Seeking Info On IRE NanoKnife

Are you seeing Jonathan Coleman at MSKCC? His group just published some early results that you can read about here:

Another NanoKnife pilot study

Here's a review of another recent pilot study that brings up what I think are some important questions about it and other focal ablation therapies:

NanoKnife or irreversible electroporation treatment as a potential focal ablation therapy

Focal HIFU has been making the news in mainstream media. Here's a commentary on the most recent published study of it:

Focal HIFU in treatment of (largely) intermediate-risk prostate cancer

• 28% had to have another treatment (either HIFU or radical treatment)
• At 2-3 years f/u, 97.6 % were pad-free, and 80.0 % were pad-free, leak-free continent.
• 86.1% had maintained baseline erectile function.

There are so many unanswered questions:
• Do side effects increase with the size and location of treated areas (e.g., large areas near the urethra or bladder)?
• Is it possible to lower the high retreatment rate with better patient selection?
• What happens to the side effect profile with re-treatment — is that where the fistulas occurred?
• What happens over time to the cancer that is not ablated?
I confess that I have doubts that the “index lesion hypothesis” is as universally applicable as Emberton seems to believe.

To keep this in perspective, it is worth pointing out that LASTING cancer control has been achieved in intermediate-risk patients with the same favorable side effect profile. At 5 years in in a study of intermediate-risk patients treated with HDR brachy monotherapy:
• 94% were free of biochemical recurrence — much better than HIFU
• Maintenance of potency was equally high (82%)
• Only 2.5% used a pad occasionally or less than once a week among those without prior TURP, stroke or tremor. This is also similar to HIFU.

There are several other focal therapies (cryo, PDT, laser, RF...). They all seem to have about a 20-30% failure rate in favorable risk men. Better technologies are improving outcomes and our understanding is increasing with time, so you are likely to have better outcomes the longer you can put off treatment.

- Allen

George and Tall Allen,

Thanks so much for your responses.

Allen, I am seeing Dr. Behfar Ehdaie who is a colleague of Dr. Coleman at MSKCC and is one of the surgeons involved with Focal Therapies there.

From what I'm reading, focal ablation therapies are showing good promise for intermediate risk men, and even those who are multi-focal, bi-lateral, etc.

However, several questions regarding side effects. I assume since the treatment is focal that the SE's are significantly less profound than current radical treatments---ie, less incontinence, less ED, maintaining some or most of one's ejaculate, etc. (is this last one accurate?).

It seems like this might be a good option for those of us sitting on the fence between treatment and AS.

Thanks again in advance.

Earl96 said...
George and Tall Allen,

Thanks so much for your responses.

Allen, I am seeing Dr. Behfar Ehdaie who is a colleague of Dr. Coleman at MSKCC and is one of the surgeons involved with Focal Therapies there.

From what I'm reading, focal ablation therapies are showing good promise for intermediate risk men, and even those who are multi-focal, bi-lateral, etc.

However, several questions regarding side effects. I assume since the treatment is focal that the SE's are significantly less profound than current radical treatments---ie, less incontinence, less ED, maintaining some or most of one's ejaculate, etc. (is this last one accurate?).

It seems like this might be a good option for those of us sitting on the fence between treatment and AS.

Thanks again in advance.

As someone who had focal treatment 8 years ago the only side effect I have is perhaps a 60% loss of ejaculant volume and a much smaller but still working prostate. My PSA bounces between .12 and .32 annually. My doctor has told me that something will eventually kill me but it won't be PCa. That said as low risk as I was if diagnosed today I would choose AS. But back in 07 -08 that wasn't as proven an option as it is today. People thought I had a death wish when I chose then the new TFT.

Thank you all for your responses.

Allen, thank you for better clarifying this issue.

I think the areas they are going to look at most closely will be;

---Left Base Lateral

---Right Lateral Mid MRI Lesion (MR-F, Vt.)

I don't know where these are in relation to the seminal vesicles---hoping you could educate me.

Ziggy, it is my understanding that the Cryosurgery you had done is different than IRE NanoKnife. The NanoKnife is much more precise---and more men may be eligible for it (i.e, multi-focal, bi-lateral, etc.) than would be for other ablation treatments.

Thanks again in advance.

Whole gland ablation with NanoKnife is only done in Offenbach, Germany to my knowledge.

I would do not go for any focal treatment if both sides of the prostate are involved. Chances are too high that a lesion remains untreated. You may have it treated with SBRT though which I would consider semi-focal.

I agree with you that non-thermal focal ablation (like IRE) may have fewer SEs than thermal focal ablation (like cryo, laser, HIFU and PDT) because of the heat sink effect, but you never know for sure until we get the results in from clinical trials. I was surprised when Coleman reported recurrent disease in the IRE ablation zone. Hopefully, we'll know more in 3-5 years. There is also a vaccine therapy in clinical trial that may extend time on AS, and others are testing the role of hormone therapies, nanoparticles, viruses, etc. Some interesting hypothesis-generating findings on the use of 5ARis (Proscar or Avodart). That's the nice thing about AS - the longer you stay on it, the better the chance a great new therapy will come along.

Among existing therapies, HDR brachy and SBRT have the best records of potency preservation. Some guys get to keep at least some ejaculate, but that's hard to predict.