Prostate cancer, a disease diagnosed in approximately 220,000 men in the U.S. annually, has historically been treated through extirpation of the entire gland. Unfortunately, whole-gland interventions exact a heavy toll, often resulting in incontinence and impotence. One proposed alternative is focal therapy, wherein MR-visible tumor foci are treated locally while sparing the majority of healthy tissue. This approach has great potential to deliver curative treatment while reducing costs and risks. In order to demonstrate the safety, efficacy, and practicality of focal therapy, several key questions remain:
1. How reliably can tumor location be distinguished?
2. What treatment margins are necessary?
3. Can treatment be delivered safely in a clinic setting?
This thesis presents a concerted effort to answer these questions, guided by the central hypothesis that focal therapy can be made safe and effective by registering MRI with ultrasound, pathology, and thermal data. To this end, we characterized and clinically implemented a means of accurately correlating MRI with histopathology. We discovered that many tumors extend far beyond the confines of MR-visibility, and the average tumor was three times its predicted volume. Isotropic margins in excess of 1 cm would have been necessary to treat the majority of focal therapy eligible men. However, by registering tracked biopsy data with MRI, we demonstrated that patient-specific treatment margins can greatly improve cancer prediction.
We performed clinical trials investigating the safety of focal laser ablation (FLA) of prostate cancer, a modality wherein an interstitial laser delivers thermal energy and induces coagulative necrosis. Through analysis of MRI thermometry data, we found that thermal damage could be predicted with less than 15% volumetric error (0.5 cc). In a second clinical trial, FLA was performed under the guidance of MRI-US fusion imaging. This trial demonstrated that focal therapy could be performed safely, in a clinic setting, and without risk of incontinence or impotence. Furthermore, clinically significant cancer was eliminated from 60% of men, demonstrating the potential efficacy of localized treatment.
Future work is necessary to refine all aspects of prostate focal therapy. However, this thesis lays a foundation for safe and effective treatment of localized prostate cancer.
