Case Discussions: Patient and Treatment Selection

A multidisciplinary group of experts led by Abhinav Sidana, MD, MPH, FACS, Associate Professor, Surgery, Director, Prostate Cancer Focal Therapy Program, Director, GU Clinical Trials, Co-Director, High-Risk and Advanced Prostate Cancer Clinic, Urologic Oncologist, University of Chicago, Chicago, Illinois, discusses complex prostate cancer cases with focal therapy considerations. The panel begins with a patient who presents with bilateral MRI visible lesions. Panelists emphasize that multifocal or bilateral clinically significant disease limits the appropriateness of focal therapy and increases the likelihood of future recurrence or need for radical treatment. They discuss how candidate selection depends on defining an index lesion that drives prognosis and confirming the absence of clinically significant disease in untreated zones through targeted and systematic biopsy. Some panelists favor whole gland ablation in such settings, while others recommend surgery or radiation. The second case focuses on a younger patient with an anterior transition zone lesion. The panel notes that anterior tumors often respond well to focal therapy due to distance from neurovascular bundles, but require precise targeting using fusion guidance. They emphasize the importance of verifying lesion boundaries with high-quality multiparametric magnetic resonance imaging (MRI) and targeted biopsy, as well as ensuring a clear understanding of the patient’s need for ongoing prostate-specific antigen (PSA) testing, MRI, and potential rebiopsy. Another case involves intermediate risk disease with high genomic classifier scores. Panelists explain that elevated genomic risk increases the probability of in-field or out-of-field recurrence after focal therapy and may favor surgical or radiation-based approaches for durable disease control. Across cases, the panel repeatedly emphasizes the importance of shared decision-making. Selection must integrate disease characteristics, radiologic visibility, biopsy concordance, patient anxiety, comorbidities, prior functional status, and willingness to undergo structured follow-up. Focal therapy is presented as a valid option for appropriately selected men, but not a default choice for multifocal, high-volume, or unfavorable genomic disease. Don't forget to join the GRU Community: https://grandroundsinurology.com/regi... Follow us on Twitter/X: https://x.com/GRUrology And like and subscribe to us here on YouTube!