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Focal laser therapy or focal HDR Brachytherapy?

Vulcanologist profile image

I have a 2 cm lession in the left apex. I'm considering either focal laser thereapy or HDR brachytherapy. ED and incontinence are my biggest concerns. Does anyone have any experience with either method or with Dr. Eric Walser (laser) at UTMB, or Dr. Albert Chang (brachytherapy) at UCLA?

56 Replies

Impossible to answer without more info. Please provide.

The lefte apex lesion has extraprostatic capsule extension approaching the NVB and abuts the urethral sphincter. It doesn't appear to have extended beyond the prosate capsule. Does anyone have any experience with ED issues from either laser therapy, or HDR brachytherapy, and/or any experience with Dr. Walser or Dr. Chang?

Perhaps I wasn’t clear. What is your situation? Never treated? Salvage after treatment? If so, what treatment? You posted in advanced Pc. - do you have metastases? If so, how many and where?

Vulcan-

i had a right sided transitional zone 5cm lesion G7 (3+4) in 2016. PSA of 7.2.

after much consideration of full gland treatment i decided to try a focal remedy because, like you (most men), i was concerned with ED and QOL.

i consulted with walser, liked him and treated in 10/2016. i did not view the treatment as a "cure" but was willing to kick things down the road a bit (i was only 50 years old).

Good News- i really like Walser, and his staff, and think he is an excellent practitioner of this particular procedure. the procedure did NOT affect my function.

Bad News- after about 3 years, my PSA started to creep up, then spiked in the 5th year. Tests showed a recurrence (even in the ablated tissue area!) and i am in a slightly worse position now, with disease on both sides and some G7 (4+3).

i took a shot, it bought me 5 years... BUT, be wary that there is, i believe, a significant recurrence issue with the procedure because it is targeted and cancer (microscopic) is not...

Tall_Allen profile image
Tall_Allen in reply to chrisNYC

You may be interested in whole-gland salvage using SBRT . It had pretty good results in this study of post-cryotherapy patients:

advancesradonc.org/article/...

chrisNYC profile image
chrisNYC in reply to Tall_Allen

Tall-

i am about to get whole gland treatment at this point.

not inclined toward surgery, just not my thing.

Have evaluated RT therapies. bc of the 4+3 i have been recommended:

SBRT (NYU CK) with 3 months ADT; or

HDR with 5 weeks ERBT

told ROs i would not take ADT with the SBRT (informed 10% increase in survival rate); or the 5 weeks of ERBT with the HDR. both were fine with "skipping" the enhanced treatment and doing the mono therapies. i am "only" 55 and am concerned about QOL as well as beating my body down with the ADT or increasing risk of secondary issues with too much radiation.

its all a balance, i get it, and this is where i am comfortable drawing the line.

Dr Haas at NYU (CK) .. seems a straight shooter... any thoughts?

Tall_Allen profile image
Tall_Allen in reply to chrisNYC

Salvage surgery is a terrible idea- very high morbidity.

Haas is the lead author of that study I linked.

Bigmls profile image
Bigmls in reply to chrisNYC

See, if Dr Walser can re treat the areas.have you inquired with Newest Elestra laser TPLA, procedure. Have you had a PSMA pet to know if the areas outside of capsule are clear. Also did you have a new biopsy targeted to determine the occurrence areas? Is the disease G7 4+3 on both lobes, what % pathology samples, Did you notice any ejaculate semen volume decline from your function from first procedure.?

Bigmls profile image
Bigmls in reply to chrisNYC

Was the procedure with MRI guided in the machine , or the Elestra laser ?

Bigmls profile image
Bigmls in reply to chrisNYC

Just had 3+4 G7 done, right apex and transitional zone. Dr Walser is using newest Elestra laser. His data is under 20% occurrence after 3 years. My ED function and ejaculate though reduced seems to be preserved and no urinary retention. It can be retreated in the area you should speak to Dr Walser again.

chrisNYC profile image
chrisNYC in reply to Bigmls

Big-

many thanks.

i became very friendly with walser. his offices have followed my progress (i treat in nYC with NYU) for the past 5 years, through repeat PSA blood tests and MRIs. My PSA spiked this year, up to 10.2. CT and nuclear medicine bone scans showed no escape (insurance wouldnt pay for PET scan).. Repeat biopsy showed 6/14 cores, disease on both sides.

walser reviewed the biopsy and recommended RT or surgery.

dont know for sure, but think he would try FLA on someone with my current level of disease, but knowing each other and knowing it "failed" not sure he wanted to try again.

FLA seems to work better for some than others. as noted, my cancer came back IN the ablated tissue; meaning, the laser did not kill the disease.

Bigmls profile image
Bigmls in reply to chrisNYC

What were from initial post treatment period 6 months and first 3 years your PSA levels and MRI's showing? treatment and why did you wait to have a biopsy follow up only in the 5th year and not sooner years? What % of cancer G7 3+4 were the initial cores. Did you do the biopsy trans rectal or transperineal in NYC or with Dr Walser?

chrisNYC profile image
chrisNYC in reply to Bigmls

yes, i had PSA tested every 6 months and a MRI once per year.the PSA hovered around 2.0 (it doesnt go to zero from FLA) and MRIs were repeatedly negative. even when the PSA spiked the MRI continued to be negative, leading to the conclusion that it was "inflammation" and that "many other factors can drive PSA"... when PSA hit 10.0, they ordered CT scan and Nuclear Body scan, then suggested a biopsy. all treatment done in NYC, but Walser and staff reviewed the findings. NYU did most recent biopsy, which showed 6/14 cores, almost all on the right side in the area of the ablation. one core was 4+3, on 80% of tissue (60% 4), not good... other cores were 20-30% of tissue, i had pathology reviewed and confirmed by JHU

Mlsliver78 profile image
Mlsliver78 in reply to chrisNYC

Was you treatment done under general anesthesia in the MRI tube,? When was the first spike post treatment ? and what were the number's, when was2nd spike , ? what were the PSA , numbers , why did you not have Dr walser do a BIOPSY?

Mlsliver78 profile image
Mlsliver78 in reply to chrisNYC

What was the size of your prostate CC/g pre and post treatment of FLA. Have you had PSMA pet scan to determine, no extra capsular extensions.? If the 6/14 +cores are all on the right side why cannot the area be retreated hemi-gland has Dr. Walser specifically said he wouldn't retreat your area based on lesion biopsy locations, grade and cm size?

Bigmls profile image
Bigmls in reply to chrisNYC

Was you treatment done under general anesthesia in the MRI tube,? When was the first spike post treatment ? and what were the number's, when was2nd spike , ? what were the PSA , numbers , why did you not have Dr walser do a BIOPSY?

What was the size of your prostate CC/g pre and post treatment of FLA. Have you had PSMA pet scan to determine, no extra capsular extensions.? If the 6/14 +cores are all on the right side why cannot the area be retreated hemi-gland has Dr. Walser specifically said he wouldn't retreat your area based on lesion biopsy locations, grade and cm size?

chrisNYC profile image
chrisNYC in reply to Bigmls

Big-

believe me, i would laser and laser again, if i thought it was responsible.

i had NO side effects.

but, it came back, even in the lasered tissue.

walser continued to tell me PSA rise was inflammation. MRI showed little. CT scan and NM scan, fortunately, negative. i got biopsy locally (NYC) because Walser is in texas. i had discussed going there for biopsy but it would have been all out of pocket (5K).. guess is, he might have taken it and considered re FLA ...

but, with 2 side (now on left as well) he has deferred and recommended a "skilled" RO.

as i said, i really like Walser, and, i took my shot... had 5 more years of a symptom free lifestyle.. perhaps you get more, even a lifetime, but i am where i am now...

CDG

Bigmls profile image
Bigmls in reply to chrisNYC

You realize in the first 4 years you could of gone back to Dr. Walser who could of simultaneously biopsied and retreated with laser in the BCR areas of the gland. Didn't Dr Walser tell you this each year when you saw the PSA come up from 2 , what was the velocity of the PSA changes ? was it 2 to 3 then to 4 or 5, then in 5th year then spike to 10?

chrisNYC profile image
chrisNYC in reply to Bigmls

no, he did not. he told me the MRI showed nothing and it was likely inflammation.he did not recommend a follow up biopsy.

change was gradual in first 4 years, from 2 up to 5. went from 5 to 10 in past year.

Bigmls profile image
Bigmls in reply to chrisNYC

Was you procedure in a MRI guided tube originally with Walser. Did you have LUTS prior to treatment. and notice your ED function change in the first.3 years post ablation did u take tadalafil ? is your ejaculation seminal volume levels changed pre and post your Focal Ablation.

Bigmls profile image
Bigmls in reply to chrisNYC

Was you procedure in a MRI guided tube originally with Walser. Did you have LUTS prior to treatment. and notice your ED function change in the first.3 years post ablation did u take tadalafil ? is your ejaculation seminal volume levels changed pre and post your Focal Ablation

I know the temptation of treating only what you can see on imaging. Unfortunately, focal ablation just doesn't work. It does a poor job at curing prostate cancer even when the whole gland is treated:

prostatecancer.news/2021/03...

The oncological results are similarly poor for focal FLA:

auajournals.org/doi/pdf/10....

ncbi.nlm.nih.gov/pmc/articl...

You and I had similar concerns (preserving potency and continence). I narrowed my choices down to two: SBRT and HDR brachy (as whole gland treatment). They are both excellent. In the LA area, I suggest you meet with Amar Kishan at UCLA about SBRT, and Mitch Kamrava at Cedars-Sinai about HDR brachy. I know them both, and they are both excellent. I haven't met Albert Chang, but have heard some feedback from a patient of his that is less than complementary about his demeanor and follow-up. I suggest you make up your own mind.

I read the studies. What am I missing here? It seems to me FLA does a pretty good job at eliminating prostate cancer in substantially greater than 50% of the individuals, with little to no long term incontinence and ED issues. If it fails, it is my understanding that it doesn’t preclude other salvage methods later. Since it is my understanding that virtually all forms of radiation therapy end with a high percentage 20% - 40% of incontinence and ED at 12 to 50 months out, so why wouldn’t FLA be a reasonable first choice, with salvage radiation therapy later if required?

"It seems to me FLA does a pretty good job at eliminating prostate cancer in substantially greater than 50% of the individuals" That is awful. The table shows the comparable results and risks for SBRT - virtually no local cancer remaining in low and intermediate risk patients. And equal or fewer lasting side effects. One and done.

"If it fails, it is my understanding that it doesn’t preclude other salvage methods later." Salvage SBRT or brachy is certainly possible. It works about ⅔ -¾ of the time. And morbidity is high, worse than if those therapies are used as primary. One should never go into a primary therapy with the intent of doing salvage later.

"Since it is my understanding that virtually all forms of radiation therapy end with a high percentage 20% - 40% of incontinence and ED at 12 to 50 months out," Your "understanding" is completely wrong. Incontinence is a vary rare outcome (<4%) for primary radiation, and ED rates are actually less than with focal therapy.

prostatecancer.news/2016/09...

No doubt, you were misled by the focal therapy "used car salesmen." What they do is trot out retrospective numbers that include patients who were treated 30 years ago and do not correct for age. 30 years ago, radiation techniques and doses were not curative - it didn't matter because radiation patients were much older - they were likely to die of something else first. Potency and continence deteriorates with age (with no treatment), so one can't compare 70 yo patients to 60 yo patients. The only way to compare is with a randomized clinical trial (like ProtecT above).

Bigmls profile image
Bigmls in reply to Tall_Allen

This is not the case you challenge the newest clearer margin zone FLA therapy is TPLA -Elestra laser. The data is shows from 2013 and up the numbers are under 20% reoccurance after 3 yrs. You need to monitor with MRi 6 months and probably biopsy under 1-2 yrs out from treatment but no urinary retention, ED and ejaculate function is mostly maintained with little intervention , or margin use of tadalafil, if one has early to intermediate stage you should research- Dr. Walser's results at UTMB. The index tumor theory has a lot of data around it and the fact that G6 does not tend to spread. Your are championing SBRT and HDR though effective the facts are they eliminate all ejaculate and also ED levels are reduced substantially. Also long term risk of cellular mutation create possibilty 3 to 10 years out of low grade becoming a very aggressive stage and then spreading outside capsule and going metastatic Please weigh the truths. If a man is under 60 they want to have a sex life , that is not small thing. If it fails one can still do SBRT or HDR brachytherapy. Those are the consequences.

Tall_Allen profile image
Tall_Allen in reply to Bigmls

Do you have any peer-reviewed journal data for it? Anyone can make up numbers, getting them published in a peer-reviewed journal is another matter. Be careful of your sources. Nothing of what you claim to me true has any data behind it - pure fiction.

Bigmls profile image
Bigmls in reply to Tall_Allen

Focal Laser Ablation of Prostate Cancer: Results in 120 Patients with Low- to Intermediate-Risk Disease - Journal of Vascular and Interventional Radiology

jvir.org/article/S1051-0443...

Tall_Allen profile image
Tall_Allen in reply to Bigmls

Thanks - as I said these are very poor results. Here is the full text:

ncbi.nlm.nih.gov/pmc/articl...

17% recurrence in just one year in almost entirely favorable risk patients is very poor. Figure 4 shows continued deterioration to about 28% recurrence after 2 years. That compares to no local recurrence in 2 years of follow-up with SBRT or HDR brachy.

As for your other assertions:

• Urinary retention: Supp. Table 3 shows 14% (grade 1+2)

• 2 rectourethral fistulae post FLA requiring 4–6 weeks of continuous urinary catheterization

• 1 serious (grade 3) UTI

• ED rates are similar for FLA, SBRT and HDR brachy.

• I've seen no data on ejaculate after thermal ablation - but I'd like to if you have any

• New prostate cancer emerging from healthy irradiated cells has never been detected 3-10 years after treatment of low grade cancer with radiation.

• The index tumor theory has very little data behind it -only 2 small studies, Discussed in the link below in the section "Index Tumor Theory."

prostatecancer.news/2016/12...

Bigmls profile image
Bigmls in reply to Tall_Allen

Personal experience- No. Urinary retention , catheter under 5 days. UTI if any are treated short course antibiotics. ED is very low occurrence rate with the newest Laser- Elestra , fiber optic needles create better margins. TPLA, very low ED issues, it seems that the reoccurance rates for the procedure for intermediate are under 28% , so far better than 50%. 72 % cure rate your admission. Fact you have no semen or ejaculate with HDR and SBRT one and done. We are not talking about G6 also talking about G7 3+4, lesions treated coming more aggressive. Not healthy but irradiated cancer cells. Insurance is starting to code cover vaporization of prostate cancer tissue.

chrisNYC profile image
chrisNYC in reply to Bigmls

my FLA resulted in, by subjective observation, a 70% reduction in seminal fluid, as walser burned most of the right side of my prostate, which is the water factory. i wasnt worried about "money shots" so that is okay (and, if you save up, you can have one occasionally). no "physical" ED but i have to admit this whole thing played with my mind too much. am fine alone, and if i am really attracted to someone.. but the "ah, what the heck?" approach of no interest to me anymore, of course, that might be age and maturity.... no issues with urinary function... virtually without consequence... but for the nasty issue of recurrence... going SBRT this time, hoping for the best

Tall_Allen profile image
Tall_Allen in reply to Bigmls

I'm glad it worked for you. But get an mp-MRI targeted biopsy every year. About a third of favorable risk patients treated with any kind of thermal ablation have recurrences, as you can see. Just horrible!.

Pure fantasy on your part about G7 cells being turned to monsters by radiation. Sounds like a novel.

Medicare won't cover thermal ablation except as a way to remove healthy prostate tissue - like a TURP. It has been proven to be ineffective as a cancer treatment.

What is the effect on scarring and prostate from yearly mp-MRI targeted biopsy every year. What about function and retention is that why most urologists , RO do not recommend annual biopsy.

Another reason to avoid thermal ablation! PSA is an almost useless tool and mpMRI is very difficult to read. Without frequent biopsies, how can one know if there is progression (given the high likelihood of progression after thermal ablation)?

msutin789 profile image
msutin789 in reply to Tall_Allen

You have the opportunity to discuss the newer laser Elestra , and the TPLA entry micro fiber ablation needles, they do not go through the rectum, transperineal, they can go around the nerve bundles and create a 1cm margin. If you believe that Dr. Walser's data is so poor challenge him on the 400 + TPLA ablations done in the last 4 years see if you can get him to opine that 30% or over 100 patients have reoccurrence and need retreatment of salvage radiation. Be an advocate for your fellow prostate cancer brethren, not stop people from avoiding overly aggressive treatment at the early stage of their disease. You do it to keep your erectile function without necessarily tadalafil or penile injections and some of your ejaculate volume and avoid long-term risks of radiation mutation, which gives a worse staging. Like you said people are showing scarring and bleeding years out after SBRT or HDR brachytherapy. The prostate tissue is hardend and scarred.

Tall_Allen profile image
Tall_Allen in reply to msutin789

Building a better machine to do thermal ablation is to no one's advantage if thermal ablation doesn't cure prostate cancer. A similar technological improvement occurred with HIFU using the TULSA-PRO technology. It had similarly poor outcomes as FLA. I fail to understand the advantage of a device that lowers toxicity if it doesn't cure prostate cancer.

SBRT and HDR brachy do cure prostate cancer in equivalent patients, and ED rates are identical to focal thermal ablation. Thermal ablation causes even more scarring - that's what "ablation" means. It leaves a scar of necrotic tissue in the entire area. So thermal ablation destroys healthy prostate tissue (that's exactly what it's FDA-approved to do) whereas radiation has little effect on healthy tissue.

msutin789 profile image
msutin789 in reply to Tall_Allen

How many Biopsies clear post-FLA would be necessary to consider a cure over the long term, and isn't ejaculation gone after SBRT and HDR .

Tall_Allen profile image
Tall_Allen in reply to msutin789

Considering the lack of valid biomarkers and the steep increase over time in clinical recurrence with FLA, I think that biopsies every year for 5 years post FLA are needed.

"Prior to treatment, 7.6% of men reported that they were very to extremely bothered by their ejaculatory dysfunction. The number of patients reporting this concern... increased to 10.6% at 18 months post-SBRT."

redjournal.org/article/S036...

So that's an increase of 3% over baseline for SBRT. What #s can you cite for FLA published in a peer-reviewed journal?

Bigmls profile image
Bigmls in reply to Tall_Allen

What about painful ejaculation thats seems constant

Tall_Allen profile image
Tall_Allen in reply to Bigmls

You didn't answer my question - What % of men getting FLA lose ejaculatory function ? (published in a peer-reviewed journal)

Pain during ejaculation can occur with RP, RT, HIFU, FLA or any other prostate therapy. With SBRT it occurred in fewer than 10% and was completely relieved by alpha blockers. It disappeared in everyone after 2 years, according to the study I just cited.

What is the rate for FLA?

Your inability to quote similar statistics for FLA demonstrates the lack of follow-up typical of such treatment.

msutin789 profile image
msutin789 in reply to Tall_Allen

are you saying they don't need long term use of tadalafil for erection and pain

Tall_Allen profile image
Tall_Allen in reply to msutin789

That's what I'm saying. I had SBRT 11 years ago and haven't used any drugs in over 10 years. My experience is typical. It sounds like you've been lied to about FLA.

What are your thoughts on focal HDR Brachytherapy?

For salvage, it's fine. But not for primary therapy. In 90% of men with localized PCa, the cancer is multifocal. Many make the mistake of thinking that what is detected on mpMRI and biopsy is all there is, forgetting the 5mm size limit for imaging and that biopsy is just a tiny sampling. Post-imaging and post-biopsy prostatectomies have proven the limitations.

More to the point, with toxicity so low, why take the risk?

msutin789 profile image
msutin789 in reply to Tall_Allen

So you speak for all who have lost their ejaculate as well

Tall_Allen profile image
Tall_Allen in reply to msutin789

I repeatedly asked for your data. Apparently you have none. I expect you will be back next year asking what kind of salvage is best. FLA should only be done under a clinical trial. Your doctor is just a money-grubbing faker if he treated you outside of a clinical trial, I'm sorry to tell you.

msutin789 profile image
msutin789 in reply to Tall_Allen

Sir have some compassion for fellow brethren we are all in this together, the hope was to preserve function and ejaculate, are u saying Dr. Walser is a money-grubber faker and the data is a fake submitted to the journals.

Tall_Allen profile image
Tall_Allen in reply to msutin789

If any doctor treated you with FLA outside of a clinical trial and promised to cure you of prostate cancer, you have been scammed.

msutin789 profile image
msutin789 in reply to Tall_Allen

Was told the right lesion is the index lesion with only 5% Gleason 4 pattern was considered as intermediate good. The procedure was done TPLA due to improved safety profile and real-time imaging of the ablation which is subsequently confirmed in MRI.

I was told with any prostate therapy up to and including prostatectomy and whole pelvic radiation, there is always a risk of recurrence. In the world of FLA, this is addressed by surveillance and targeted biopsy and retreatment if new or residual disease is suspected. Obviously will need biopsies annually along with 3tMRI.

Tall_Allen profile image
Tall_Allen in reply to msutin789

Yes, there is always a risk of recurrence, but for a favorable intermediate risk patient like yourself, the risk of recurrence with SBRT and HDR brachy is about 3% while your risk of recurrence is ten fold higher.

I'm sorry if you were misled.

Bigmls profile image
Bigmls in reply to Tall_Allen

So you have not lost your ejaculate

Go to Memorial Sloan Kettering..............68th Street and First Avenue.........

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 11/22/2021 9:40 PM EST - President JFK assassinated in 1963

Dr Walser very good team, the Elestra Laser TPLA procedure. the areas of re- occurrence can also be retreated down the line. Need to do you yearly MRI after treatment. Is your staging G7 3+4 ? And what % of pathology, G6 or G7 for ex? The lesion get PSMA,- pet make sure area capsule contained, then do TPLA focal laser ablation. Your function should be preserved.

The newer laser can treat around the capsule and sphincter the ability to move NVB bundles create ablation treatment space comes with technique of the practitioner. The trend to focal laser ablation as first choice for early and intermediate PCa G6 and G7 , 3+4, capsule contained will continue. The RP surgery and RT oncologists will not admit to the mutation risk and long term ED loss of function, ejaculate and retention side effects. Aslo, the salvage treatment benefits. The interventional radiologists will erode away a huge portion of their business and save many men from to radical and excessive treatment therapy early on. Its a shame more urologists wont pass this information on.

Thanks for all of the replies with helpful information. This will be my initial attempt at dealing with this. I didn't realize I was on an advanced board, so I'll move on. Thanks again.

Jpl506 profile image
Jpl506 in reply to Vulcanologist

This isn’t the advanced board, you’re in the right place. Stick around as long as you’d like.

Bigmls profile image
Bigmls in reply to Vulcanologist

Speak to Dr Walser in houston UTMB

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