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

Abstract

Introduction:Focal therapy for prostate cancer is increasingly recognized as an acceptable therapeutic option in well-selected men. A focal therapy multidisciplinary tumor board geared toward improving patient selection is a novel concept which has not been reported. We describe our institution’s initial experience with a multidisciplinary tumor board for focal therapy and its outcomes in terms of patient selection.Methods:This was a single-center, prospective study of patients referred to a multidisciplinary tumor board. All prostate MRIs were re-reviewed by a single radiologist with >10 years of experience, and the number, size, location, and Prostate Imaging Reporting & Data System scores of lesions visible on MRI were recorded and compared to the original report. Outside histopathology, when requested, was also re-reviewed for cancer grade groups and adverse pathological features. A descriptive statistical analysis was performed.Results:Seventy-four patients were presented at our multidisciplinary tumor board (January-October 2022). Sixty-seven patients were treatment naïve, while 7 had prior radiation±androgen deprivation therapy. MRI overread was performed on all treatment-naïve patients (67/74 [91%]), while pathology overreads were performed on 14/74 (19.9%). Following multidisciplinary tumor board, 19 patients (25.6%) were deemed suitable candidates for focal therapy. A total of 24 patients (35.8%) were not deemed candidates for high intensity focused ultrasound focal therapy based exclusively on findings identified at MRI overread. Pathology re-review changed management for 3/14 patients, with two-thirds being downgraded to grade group 1 disease and opting for active surveillance.Conclusions:Multidisciplinary tumor board for focal therapy is feasible. MRI overread is an essential component of this process and demonstrates significant findings that alter eligibility or management in over a third of patients.

Editorial Commentary

“…In this particular study, eligibility for focal therapy was based primarily on review of pathological and imaging results. Given the discordance of and variation in interpreting biopsy and MRI studies, it might be useful to expand the selection criteria to incorporate ( 1 ) molecular and genetic evaluation of the tissue to assess underlying aggressiveness of the cancer, and (2) advanced imaging (such as prostate-specific membrane antigen−positron emission tomography) to more accurately localize the extent of disease. Granted that while the objective of this study was to report on the creation of the selection panel concept, hopefully the authors will update their results and report on outcome data as well as pathology data on those patients deemed inappropriate for focal therapy and those who failed focal therapy who ultimately had resections.…”

Reply by Authors

“…We demonstrate that the pooling of dedicated genitourinary radiologist, pathologist, radiation oncologist, and urologist to refine candidates for focal therapy results in the substantial exclusion of numerous “potential candidates” who were originally considered suitable for focal therapy. 1 MRI and pathology overreads identify new findings that alter candidacy. We believe that focal therapy has its place in prostate cancer care but should be performed after thorough pathological and radiographic overread, and through a multidisciplinary tumor board forum.…”