Focal Therapy for Prostate Cancer

Question 1

Clinical Vignette: A 65-year-old male undergoes radical prostatectomy. The pathology report reveals the presence of multiple lesions, including one that is significantly larger and of a higher grade compared to others.

Question: Which lesion is most likely to determine the grade and stage of this patient’s prostate cancer?

A. The smallest lesion
B. The index lesion
C. A nonindex lesion
D. All lesions equally contribute

Answer 1

Correct Answer: B. The index lesion

Explanation:

A: Incorrect. The smallest lesion is unlikely to determine the grade and stage.
B: Correct. Most of the time, the grade/stage is determined by the index lesion.
C: Incorrect. Only 16% of extracapsular extensions were from nonindex lesions.
D: Incorrect. Most of the tumor volume and grade/stage are contributed by the index lesion.
Memory Tool: Think of the index lesion as the “main character” in the story of prostate cancer.

Reference: Ohori et al. (2006)

Rationale: Understanding the role of the index lesion in prostate cancer helps in better diagnosis and treatment planning.

Question 2

Clinical Vignette: A 70-year-old man with suspected prostate cancer undergoes multiparametric MRI (mpMRI) with gadolinium-based contrast.

Question: What is the primary benefit of using dynamic contrast-enhanced (DCE) imaging in this scenario?

A. Improve the detection of EPE
B. Preferentially detect high-grade lesions
C. Detect lesions in the anterior zone
D. Accurately identify the index lesion

Answer 2

Correct Answer: B. Preferentially detect high-grade lesions

Explanation:

A: Incorrect. Although mpMRI can detect EPE, it’s not the primary benefit of DCE imaging.
B: Correct. DCE imaging preferentially detects larger and higher-grade cancer foci.
C: Incorrect. Anterior zone detection is a benefit but not the primary one for DCE.
D: Incorrect. While mpMRI can identify the index lesion, DCE primarily detects high-grade lesions.
Memory Tool: DCE = “D”etects “C”ritical (high-grade) “E”lements.

Reference: Arumainayagam et al. (2013); Rosenkrantz et al. (2012)

Rationale: Knowing the capabilities of imaging techniques assists in choosing the most appropriate diagnostic method.

Question 3

Clinical Vignette: A 62-year-old man diagnosed with prostate cancer is being considered for focal therapy. Several small, low-grade tumors have been identified in addition to one main lesion.

Question: What volume cutoff is often used to define an insignificant prostate cancer?

A. 1 mL
B. 0.5 mL
C. 2 mL
D. 0.2 mL

Answer 3

Correct Answer: B. 0.5 mL

Explanation:

A, C, D: Incorrect. These are not the established cutoffs for defining insignificant prostate cancer.
B: Correct. An insignificant cancer is often defined using <0.5 mL as a cutoff.
Memory Tool: Think of 0.5 mL as the “Halfway Point to Insignificance.”

Reference: Stamey et al. (1993)

Rationale: Knowing the volume cutoff for insignificant cancer aids in treatment planning and patient counseling.

Question 4

Clinical Vignette: A 58-year-old man undergoes mpMRI to evaluate a suspected prostate malignancy. The radiologist reports that the images have high specificity.

Question: What is the reported range of specificity for mpMRI in the detection of extraprostatic extension (EPE)?

A. 40% to 60%
B. 73% to 91%
C. 20% to 40%
D. 60% to 70%

Answer 4

Correct Answer: B. 73% to 91%

Explanation:

A, C, D: Incorrect. These are not the reported ranges for mpMRI specificity in EPE detection.
B: Correct. The specificity for mpMRI in detecting EPE is between 73% and 91%.
Memory Tool: Think of “Specificity” as a “Specific Range of 73-91.”

Reference: Cerantola et al. (2013); Feng et al. (2015); Kayat Bittencourt et al. (2015); Raskolnikov et al. (2015); Somford et al. (2013)

Rationale: Accurate understanding of imaging specificity is crucial for interpreting diagnostic results.

Question 5

Correct Answer: B. 73% to 91%

Explanation:

A, C, D: Incorrect. These are not the reported ranges for mpMRI specificity in EPE detection.
B: Correct. The specificity for mpMRI in detecting EPE is between 73% and 91%.
Memory Tool: Think of “Specificity” as a “Specific Range of 73-91.”

Reference: Cerantola et al. (2013); Feng et al. (2015); Kayat Bittencourt et al. (2015); Raskolnikov et al. (2015); Somford et al. (2013)

Rationale: Accurate understanding of imaging specificity is crucial for interpreting diagnostic results.

Answer 5

Correct Answer: C. Monitoring PSA levels post-treatment

Explanation:

A, B, D: Correct. These are key components of a successful focal therapy strategy.
C: Incorrect. After focal therapy, PSA is less relevant as its levels are affected by the amount of residual prostate epithelium.
Memory Tool: Post-Focal Therapy, PSA is “Post-Scripted Away.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Understanding the limitations of PSA post-focal therapy helps in choosing more accurate monitoring tools.

Question 6

Question 6: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 68-year-old man has been diagnosed with multifocal prostate cancer. Genetic studies are being considered.

Question: What is suggested about the origin of metastatic or lethal prostate cancer based on genetic studies?

A. Polyclonal origin
B. Biclonal origin
C. Monoclonal origin
D. Multiclonal origin

Answer 6

Correct Answer: C. Monoclonal origin

Explanation:

A, B, D: Incorrect. Genetic studies suggest a monoclonal origin of metastatic or lethal prostate cancer.
C: Correct. Most, if not all, metastatic prostate cancers have a monoclonal origin.
Memory Tool: Metastatic or lethal = “Mono” makes it critical.

Reference: Liu et al. (2009)

Rationale: Understanding the clonal origin can guide targeted therapies and prognostic assessments.

Question 7

Question 7: Topic - Advanced Imaging Techniques in Prostate Cancer
Clinical Vignette: A 60-year-old man with suspected prostate cancer undergoes mpMRI. The radiologist suggests additional imaging for the anterior zone of the prostate.

Question: Why is additional imaging for the anterior zone often recommended?

A. It is highly vascularized
B. It is inaccessible to TRUS biopsy
C. It is prone to calcifications
D. It is usually more malignant

Answer 7

Correct Answer: B. It is inaccessible to TRUS biopsy

Explanation:

A, C, D: Incorrect. These are not the primary reasons for additional imaging of the anterior zone.
B: Correct. Anterior-zone cancers are generally diagnosed late because the location is relatively inaccessible to TRUS biopsy.
Memory Tool: Anterior = “A”ccess “N”ot “T”ypically “E”asy for “R”egular “I”maging or “O”btaining “R”esults.

Reference: Nevoux et al. (2012); Al-Ahmadie et al. (2008); Bott et al. (2002)

Rationale: Being aware of the limitations of TRUS biopsy in the anterior zone can guide better diagnostic planning.

Question 8

Question 8: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 50-year-old man is discussing treatment options for his recently diagnosed prostate cancer. Focal therapy is being considered.

Question: What is the biological basis for considering focal therapy in this patient?

A. All prostate cancers are low-grade
B. The index lesion drives cancer progression
C. Focal therapy treats all lesions equally
D. Secondary cancers are usually high-grade

Answer 8

Correct Answer: B. The index lesion drives cancer progression

Explanation:

A, C, D: Incorrect. These statements are not the basis for considering focal therapy.
B: Correct. The index lesion is the dominant tumor focus that drives cancer progression and metastasis.
Memory Tool: Focal Therapy = Focus on the “Index” for the “Outcome.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Understanding the biological basis for focal therapy helps in choosing the most appropriate treatment modality.

Question 9

Question 9: Topic - Advanced Imaging Techniques in Prostate Cancer
Clinical Vignette: A 72-year-old man is undergoing preprostatectomy mpMRI. The goal is to accurately identify the index lesion.

Question: What is the reported sensitivity of mpMRI for detecting index lesions?

A. 47%
B. 72%
C. 80%
D. 35%

Answer 9

Correct Answer: C. 80%

Explanation:

A, B, D: Incorrect. These are not the reported sensitivities for detecting index lesions.
C: Correct. The sensitivity of mpMRI for detecting index lesions is reported to be 80%.
Memory Tool: “Index” = “80,” both end with the letter “x.”

Reference: Le et al. (2015)

Rationale: Knowing the sensitivity of mpMRI for index lesions assists in its utility for pre-surgical planning.

Question 10

Question 10: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 64-year-old man has successfully undergone prostate focal therapy. Follow-up evaluations are being planned.

Question: Which of the following is NOT recommended for assessing the treated area post-focal therapy?

A. MRI
B. Prostate biopsies
C. PSA levels
D. Clinical examination

Answer 10

Correct Answer: C. PSA levels

Explanation:

A, B, D: Correct. These are recommended for assessing the treated area post-focal therapy.
C: Incorrect. PSA is less relevant for post-focal therapy evaluation as it is affected by the amount of residual prostate epithelium.
Memory Tool: Post-Focal = “PSA Postponed.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing what is not recommended for follow-up assessments post-focal therapy helps in better patient management.

Question 11

Question 11: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 59-year-old man is diagnosed with prostate cancer and is considering focal therapy. His medical team is discussing the strategy for treatment.

Question: What is essential for a successful focal therapy strategy?

A. Only complete ablation of the index lesion
B. A multidisciplinary team and patient compliance
C. Sole reliance on advanced imaging
D. Ignoring secondary cancers

Answer 11

Correct Answer: B. A multidisciplinary team and patient compliance

Explanation:

A, C, D: Incorrect. These are not sufficient alone for a successful focal therapy strategy.
B: Correct. A multidisciplinary team and patient compliance are key components for a successful focal therapy strategy.
Memory Tool: “Multi-Team, Multi-Compliance” for Multi-faceted Success.

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing the key components of a successful focal therapy strategy aids in optimal treatment planning.

Question 12

Question 12: Topic - Advanced Imaging Techniques in Prostate Cancer
Clinical Vignette: A 66-year-old man undergoes mpMRI for evaluation of prostate cancer. The findings suggest the possibility of extraprostatic extension (EPE).

Question: What is the reported positive predictive value (PPV) range for mpMRI in the detection of EPE?

A. 10% to 25%
B. 36% to 85%
C. 50% to 60%
D. 90% to 100%

Answer 12

Correct Answer: B. 36% to 85%

Explanation:

A, C, D: Incorrect. These are not the reported PPV ranges for mpMRI in EPE detection.
B: Correct. The PPV for mpMRI in detecting EPE is between 36% and 85%.
Memory Tool: “PPV for EPE” rhymes with “36 to 85.”

Reference: Cerantola et al. (2013); Feng et al. (2015); Kayat Bittencourt et al. (2015); Raskolnikov et al. (2015); Somford et al. (2013)

Rationale: Understanding the PPV can guide the interpretation and the need for confirmatory tests for EPE.

Question 13

Question 13: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 47-year-old man with localized prostate cancer is exploring focal therapy options. Various ablation technologies are being considered.

Question: Which of the following is NOT an ablation pattern used in focal therapy for prostate cancer?

A. Hemiablation
B. Quadrant ablation
C. Lesion ablation
D. Whole-gland ablation

Answer 13

Correct Answer: D. Whole-gland ablation

Explanation:

A, B, C: Correct. These are patterns of ablation used in focal therapy.
D: Incorrect. Whole-gland ablation is not a focal therapy pattern; it targets the entire gland.
Memory Tool: “Focal is Local; Whole-gland is Grand.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing the various ablation patterns helps in selecting the most appropriate focal therapy method.

Question 14

Question 14: Topic - Advanced Imaging Techniques in Prostate Cancer
Clinical Vignette: A 73-year-old man with suspected prostate cancer is being evaluated. His medical team is considering other imaging modalities besides mpMRI.

Question: What is the miss rate associated with mpMRI for evaluating the prostate gland before focal therapy?

A. 5% to 10%
B. 10% to 15%
C. 20% to 25%
D. 30% to 40%

Answer 14

Correct Answer: B. 10% to 15%

Explanation:

A, C, D: Incorrect. These are not the reported miss rates for mpMRI in evaluating the prostate gland before focal therapy.
B: Correct. The miss rate with mpMRI is 10% to 15%.
Memory Tool: “Miss and mpMRI both start with ‘m’; the rate is 10 to 15.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Awareness of the limitations of mpMRI aids in the need for complementary diagnostic methods.

Question 15

Question 15: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 52-year-old man has recently undergone focal therapy for prostate cancer. His healthcare team is planning future research endeavors.

Question: What should future research in focal therapy for prostate cancer focus on?

A. Completely replacing whole-gland treatment
B. Ignoring the role of imaging
C. Better patient selection and cost-effectiveness studies
D. Limiting the use of ablation technologies

Answer 15

Correct Answer: C. Better patient selection and cost-effectiveness studies

Explanation:

A, B, D: Incorrect. These are not the recommended focuses for future research in focal therapy.
C: Correct. Future research should focus on better patient selection using clinical, imaging, and/or genetic biomarkers, and cost-effectiveness studies.
Memory Tool: “Future is Focused on the Finest and Most Feasible.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing the direction of future research can help in anticipating advancements in focal therapy.

Question 16

Question 16: Topic - Advanced Imaging Techniques in Prostate Cancer
Clinical Vignette: A 67-year-old man with suspected prostate cancer undergoes mpMRI. The radiologist also considers using multiparametric ultrasonography or PSMA-PET CT/MRI for further evaluation.

Question: Which of the following statements is true regarding the role of mpMRI in prostate focal therapy?

A. mpMRI has fully replaced systematic biopsy
B. mpMRI has a key role but systematic biopsy remains necessary
C. mpMRI is not recommended for focal therapy
D. mpMRI has no miss rate

Answer 16

Correct Answer: B. mpMRI has a key role but systematic biopsy remains necessary

Explanation:

A, C, D: Incorrect. These statements are not true regarding the role of mpMRI in focal therapy.
B: Correct. mpMRI has become a key enabler for prostate focal therapy, but a 10% to 15% miss rate means systematic biopsy remains necessary.
Memory Tool: mpMRI is “Major but Misses a Minor.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Understanding the limitations of mpMRI can guide better diagnostic and therapeutic decision-making.

Question 17

Clinical Vignette: A 63-year-old man who has undergone focal therapy for prostate cancer is due for a follow-up. His healthcare team discusses the monitoring strategy.

Question: What is less relevant in evaluating therapeutic success after focal therapy?

A. MRI
B. Prostate biopsies
C. PSA levels
D. Clinical examination

Answer 17

Correct Answer: C. PSA levels

Explanation:

A, B, D: Correct. These are recommended for evaluating therapeutic success after focal therapy.
C: Incorrect. PSA levels are less relevant because they are affected by the amount of residual prostate epithelium.
Memory Tool: “Post-Focal, Put PSA Aside.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing the limitations of PSA in the post-focal therapy setting aids in better patient management.

Question 18

Clinical Vignette: A 55-year-old man is considering focal therapy for prostate cancer. The healthcare team discusses the choice of ablative technology.

Question: Which of the following is NOT a consideration in choosing the ablative technology for focal therapy?

A. Location of the tumor
B. Desired ablative technology
C. Patient’s age
D. Anatomic considerations

Answer 18

Correct Answer: C. Patient’s age

Explanation:

A, B, D: Correct. These are considerations in choosing the ablative technology.
C: Incorrect. Patient’s age is not specifically mentioned as a consideration for choosing ablative technology in focal therapy.
Memory Tool: “Ablation without Age-ation.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Understanding the considerations for choosing ablative technology ensures optimal treatment planning.

Question 19

Question 19: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 61-year-old man with prostate cancer undergoes focal therapy. The medical team is considering future targeted treatment options.

Question: What is the post-treatment strategy after focal therapy?

A. Ignoring persistent or de novo disease
B. Converting to whole-gland treatment as necessary
C. No further monitoring is required
D. Focusing only on PSA levels

Answer 19

orrect Answer: B. Converting to whole-gland treatment as necessary

Explanation:

A, C, D: Incorrect. These are not the recommended post-treatment strategies after focal therapy.
B: Correct. The post-treatment strategy includes future targeted treatment of either persistent or de novo disease, or conversion to whole-gland treatment as necessary.
Memory Tool: “Focal to Whole, if the Situation Unfolds.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing the post-treatment strategy is crucial for long-term patient management.

Question 20

Question 20: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A research team is planning a study on the efficacy of focal therapy in prostate cancer. They aim to improve patient selection.

Question: What should be the focus of future research endeavors in focal therapy?

A. Replacing other treatment modalities
B. Ignoring the role of imaging
C. Better patient selection and cost-effectiveness
D. Limiting the use of advanced imaging

Answer 20

Question 20: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A research team is planning a study on the efficacy of focal therapy in prostate cancer. They aim to improve patient selection.

Question: What should be the focus of future research endeavors in focal therapy?

A. Replacing other treatment modalities
B. Ignoring the role of imaging
C. Better patient selection and cost-effectiveness
D. Limiting the use of advanced imaging

Question 21

Question 21: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 58-year-old man with prostate cancer is being counseled about treatment options. The possibility of focal therapy is discussed.

Question: What is the biologic basis of focal therapy in prostate cancer?

A. The index lesion is usually low-grade
B. All prostate cancers are multifocal
C. The index lesion drives cancer progression and metastasis
D. Secondary cancers are usually more aggressive

Answer 21

Correct Answer: C. The index lesion drives cancer progression and metastasis

Explanation:

A, B, D: Incorrect. These statements do not represent the biologic basis for focal therapy.
C: Correct. The index lesion is the dominant tumor focus that drives cancer progression and metastasis.
Memory Tool: “Index is the Instigator.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Understanding the biologic basis helps in selecting appropriate treatment modalities for prostate cancer.

Question 22

Question 24: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 64-year-old man has undergone focal therapy for prostate cancer. The medical team is planning post-treatment monitoring.

Question: Which of the following is recommended to assess the untreated (outfield) area after focal therapy?

A. Only PSA levels
B. MRI and prostate biopsies
C. Clinical examination alone
D. No further assessment is needed

Answer 22

orrect Answer: B. MRI and prostate biopsies

Explanation:

A, C, D: Incorrect. These are not the recommended methods for assessing the untreated area post-focal therapy.
B: Correct. MRI and prostate biopsies are recommended to assess both the treated (infield) and untreated (outfield) areas.
Memory Tool: “For Outfield Assessment, Bring in Both MRI and Biopsies.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing the recommended post-treatment assessments can guide long-term patient management.

Question 23

Question 25: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 49-year-old man with prostate cancer is considering focal therapy. He inquires about the patterns in which focal therapy can be applied.

Question: Which of the following is a pattern of focal therapy?

A. Whole-gland ablation
B. Quadrant ablation
C. Global ablation
D. Peripheral ablation

Answer 23

Correct Answer: B. Quadrant ablation

Explanation:

A, C, D: Incorrect. These are not patterns of focal therapy.
B: Correct. Focal therapy can be applied in various patterns including quadrant ablation.
Memory Tool: “Quadrant for Quality Control in Focal Therapy.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing the patterns of focal therapy helps in discussing treatment options with patients.

Question 24

Question 26: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 57-year-old man with prostate cancer is exploring treatment options. Focal therapy is discussed, and the team considers the patient’s compliance for follow-up.

Question: What is crucial for the success of a focal therapy strategy?

A. Patient’s age
B. Complete reliance on imaging
C. Patient compliance to follow-up
D. Immediate conversion to whole-gland treatment

Answer 24

Correct Answer: C. Patient compliance to follow-up

Explanation:

A, B, D: Incorrect. These factors are not crucial for the success of a focal therapy strategy.
C: Correct. A successful focal therapy strategy depends on patient compliance to follow-up.
Memory Tool: “Compliance Completes the Focal Circle.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Understanding the importance of patient compliance helps in patient selection for focal therapy.

Question 25

Question 27: Topic - Advanced Imaging Techniques in Prostate Cancer
Clinical Vignette: A 65-year-old man is suspected of having anterior zone prostate cancers. His medical team is discussing diagnostic strategies.

Question: What advantage does mpMRI offer in diagnosing anterior zone prostate cancers?

A. It is less sensitive in the anterior zone
B. It improves the detection of anterior zone prostate cancers
C. It cannot detect cancers in the anterior zone
D. It has no advantages in the anterior zone

Answer 25

Correct Answer: B. It improves the detection of anterior zone prostate cancers

Explanation:

A, C, D: Incorrect. These statements are not true regarding mpMRI in diagnosing anterior zone prostate cancers.
B: Correct. mpMRI improves the detection of anterior zone prostate cancers.
Memory Tool: “Anterior Attention Amplified by mpMRI.”

Reference: Nevoux et al. (2012); Al-Ahmadie et al. (2008); Bott et al. (2002)

Rationale: Knowing the advantages of mpMRI in the anterior zone aids in diagnostic planning.

Question 26

Question 28: Topic - Focal Therapy for Prostate Cancer
Clinical Vignette: A 60-year-old man who has undergone focal therapy for prostate cancer is due for a follow-up. His PSA levels are found to be elevated.

Question: What is the relevance of elevated PSA levels after focal therapy?

A. Highly relevant, indicative of therapeutic failure
B. Not relevant due to residual prostate epithelium
C. Only relevant if accompanied by symptoms
D. Always indicates a need for immediate whole-gland treatment

Answer 26

Correct Answer: B. Not relevant due to residual prostate epithelium

Explanation:

A, C, D: Incorrect. Elevated PSA levels are not necessarily indicative of therapeutic failure or a need for whole-gland treatment after focal therapy.
B: Correct. Elevated PSA levels are less relevant after focal therapy as they are affected by the amount of residual prostate epithelium.
Memory Tool: “Post-Focal PSA? Partially Pointless.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Understanding the limitations of PSA post-focal therapy helps in better patient management.

Question 27

Correct Answer: B. Not relevant due to residual prostate epithelium

Explanation:

A, C, D: Incorrect. Elevated PSA levels are not necessarily indicative of therapeutic failure or a need for whole-gland treatment after focal therapy.
B: Correct. Elevated PSA levels are less relevant after focal therapy as they are affected by the amount of residual prostate epithelium.
Memory Tool: “Post-Focal PSA? Partially Pointless.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Understanding the limitations of PSA post-focal therapy helps in better patient management.

Answer 27

Correct Answer: A. Laser

Explanation:

B, C, D: Incorrect. These are not commonly used as ablative technologies in focal therapy.
A: Correct. Laser is one of the ablative technologies used in focal therapy.
Memory Tool: “Laser Lights the Way in Focal Therapy.”

Reference: Campbell’s Urology textbook 12th edition

Rationale: Knowing the types of ablative technologies can guide discussions on treatment options.