Recent advances in multiparametric MRI of the prostate allow identification of focal prostate cancer
with high sensitivity and specificity. As prostate cancer becomes visible by new imaging techniques, a
shift in treatment strategies occurs. Rather than radical “whole-gland” elimination triggered by positive
results obtained during multiple blind transrectal biopsies, targeted biopsy and focal therapy is
achievable and moves the treatment of prostate cancer into more traditional patterns of cancer
diagnosis and care, such as that seen with breast imaging and lung cancer CT screening.
Recent multicenter trials in Europe and the US, including the most recent PIVOT trial indicate that, in the
setting of biopsy-proven non-aggressive prostate cancer, the 10 year mortality is no different in men
who undergo radical prostatectomy versus surveillance. Given the indolent behavior of most prostate
cancers and the life-changing complications of whole gland therapies or prostatectomy, a focal tumor
ablation method with fewer side effects and shorter recovery is a welcome alternative.
Laser interstitial tumor therapy (LITT) is used in several areas for tumor treatment and for control of
seizure foci in patients with refractory epilepsy. The Visualase laser ablation system in use at UTMB
consists of 30 watt diode lasers tuned to 980nm and proprietary software which enables MRI
thermometry or real-time temperature measurement during tumor ablation using a special MRI
sequence. Interventional radiologists at UTMB have experience in treating over 30 patients with LITT,
including cancers in the kidney, liver, prostate and lung.
This newer thermal ablative technique is cleared by the FDA for human use and seems especially suited
for prostate cancer for three main reasons:
1) Laser ablation is carried out in MRI which is the only modality able to visualize prostate cancer
with sufficient sensitivity and specificity (around 90%).
2) Lasers create a very focal ablation with a sharp margin. This increases safety particularly around
the neurovascular bundles (responsible for micturation and sexual function) which frequently
lay close to prostate tumors in the peripheral zone.
3) MRI sequences can show tissue temperature in real-time. Therefore, the extent of tumor
ablation is visible as it occurs.
4) The ablation time for laser is very short (90 sec to 3 minutes)
5) There is some evidence that laser ablation may cause immunostimulation of the host against
remaining or recurrent tumor cells
I recently imaged and counseled a member of your company with a diagnosis of low or intermediate
grade prostate cancer. He received the standard urologic recommendations regarding this disease,
including radical or robotic prostatectomy, radiation therapy (brachytherapy, IMRT, or proton beam
therapy), or active surveillance, including transrectal biopsies and clinical examination on a yearly basis
I believe that your employee is a good candidate for laser ablation of his prostate cancer (LITT or laser
interstitial thermal therapy) as he has a focal, low grade, unilateral lesion, visible by MRI and confined to
the prostate.
Why is my procedure a better choice?
1) LITT poses a very low risk of lifestyle altering complications, such as impotence and incontinence
(less than 5% as opposed to the surgical risk which exceeds 20%)
2) It is usually performed as an outpatient procedure, allowing return to work within a few days
3) It is lower cost compared to surgery and radiation therapy due to fewer inpatient days and
clinic/hospital visits consumed treating complications
4) It is lower cost and improved safety compared to active surveillance as the follow up is based on
MRI rather than repeated yearly transrectal biopsies.
5) It treats a visible cancer rather than an entire gland that is always riddled with insignificant
cancers as we age. It is a fact that we over-treat prostate cancer in men at tremendous cost and
infliction of serious complications. If prostate MRI is normal, we feel that no biopsy or treatment
is needed. Random biopsy of the prostate almost always finds cancers- many insignificant- and
usually provokes unnecessary treatment.
6) It can be repeated if new cancers arise. The option of prostatectomy remains if LITT fails.
Radiation therapy or resection destroys all future surgical options.
In summary, we feel that the cost and effectiveness of LITT over other options should persuade you to
reimburse for this procedure.