability for RP
Appropriateness of focal therapy “lumpectomy”

3. 3D Mapping Biopsies/Technique

4. CD-US false negative Bilateral Gleason 8 Normal CD-US 54 yr old
Gleason 6, 1mm, Rt side
One year WW
Bilateral Gleason 8

5. Increasing Stage 60 yr old PSA 5.3, T1c TRUS bx, 1.3 mm, 1 core, left
Gleason 6
Considering WW
3D PMB
78 cores
14 cores positive bilat
I one, cancer into fat T3

6. 3D Mapping-Results Bilateral cancer, (55%)
N=180 all previous TRUS bx,
ALL positive only one side TRUS BX
3D-PMB shows that:
Bilateral cancer, (55%)
Increased Gleason score (22%)
Over 70% would have management changed
Morbidity-
hematuria (1.2%),
retention (7%)

7. Focal Therapy for Prostate Cancer
The Male Lumpectomy

8. Local Control of PCa Matters!!!!
Accepted Theory-Mets already present
LOCAL CONTROL DOES NOT CHANGE SURVIVAL
Recent evidence to the contrary
Zelefsky MJ et al. “Higher radiation dose levels (better local control) improved biochemical tumor control and decreased risk of distant metastases.” Int J Radiat Oncol Biol Phys Jul 15;71(4):
Trock et al. “Salvage radiotherapy (better local control) administered within 2 years of biochemical recurrence was associated with a significant increase in prostate cancer-specific survival.”

9. Focal Therapy and Local Control
Hypothesis: Focal Therapy with Cryo Provides better local control than RP or Rad
Superior treatment of ECE
Only treatment that can be repeated
Treatment rad failures
Achieved with significantly lower morbidity.

10. Superiority of Local Control-ECE
3 yrs P/O
PSA=200 ng/ml
74 yr old
Gleason 10
12 months, CHT resistant
4 yrs Post op
PSA undetectable off CHT

11. Superiority of focal Therapy/Retreatment
52 yr old, 6/2002, PSA 6.3, G6 left gland, Re TRUS bx rt side negative,
left hemi cryo, PSA stable 6 years then rise, Mapping bx +, retreat, PSA .4 stable

12. Risk level N= year F/U

13. 100% local control, 8 patients retreated Focal Therapy Results Total
Risk Level N=
ASTRO
Pheonix
Rad failure 11
2 (81%)
Total
120
8 (93%)
7 (94%)
100% local control,
8 patients retreated

14. Male Lumpectomy Results
high RP/45%
Lodde M, et al

15. FOCAL THERAPY MORBIDITY N=120
CONTINENCE 100%
POTENCY 85%
Reproduced 2 published studies

16. CONCLUSION
In the patients who need treatment the most Focal therapy provides better local control of prostate cancer. This will translate into improved survival
Focal therapy, promises better cancer results with lower morbidity
It is now an obligation of the medical community to produce a randomized trial comparing focal ablation to Robotic RP