Considering initial focal therapy (HIFU, FLA, Cryo, IRE, etc.)? Here are some things to think about.

[Tall_Allen]

I updated this article with some more recent info, and thought I would post it here:

pcnrv.blogspot.com/2016/12/...

And here are some questions you may wish to ask:

pcnrv.blogspot.com/2017/12/...

[cesanon]

Nice article. It seems like the most important question, what are the therapy options if this treatment fails, has no evidence based answer.

That by itself would seem good reason to make other treatment choices, unless your particular situation provides a compelling reason to select this particular type of treatment over the other options for which there is more medical experience out there to tap.

[Tall_Allen in reply to cesanon]

Good points. Most often, salvage involves a "re-do," where they re-treat the same area or other areas. Sometimes, that's all that's required. Of course, that raises the out-of-pocket costs considerably (most focal therapy is not covered by insurance). But, as you suggest, when salvage involves surgery or radiation a whole new set of side effects must be considered. I imagine salvage surgery of necrotic tissue is difficult, and I don't know how effective salvage radiation is on cancer cells that have been protected by heat-shock proteins.

One of the big questions is: what is the goal of such therapy? On this side of the Atlantic, many practitioners see it as a way of extending active surveillance in low risk patients. On the other side of the pond, the Ahmed/Emberton group selects intermediate risk patients only because they believe that low risk patients should be on active surveillance. Gary Onik has a clinical trial among high risk patients. We have a lot to learn about optimum patient selection. Note the comparison table between SBRT and Photodynamic therapy (PDT) in terms of oncological and toxicity outcomes:

pcnrv.blogspot.com/2017/01/...

[adlerman in reply to Tall_Allen]

The only treatment that offers do-over is Cryosurgery.

[Tall_Allen in reply to adlerman]

All focal ablation therapies, including cryo, HIFU, FLA, PDT, etc. have high rates of multiple treatments. In the Ahmed/Emberton HIFU study, for example, 20% of all patients were treated multiple times.

[adlerman in reply to Tall_Allen]

I meant that cryo (freezing) doesn't destroy the tissue making a re-do difficult as other procedures do.

[Tall_Allen in reply to adlerman]

All forms of thermal ablation, including cryotherapy, destroy tissue. That's what ablation means.

[iampete]

As this article was written in 2016, I'm glad you updated it, but it would be helpful if you somehow highlighted the "updates".

[Tall_Allen in reply to iampete]

I only updated the data on incomplete ablation in the ablation zone. You can tell by the date of the links if they are updates. I was hoping that there would be fewer such cases as practitioners got better at it, but that doesn't appear to be the case.