UPJ INSIGHT Feasibility and Value of a Focal Therapy Multidisciplinary Tumor Board in Prostate Cancer Patients

By: Tarik Benidir, MD, MS, Cleveland Clinic Glickman Urological & Kidney Institute, Ohio; Andrew Wood, MD, Cleveland Clinic Glickman Urological & Kidney Institute, Ohio; Zaeem Lone, BA, Cleveland Clinic Lerner College of Medicine, Ohio; Zeyad Schwen, MD, Cleveland Clinic Glickman Urological & Kidney Institute, Ohio; Robert Abouassaly, MD, Cleveland Clinic Glickman Urological & Kidney Institute, Ohio; Jane Nguyen, MD, PhD, Cleveland Clinic Pathology Institute, Ohio, Ruben Olivares, MD, Cleveland Clinic Glickman Urological & Kidney Institute, Ohio; Christopher J. Weight, MD, MS, Cleveland Clinic Glickman Urological & Kidney Institute, Ohio; Andrei S. Purysko, MD, Cleveland Clinic Imaging Institute, Ohio | Posted on: 20 Jul 2023

Benidir T, Wood A, Lone Z, et al. The feasibility and value of a focal therapy multidisciplinary tumor board, including radiographic and pathological overreads in refining the selection for high intensity focused ultrasound in prostate cancer patients. Urol Pract. 2023;10(4):371-378.

Study Need and Importance

Focal therapy is increasingly recognized as an appropriate treatment strategy in well-selected men with prostate cancer. Patients are increasingly seeking treatments that minimize the morbidity of whole-gland radical therapies. Despite encouraging medium-term oncologic outcomes, other publications suggest a meaningful recurrence rate of clinically significant prostate cancer within 1 year of treatment. Re-treatments are associated with a decline in functional outcome, increased complication rates, and a threat to oncologic control. Optimal patient selection is a necessary area of research. The feasibility and value of a dedicated focal therapy tumor board including pathological and radiographic overreads remain unexplored and intriguing.

What We Found

Of the 74 patients prospectively reviewed in our high intensity focused ultrasound focal therapy tumor board, prostate MRI overreads were concordant with the original read in 60% of cases. MRI overreads excluded 35.8% of patients from being focal therapy candidates. MRI overreads had discordant Prostate Imaging Reporting & Data System (PI-RADS) scores in 25.6% of cases, with numerous lesions being upgraded from PI-RADS 1-3 to PI-RADS 4-5, thus requiring additional workup (see Table). Pathology overreads were performed in 18.9% of patients, among which 20% received grade group reclassification. Following tumor boards, only 25.6% of patients were deemed candidates for focal therapy.

Table. Confusion Matrix for Focal Therapy Cohort

Initial PI-RADS score	MRI overread PI-RADS score					Totals
Initial PI-RADS score	1	2	3	4	5	Totals
1	2	1	0	1	1	5
2	0	2	0	2	0	4
3	0	0	2	5	2	9
4	0	0	0	28	2	30
5	0	0	0	5	14	19
Totals	2	3	2	41	19	67
Abbreviations: MRI, magnetic resonance imaging; PI-RADS, Prostate Imaging Reporting & Data System. Bold text indicates concordant finding; italicized, discordant finding; highlighted, discordant finding requiring further investigation.

Limitations

This was a single-center study using a single focal therapy modality (high intensity focused ultrasound). Whether the change in focal therapy candidacy will lead to improved oncologic outcomes has yet to be evaluated.

Interpretation for Patient Care

When prostate MRIs are overread with focal therapy in mind, meaningful findings arise which challenge patient candidacy. These include the identification of new nonindex lesions, changes in PI-RADS scores, and the relationship of index lesions with respect to rectum and urethra. Pathology overread also impacts risk group classification. Focal therapy tumor boards should be encouraged at centers that practice this therapy.