Multiparametric MRI before and after Focal Therapy for Prostate Cancer: Pearls and Pitfalls for the Reporting Radiologist

Sep 23, 2026

Uploaded by Aurelia

The review addresses how to use multiparametric MRI (mpMRI) for prostate cancer assessment before and after focal therapy, focusing on accurate detection of low-volume clinically significant disease and effective posttreatment surveillance. It emphasizes that radiologists must recognize expected post–focal therapy changes and common pitfalls when evaluating possible recurrence. The article discusses pretreatment mpMRI roles in patient selection and treatment planning, covers commonly used focal modalities, and reviews standardized assessment systems such as PI-FAB and TARGET.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages14

Reading Time35 min

AccessFree to download

Review

Oncologic Basis of Focal Therapy

Role of Multiparametric MRI in Prostate Cancer Surveillance After Focal Therapy

REVIEW Multiparametric MRI before and after Focal Therapy for Prostate Cancer: Pearls and Pitfalls for the Reporting Radiologist Anna L. Lai, MBChB, FRCR1 • Jyothirmayi Velaga, MBBS, DNB, EDiR, FRCR, FRANZCR2 • Kae Jack Tay, MBBS, MRCS (Ed), MMed (Surgery), MCI, FAMS (Urology)3 • Guanqi Hang, MD1 • Yu Guang Tan, MBBS, MRCS (Ed), MCI, FAMS (Urology)3 • John S. P. Yuen, MBBS, MMed (Surgery), MRCS (Edin), FAMS (Urology), DPhil (Oxon)3 • Christopher W. S. Cheng, MBBS, FRCS (Edin & Glasg), MMed (Surg), FAMS (Urology)3 • Nye Thane Ngo, MBBS, MRCP, FRCPath4 • Yan Mee Law, MBBS, FRCR1 Author affiliations, funding, and conflicts of interest are listed at the end of this article. Radiology: Imaging Cancer 2025; 7(2):e240269 • [https://doi.org/10.1148/rycan.240269](https://doi.org/10.1148/rycan.240269) • Content codes: In this era of personalized precision medicine, the accuracy of multiparametric MRI (mpMRI) and targeted biopsy in helping detect low-volume clinically significant prostate cancer has rekindled interest in focal therapy for primary prostate cancer. Such therapy may reduce the debilitating morbidity of radical whole-gland treatment. Post–focal therapy mpMRI surveillance is critical for assessing oncologic efficacy. Radiologists interpreting post–focal therapy mpMRI must be familiar with expected posttreatment changes and pitfalls in assessing posttreatment recurrence. In this review, the authors present their experience with mpMRI before and after focal therapy. While cryotherapy and irreversible electroporation are the primary modalities of focal therapy offered in their institution, the authors aim to provide a comprehensive overview of the more common focal therapy modalities in use. Pertinent considerations of mpMRI in pretreatment patient selection and treatment planning are discussed. The recently proposed standardized post–focal therapy assessment systems, Prostate Imaging after Focal Ablation (ie, PI-FAB) and Transatlantic Recommendations for Prostate Gland Evaluation with MRI after Focal Therapy (ie, TARGET), as well as pearls and pitfalls in the detection of tumor recurrence and medium-and long-term mpMRI surveillance of the post–focal therapy prostate, are also discussed. This review aims to provide a valuable reference for radiologists involved in the care of patients in the evolving field of prostate cancer focal therapy. Published under a CC BY 4.0 license. Oncologic Basis of Focal Therapy Whole-gland treatment approaches such as radical prostatectomy and radiation therapy have long been regarded asthe reference standard of definitive treatment of prostate cancer, with robust long-term oncologic outcome data (1) . However, these interventions are associated with substantial morbidities, including urinary incontinence and erectile dysfunction (2) . To reduce overtreatment of prostate cancer, active surveillance was introduced 2 decades ago, where patients with low-risk or favorable intermediate-risk disease are closely monitored and undergo definitive treatment only when more aggressive disease manifests. While active surveillance is a reasonable option for low-grade, localized cancers, controversy remains over whether patients with intermediate-risk disease are suitable candidates. Besides the risk of progressive disease, active surveillance is disadvantageous, as patients are subjected to frequent follow-up visits, repeat imaging and biopsies, and anxiety and financial strain (2) . Consequently, various focal therapy options have been explored in an attempt to find a middle ground between wholegland therapy and active surveillance. Considerable evidence suggests that although prostate cancer is often multifocal, it is the pathologic characteristics of the largest or most aggressive cancer focus (index lesion) that determines tumor progression and metastasis risk (3,4) . It may therefore be sufficient to treat the index lesion and adopt active surveillance for the remaining low-risk lesion

FAQs

Why is multiparametric MRI important after focal therapy for prostate cancer?

Post–focal therapy mpMRI surveillance is critical for assessing oncologic efficacy. Radiologists must understand expected posttreatment changes and pitfalls to correctly evaluate recurrence.

Why is PSA less reliable after focal therapy?

PSA is produced by substantial residual prostate tissue after focal treatment, so PSA levels can remain informative for non-recurrence reasons. False-positive PSA “bounces” unrelated to tumor can occur.

What surveillance approaches are discussed beyond PSA and routine biopsy?

The review notes that guidelines often advocate protocol ablation zone biopsies, but these carry risks and may have poor compliance. It highlights the need for noninvasive, reliable surveillance, supported by concepts such as multifocal disease and residual untreated gland.

Sep 23, 2026

Uploaded by Aurelia