What is Focal Therapy and why do we need it?​

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Prostate cancer might affect 1:6 man during their lifetime. Nevertheless, the issue of "over-treatment" is important due to the morbidity accompanying radical treatments and the fact that most patients will not be affected by their tumour. A population of 781 man needs to be screened for Prostate Cancer, and 26 needs to be treated in order to save 1 patient's life. 34% of prostate cancer patients are regarded as "Intermediate risk patients" based on their biopsy grade (Gleason score or ISUP), blood PSA level and physical examination. in about 20% of patients the tumour is located within the prostate in a single focus. In the same manner that in renal and breast cancer, these days, we sometimes preserve the organ, prostate care has also developed in to "focal therapy" era in selected cases. 

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What made this possible?​

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Over time, mpMRI imaging became better and more available. This enabled us "to see" the tumour within the prostate and to use "Trans-perineal, MRI fused, template mapping biopsy".

The new technique enabled us to accurately locate the tumour within the prostate, and to decide if it is focal or not. By doing so we could better select the cases that can benefit from focal treatment. 

 

What kind of focal treatments are there?​

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There are a few kinds of focal therapies. For example "HIFU" is a technique which uses high intensity ultrasound waves in order to create immense heat inside the prostate in order to destroy the tumour. "Cryo" is another method which uses electrodes that create Ice-ball that freezes the tissue. ​

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What is IRE/Nano-Knife?​

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Irreversible Electroporation technology (Nano-Knife), is a non thermal way to ablate (destroy) the cancerous area using electrical currents. The electrical pulses create micro-holes inside the cancerous cell membrane (wall). After a while, the cell can not repair itself and shift to a self-destruction mode (apoptosis). 

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So how is it selective to the cancerous area?​

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The electrical current travels between the electrodes (usually 4 to 6), thus spare the area which is outside. ​

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Who can be a candidate for this method?​

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We use this technology for tow different scenarios. As first line, we use it to patients older then 60, who have a focal lesion (after doing "Transperineal, MRI fused, Template Mapping Biopsy") which is in "Intermediate risk group" consensus, and refuse to have radical surgery or radiation therapy. The second population are patients using this method as "salvage therapy", which means, as second line, after radiation failure. In this case, after verifying that the recurrence is solely located in the prostate (PET-PSMA and mpMRI) and focal (Transperineal, MRI fused, Template Mapping Biopsy), we consider treatment to any cancer grade ("Gleason" or "ISUP"). 

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What are the advantages of Nano-Knife?​

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Every focal therapy method has its advantages and disadvantages. Nano-Knife does not use heat or ice in order to destroy the tumour. This enables it to spare "collagenous" tissues (like the urethra). Nano-Knife is a single treatment method which can be repeated if needed. Also, since the destruction area is very evident in MRI (over 90% of NPV), it is easy to follow the patient and evaluate the treatment. 

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What are the disadvantages of "Nano-Knife"?​

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Nano-Knife was approved by the FDA in 2008. It was first used for liver and pancreatic cancer and later-on was used for Prostate Cancer. Due to its innovative nature, we do not have the long follow up as with conventional methods. The literature published so far shows very high success rates with very low morbidity profile. But, in the meanwhile we still consider it as investigational. 

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How does the procedure done?​

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The procedure is done as a "Day surgery" protocol. The patients arrives to the hospital at the day of procedure while fated for 8 hours before. Then, we will anaesthetise the patient for less then an hour. At that time we will use MRI/Ultrasound fusion system (Biojet) in order to locate the tumour within the prostate and encircle it with a few electrodes. The electrodes are being inserted through the perineum (the skin between the anous and scrotum). We then activate short electrical pulses between the sets of electrodes. Once we finish we remove the electrodes, and wake the patient. A few hours later the patient can go home. We leave a urinary catheter which is strapped to the hip (any activity can be done while carrying the catheter), and we remove it in 3-5 days. ​

 

What is the next step?

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In the day of catheter removal we will have MRI scan done in order to verify the treatment location. Then we will meet again after 3 months in order to check blood PSA levels. In 6 months we will have another MRI done to make sure that the treatment area has been replaced with scar tissue. A year from therapy we will perform another transperineal, MRI fused, template mapping biopsy. This is done to verify that there is no cancerous tissue left viable. 

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What are the common sideeffects of the treatment? 

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The side effects are mostly minimal but may include blood in the urine or semen, mild discomfort and temporary changes in urinary flow. 

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What is your qualification for providing the treatment?​

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After I was fully trained as a consultant Urological Surgeon, I did a fellowship program in Robotic and Minimal invasive cancer surgery, under the supervision of Prof. Phillip Stricker at St. Vincent's hospital and the Kinghorn cancer centre, Sidney, Australia. The centre is one of the leading clinical and research centres in the IRE technology. After returning to Israel we set up the sister- unit in Hadassah with co-operation with the Australian unit. 

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