Correas, Jean-Michel; Dariane, Charles; Renard Penna, Raphaele; Ghai, Sangeet; Bladou, Franck; Cathelineau, Xavier; Ward, John F; ... de la Rosette, Jean; + view all Correas, Jean-Michel; Dariane, Charles; Renard Penna, Raphaele; Ghai, Sangeet; Bladou, Franck; Cathelineau, Xavier; Ward, John F; Emberton, Mark; Laguna, Pilar; Chiu, Peter; de Nunzio, Cosimo; Klotz, Laurence; Futterer, Jurgen; de la Rosette, Jean; - view fewer (2025) Imaging in focal therapy: advanced ultrasound imaging and mpMRI—a comprehensive review. Prostate Cancer and Prostatic Diseases 10.1038/s41391-025-01017-z. (In press).

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Abstract

Standard therapeutic options for localized prostate cancer (PCa) include whole gland treatment such as radical prostatectomy (RP) or radiation, administered according to various protocols. These treatments may result in erectile and urinary dysfunction in 50% or more of patients. Active surveillance (AS) does not affect functional outcomes and should be offered to patients presenting with low-risk and favorable intermediate-risk PCa. Due to improved risk stratification and increasing use of multiparametric Magnetic Resonance Imaging (mpMRI) in PCa follow-up, the cancer survival of patients on AS is not affected if appropriate follow-up is done. Focal therapy (FT) represents an alternative between radical therapies and observation. Regretfully, it is not recommended in many guidelines despite its good safety profile and the demonstrated superiority of post treatment erectile and urinary functions rates. This reflects the lack of randomized trials and limited data on long term oncologic outcomes [1, 2]. Many energy sources have been used including high-intensity focused ultrasound, cryoablation (CA), laser ablation (LA), irreversible electroporation, microwave focal ablation, focal brachytherapy (BT), and MR-guided transurethral US ablation (TULSA). Two approaches have evolved, either half/whole gland treatment, or selective destruction of identified clinically significant PCa (CsPCa). The latter should induce fewer complications or side effects and better spare erectile and sphincter function, whereas limited prostate volume ablation may lead to a higher recurrence rate [3]. Few randomized trials have been conducted comparing FT techniques. FT should be proposed only in expert centers after appropriate patient information is provided. Clinical trials and well-designed registries should be supported where possible [1]. Imaging plays a key role at each step of FT for patient selection, guiding the placement of treatment needles, assessing the FT efficacy, and follow-up for detection of recurrence. Imaging should identify the index lesion (lesion with a higher ISUP grade and size) with high sensitivity. Two imaging techniques can be combined to better assess PCa in FT candidates, mpMRI and transrectal ultrasound (TRUS). TRUS includes two different techniques: multiparametric TRUS and micro-ultrasound (mUS). Imaging assessment of both imaging modalities following treated and recurrent PCa following FT remains limited in the literature. We present the pross and cons of both imaging technologies within the framework of FT for the treatment of localized PCa.

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