Woodrum-MR-guided focal therapy for native and recurrent prostate cancer

This manuscript presents a current review of the importance of MR imaging, biopsy and ablation for treatment of prostate cancer either early native disease or recurrent prostate cancer after surgery or radiation. Prostate cancer is the most common cancer diagnosis for men, with approximately 35,000 men dying from it each year in the United States¹. Many men with prostate cancer are often managed with aggressive therapy including radiotherapy or surgery.  No matter how expertly done, these therapies carry significant risk and morbidity to the patient’s health-related quality of life with impact on sexual, urinary, and bowel function². Furthermore, screening programs using prostatic specific antigen (PSA) and transrectal ultrasound (TRUS) guided systematic biopsy have increasingly identified patients earlier, in the low-risk, low-grade “localized” prostate cancer categories.  The indolent nature of many prostate cancers presents a difficult decision of when to intervene given the possible comorbidities and side effects of aggressive treatment.  Active surveillance has been increasingly instituted to balance cancer control versus treatment side effects³. Although active debate continues on the suitability of focal or regional therapy for these low- or intermediate-risk prostate cancer patients, many unresolved issues remain which complicate this approach of management. Some of the largest unresolved issues are: prostate cancer multifocality, limitations of current biopsy strategies, suboptimal staging by accepted imaging modalities, less than robust prediction models for indolent prostate cancers, and whether established curative therapies can be safely and effectively used following focal therapy for prostate cancer. Despite these restrictions, focal therapy continues to confront the current paradigm of therapy for low- and even intermediate-risk disease⁴. Therefore, accurate assessment of cancer risk (i.e. grade and stage) using imaging and targeted biopsy is critical. Advances in prostate imaging with MRI have been accompanied with advances in MR-guided therapy, propelling prostate treatment solutions forward faster than ever. The following manuscript reviews the current state of MR imaging, biopsy and MR-guided prostate ablations for native and recurrent prostate cancer using laser ablation, cryoablation, and focused ultrasound.