Prostate Artery Embolization in the Setting of Prostate Cancer: Review and Opinion

Abstract

Prostate Artery Embolization (PAE) is a novel minimally invasive angiographic technique that has been used effectively to treat men with lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH). However, applications of PAE for men with prostate cancer have been minimally studied. This review serves as an update on the status of PAE in men with prostate cancer, as well as a discussion of emerging indications.

Keywords: definitive radiotherapy; emerging indications; prostate artery embolization; prostate cancer.

Figure 1.

Comparison of pre- and post-PAE images demonstrating peri-urethral necrosis (“black hole” phenomenon). (A): Pre-embolization, axial post-contrast T1 fat-saturated (FS) large field of view (FOV) MR images demonstrate homogenous enhancement throughout the prostatic parenchyma, notably within the peri-urethral transition zone (TZ) (white arrow). Baseline prostate volume in this patient was 180 cc. (B): 12 weeks post-embolization, axial post-contrast T1-FS large FOV MR images demonstrate peri-urethral necrosis with “black-hole” appearance that represents devascularized prostatic parenchyma. 12-week post PAE volume in this patient was 66 cc, representing 63% prostate volume reduction.

Figure 2.

Flowchart of clinical indications for PAE Indications for PAE in the setting of prostate cancer are classified by relation to timing of definitive therapy. Prior to definitive therapy, neoadjuvant PAE for LUTS improvement or volume reduction represent particularly impactful indications. After definitive therapy, men with medically recalcitrant CP/CPPS can benefit greatly from PAE. Of note, no role has been identified for PAE prior to prostatectomy in men with prostate cancer.

Figure 3.

Example patient undergoing neoadjuvant PAE prior to XRT. 66 yo man with GGG2 prostate cancer and baseline AUA, QoL, PV of 16, 4 and 101 cc, respectively on dual medical therapy (A). 12 weeks post PAE patient’s AUA was 2 and he has been weaned off urinary medications, (B) PV 65 cc (40% reduction) patient began standard fractionation external beam radiotherapy with 7800 cGy in 39 fractions. Left transition zone is almost entirely necrosed (yellow arrow). At 1.5 years post XRT, patient has AUA 12 and QoL of 1 and remains off of urinary medications.