First International Workshop on Focal Therapy and Imaging of Prostate Cancer

s from the First International Workshop on Focal Therapy and Imaging of Prostate Cancer February 21–22, 2008 The Duke Comprehensive Cancer Center and the Duke Prostate Center Durham, North Carolina The First International Workshop on Focal Therapy and Imaging of Prostate Cancer was hosted by the Duke Prostate Center and the Duke Comprehensive Cancer Center in Durham, North Carolina on February 21–22, 2008. The workshop was intended as a gathering of leaders in prostate imaging, urologic pathology, scientists, and cancer physicians with the intention of bringing to the forefront the perceived need to scientifically study this evolving field. The symposium was open to all interested, and included engineers, molecular biologists, radiologists, radiation oncologists, medical oncologists, urologists and industry leaders. The Workshop highlighted the latest developments in prostate cancer imaging, molecular biology/pathology, and the various techniques of focal therapy. The list of faculties included over 30 leading experts from all over the world. The two-day workshop was designed to include didactic lectures and panel discussions along with a demonstration of the actual technique through a live feed from the Duke surgical suites. Select speaker abstracts are included below. We welcome all those interested in this topic to join us at the Second International Workshop on Focal Therapy and Imaging in Prostate and Kidney Cancer to be hosted by Professor Jean de la Rosette in Amsterdam, June 10–13, 2009. Thomas J. Polascik, MD Meeting Director 001 Focal Therapy: The Pathologist’s Perspective Thomas M. Wheeler Baylor College of Medicine In this 21st century it is becoming much less common to remove an entire organ as a result of cancer involving that organ. Indeed, it has been 30 years since lumpectomy for breast carcinoma has been accepted as a viable alternative to radical mastectomy in selected patients with breast cancer. Although for some organs (e.g. liver) removal of the entire organ is not compatible with life, for the major visceral cancers, prostate stands alone without a widely accepted method for treatment of a cancer focus and not the whole organ. Surgical removal of a portion of the prostate (save for transurethral resection) is not possible at present, although other forms of focal therapy (e.g. cryo, TUNA, etc.) are possible. Major impediments to the widespread application of focal therapy for prostate cancer are the multifocality of the majority of prostate cancers and the lack of highly specific and highly sensitive imaging modalities to detect them. The evolution of the field of focal therapy of prostate cancer will be due largely to increasing refinements in focal therapy (high efficacy and low morbidity) and increasing sensitivity and specificity of imaging modalities. 002 Pathologic Characteristics of Small Prostate Cancer David G. Bostwick Bostwick Laboratories Cancer volume may be the single most important factor in predicting cancer progression, and focal therapy is probably best for patients who have small volume cancer. However, the inability to accurately determine cancer volume by existing diagnostic methods and the scant knowledge of individual tumordoubling time pose a great challenge in identifying patients who may benefit from conservative management and renders accurate preoperative determination of clinical insignificance theoretical. There is a fair (r 0.39) to good (r O.76) correlation between amount of cancer reported in biopsies and that subsequently found in radical prostatectomy specimens. This correlation is greatest for large cancers. A high volume tumor on needle biopsy is strongly suggestive of large-volume, high-stage cancer, but the converse is not always true because of sampling issues. Umfocal cancer is present in 13–33% of radical prostatectomies, and is associated with lower grade, stage, and recurrence rate than multifocal cancer. Cases are almost always in the peripheral zone, and associated with focal rather than multifocal high-grade PIN. Age and preoperative PSA are not different from patients with two or more prostate cancer foci. As adenocarcinoma enlarges, it usually becomes less differentiated and may lose some of its capacity for PSA production. PSA concentration increases with increasing Gleason grade, but, when tumor volume is held constant, PSA decreases (PSA concentration declined as Gleason grade increased). About 80% of incidental (autopsy and cystoprostatectomy-associated) tumors are small-volume (0.5 ml or less) without elements of Gleason grade pattern 4 or 5, indicating that most multifocal tumors, other than the largest or index cancer identified preoperatively, may not be of clinical significance. Long-term clinical follow-up is warranted to determine the outcome differences among patients with small-volume prostate cancer. 003 An Analysis of 1184 Prostatectomy Specimens to Define Prostate Cancer Laterality as a Rationale for the Clinical Application of Focal Ablative Therapy John Madden1, Vladimir Mouraviev2, Janice M Mayes2, Leon Sun2, Daniel George3, Judd Moul2, and Thomas J Polascik2 1Department of Pathology; 2 Duke Prostate Center and Division of Urologic Surgery, Department of Surgery; 3 Division of Medical Oncology, Department of Medicine, Duke Medical University Center, Durham, NC Introduction and Objective: Effective screening and early detection of small volume prostate cancer (PCa) has led to the concept of focal therapy to treat PCa as an organ-sparing, minimally-invasive procedure [e.g. male lumpectomy]. However, traditional dogma of PCa being a heterogeneous and multifocal disease creates concern to the adoption of this approach. We sought to determine the frequency and role of tumor laterality in order to clarify the possibility of hemiablation of the prostate using focal therapy while preserving the contralateral lobe. Methods: 1184 paraffin embedded radical prostatectomy specimens excised from patients with early stage PCa between 2002 and 2006 were sectioned at 3-mm thickness and stained with hematoxylin-eosin. Pathologic assessment had particular attention to laterality and percentage of tumor involvement (PTI) along with other routine parameters as pT-stage, pathology Gleason Score (pGS), extracapsular extension (ECE), surgical margins (SM). Based on PTI, all cancer foci were ranked from minimal ( 5) to largest ( 15%) PTI. Clinical and pathologic parameters were analyzed using univariate and multivariate methods. Results: Analysis of frequency of tumors showed that a real “therapeutic window” for focal therapy sequentially decreased with increasing PTI. Completely unilateral cancers were identified in 227 (19.2%) of 1184 patients. 164 (72.2%) of them have had PTI of 5, 40 (17.6%)PTI of 5.1 10, 9 (4.0%)PTI of 10.1 15 and 14 (6.2%) -PTI of 15, respectively (p 0.0005). African-American men had bilateral cancers more commonly that Caucasian men, e.g. 93.3% vs. 84.2%, respectively (p 0.0005). Univariate analysis suggested significant variables to be race, prostate weight, pT stage, pGS, SM. However, only race, pGS, PTI and SM were independent predictors via multivariate logistic regression (p 0.05). Conclusions: This study suggests that only a select group of men diagnosed with prostate cancer have small volume, completely unilateral cancers that would be amenable to focal ablation therapy targeting 1 lobe. Further study is needed to develop predictive models forthose patients likely to have small, unilateral cancers amenable to focal therapy. 004 A Molecular Correlate to the Gleason Grading System for Prostate Cancer Peter S. Nelson1,2,3,4, Ilsa Coleman1, Mengchu Wu1, Alan Huang1 Roger Coleman1, Elahe Mostaghel1,2, Beatrice Knudsen1, Paul Lange3.4, Robert Vessella3, Daniel Lin3, Michael Risk3, and Lawrence True3,4 Divisions of 1Human Biology and 2Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA and the Departments of 3Urology and 4Pathology, University of Washington, Seattle, WA DUKE ABSTRACTS 1094