Multifocal prostate cancer is defined as the presence of multiple distinct cancerous foci within the prostate.
Multifocal prostate cancer Is a common finding that complicates treatment planning due to the potential for both indolent and aggressive disease within the same gland.
This heterogeneity underscores the need for individualized management, risk stratification and advanced imaging.
Initial assessment should include PSA measurement, digital rectal exam, and multiparametric MRI (mpMRI) for local disease characterization, with PSMA PET/CT recommended for accurate staging and detection of metastatic or regional disease.
Microscopic grading and genomic testing, and testing for DNA repair gene mutations is considered in determining treatments.
For localized multifocal prostate cancer, treatment is based on risk category:
Low-risk disease is typically managed with active surveillance, given the low likelihood of progression.
Intermediate- and high-risk disease generally warrants radical prostatectomy or definitive radiotherapy.
Locally advanced, regional (N1), and oligometastatic disease require multimodal therapy.
The National Comprehensive Cancer Network (NCCN) recommends androgen deprivation therapy (ADT) plus external beam radiotherapy (EBRT), with consideration of systemic agents such as abiraterone, apalutamide, enzalutamide, or docetaxel for higher-risk or metastatic cases.
EBRT to the primary tumor may benefit patients with low-volume metastatic disease.
For high-volume or widespread metastatic disease, systemic therapy is standard: ADT combined with docetaxel, abiraterone, darolutamide, apalutamide, or enzalutamide, with PARP inhibitors reserved for mCRPC patients with homologous recombination repair (HRR) mutations.
Follow-up should include regular PSA testing, imaging, and clinical assessment as per NCCN guidelines.