Salvage high-intensity focused ultrasound (S-HIFU) for recurrence after primary radiotherapy of prostate cancer

OBJECTIVES

To evaluate functional and oncological outcomes of salvage high-intensity focal ultrasound (S-HIFU) after external beam radiotherapy (EBRT) failure in prostate cancer (PCa) patients.

METHODS

This single-center study included patients who underwent S-HIFU for local recurrence after EBRT between 2006 and 2023. Cancer-specific survival, metastasis-free survival and progression-free survival were illustrated using Kaplan-Meier curves. Disease progression was defined by one of the following criteria: increase of 2ng/mL or more above the PSA nadir, positive post-S-HIFU biopsy or initiation of androgen deprivation therapy (ADT). Multivariable Cox proportional hazards model was used to identify predictors of disease progression after S-HIFU.

RESULTS

A total of 52 S-HIFU sessions for 48 patients were performed. Median time between EBRT and S-HIFU was 6.5 years. Median PSA before S-HIFU was 3.2ng/mL and median PSA nadir after S-HIFU was 0.58ng/mL. A total of 39 (81.3%) complications was recorded, including 3 (6.3%) high grade complications according to the Clavien-Dindo classification. After a median follow-up period of 6 years, 14 (29.2%) patients developed metastatic disease. Eighteen (37.5%) patients had no recurrence, whereas 30 (62.5%) patients received ADT for disease progression. The estimated 5-yr cancer-specific survival (CSS), metastasis-free survival (MFS) and progression-free survival rates (PFSR) were 100%, 79.9% (95% CI 67-92) and 41.2% (95% CI 74-96), respectively. The estimated 10-yr CSS, MFS and PFSR were 80% (95% CI 45-100), 50.7% (95% CI 19.4-82.1) and 14% (95% CI 10.8-45), respectively. The hazard of progression increased with the intermediate (HR 3.8; 95% CI 0.99 to 15; p=0.049) and high pre-EBRT d'Amico-s risk group (HR 4.1; 95% CI 0.98 to 16.2; p=0.050). Also, the time between EBRT and S-HIFU was significantly associated with risk of progression (HR 0.61; 95% CI 0.43 to 0.86; p=0.004). No significant difference linked to the disease progression (DP) risk was found between focal vs whole-gland treatment (p=0.70).

CONCLUSION

Physicians should consider HIFU as a local salvage treatment after failed EBRT, thus avoiding or delaying palliative androgen deprivation therapy. Further studies are needed to improve patient selection for this therapy.

LEVEL OF EVIDENCE: 4

Focal high-intensity focused ultrasound therapy for localized prostate cancer: An interim analysis of the multinational FASST study

BACKGROUND

High-intensity focused ultrasound (HIFU) emerged as a novel approach for the treatment of localized prostate cancer (PCa). However, prospective studies on HIFU-related outcomes and predictors of treatment failure (TF) remain scarce.

MATERIALS AND METHODS

We conducted a multinational prospective cohort study among patients undergoing HIFU therapy for localized, low- to intermediate-risk PCa. Follow-up data on serial prostate specific antigen (PSA), multi-parametric magnetic resonance imaging (mpMRI), targeted/systematic biopsies, adverse events and functional outcomes were collected. The primary endpoint was TF, defined as histologically confirmed PCa requiring whole-gland salvage treatment. Uni- and multi-variable adjusted hazard ratios (HRs) were calculated using Cox proportional hazard regression models.

RESULTS

At baseline, mean (standard deviation) age was 64.14 (7.19) years, with the majority of patients showing T-stage 1 (73.9%) and International Society of Urological Pathology grading system Grade 2 (58.8%). PSA nadir (median, 1.70 ng/mL) was reached after 6 months. Of all patients recruited, 16% had clinically significant PCa, as confirmed by biopsy, of which 13.4% had TF. Notably, T-stage and number of positive cores at initial biopsy were independent predictors of TF during follow-up (HR [95% CI] 1.27 [1.02-1.59] and 5.02 [1.80-14.03], respectively). Adverse events were minimal (17% and 8% early and late adverse events, respectively), with stable or improved functional outcomes in the majority of patients.

CONCLUSIONS

This interim analysis of a multinational study on HIFU therapy for the management of low-to-intermediate-risk PCa reveals good functional outcomes, minimal adverse events and low incidence of TF over the short-term. Data on long-term outcomes, specifically as it relates to oncological outcomes, are awaited eagerly.

High-intensity focused ultrasound with visually directed power adjustment for focal treatment of localized prostate cancer: systematic review and meta-analysis

PURPOSE

To characterize patient outcomes following visually directed high-intensity focused ultrasound (HIFU) for focal treatment of localized prostate cancer.

METHODS

We performed a systematic review of cancer-control outcomes and complication rates among men with localized prostate cancer treated with visually directed focal HIFU. Study outcomes were calculated using a random-effects meta-analysis model.

RESULTS

A total of 8 observational studies with 1,819 patients (median age 67 years; prostate-specific antigen 7.1 mg/ml; prostate volume 36 ml) followed over a median of 24 months were included. The mean prostate-specific antigen nadir following visually directed focal HIFU was 2.2 ng/ml (95% CI 0.9-3.5 ng/ml), achieved after a median of 6 months post-treatment. A clinically significant positive biopsy was identified in 19.8% (95% CI 12.4-28.3%) of cases. Salvage treatment rates were 16.2% (95% CI 9.7-23.8%) for focal- or whole-gland treatment, and 8.6% (95% CI 6.1-11.5%) for whole-gland treatment. Complication rates were 16.7% (95% CI 9.9-24.6%) for de novo erectile dysfunction, 6.2% (95% CI 0.0-19.0%) for urinary retention, 3.0% (95% CI 2.1-3.9%) for urinary tract infection, 1.9% (95% CI 0.1-5.3%) for urinary incontinence, and 0.1% (95% CI 0.0-1.4%) for bowel injury.

CONCLUSION

Limited evidence from eight observational studies demonstrated that visually directed HIFU for focal treatment of localized prostate cancer was associated with a relatively low risk of complications and acceptable cancer control over medium-term follow-up. Comparative, long-term safety and effectiveness results with visually directed focal HIFU are lacking.

ASO Author Reflections: High-Intensity Focused Ultrasound will Become the Routine Practice for Treatment of Localized Prostate Cancer

PAST: Most prostate cancers are slow growing and are often diagnosed at an old age, which may result in treatment never being needed. However, definitive treatments such as radical prostatectomy and radiation therapy are often associated with many serious adverse effects, harming the physical and mental health of patients. PRESENT: In recent years, different types of minimally invasive therapy have been developed to achieve cancer control, continence, and even potency preservation, such as high-intensity focused ultrasound (HIFU). HIFU has been proposed for prostate cancer patients to provide an equivalent oncologic result to definitive treatment, with a reduced adverse effect profile, thus increasing the interest in HIFU for the treatment of localized prostate cancer. FUTURE: Sonablate® HIFU performed an outstanding cancer control in treating localized prostate cancer, with low biochemical recurrence and complication rates. As further long-term follow-up data mature, we anticipate the routine application of HIFU for localized prostate cancer within the next few years.

Single-center, prospective phase 2 trial of high-intensity focused ultrasound (HIFU) in patients with unilateral localized prostate cancer: good functional results but oncologically not as safe as expected

PURPOSE

Focal therapy (FT) for localized prostate cancer (PCa) is only recommended within the context of clinical trials by international guidelines. We aimed to investigate oncological follow-up and safety data of focal high-intensity focused ultrasound (HIFU) treatment.

METHODS

We conducted a single-center prospective study of 29 patients with PCa treated with (focal) HIFU between 2016 and 2021. Inclusion criteria were unilateral PCa detected by mpMRI-US-fusion prostate biopsy and maximum prostate specific antigen (PSA) of 15 ng/ml. Follow-up included mpMRI-US fusion-re-biopsies 12 and 24 months after HIFU. No re-treatment of HIFU was allowed. The primary endpoint was failure-free survival (FFS), defined as freedom from intervention due to cancer progression.

RESULTS

Median follow-up of all patients was 23 months, median age was 67 years and median preoperative PSA was 6.8 ng/ml. One year after HIFU treatment PCa was still detected in 13/ 29 patients histologically (44.8%). Two years after HIFU another 7/29 patients (24.1%) were diagnosed with PCa. Until now, PCa recurrence was detected in 11/29 patients (37.93%) which represents an FFS rate of 62%.One patient developed local metastatic disease 2 years after focal HIFU. Adverse events (AE) were low with 70% of patients remaining with sufficient erectile function for intercourse and 97% reporting full maintenance of urinary continence.

CONCLUSION

HIFU treatment in carefully selected patients is feasible. However, HIFU was oncologically not as safe as expected because of progression rates of 37.93% and risk of progression towards metastatic disease. Thus, we stopped usage of HIFU in our department.

Transrectal high-intensity focused ultrasound (HIFU) for management of rectosigmoid deep infiltrating endometriosis: results of Phase-I clinical trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) of the rectosigmoid is associated with painful symptoms. When medical treatment is ineffective, surgical resection remains the standard treatment, despite significant risk of adverse events. High-intensity focused ultrasound (HIFU) is a minimally invasive ablative procedure. Focal One® is a transrectal HIFU (TR-HIFU) device used in prostate cancer treatment. The primary objective of this study was to confirm the feasibility of treatment with TR-HIFU in patients presenting with posterior DIE with rectosigmoid involvement. We also assessed its safety and clinical efficacy in this context.

METHODS

This was a non-controlled, prospective, Phase-I clinical trial in a French University Hospital which is a multidisciplinary center for management of endometriosis. Included were patients older than 25 years, without plans to conceive within 6 months, who presented with a single lesion of posterior DIE, with rectosigmoid invasion, after failure of hormonal therapy. All lesions were assessed preoperatively using transvaginal sonography and magnetic resonance imaging. Patients completed questionnaires on gynecological and intestinal symptoms (similar to a visual analog scale (VAS)), and on quality of life (Medical Outcomes Study 36-item short-form survey (SF-36) and, for the second half of patients recruited, symptom scoring system for constipation (KESS), female sexual function index (FSFI) and endometriosis health profile short-version score (EHP-5)), before, and at 1, 3 and 6 months after, TR-HIFU treatment with a Focal One real-time ultrasound-guided HIFU device.

RESULTS

Twenty-three consecutive patients were included in the study between September 2015 and October 2019. All 23 lesions were visualized, giving a detection rate of 100%. Twenty lesions were treated ('feasibility rate', 87.0%): in 13 the whole lesion was treated and in seven the lesion was treated partially. The mean duration of the TR-HIFU procedure was 55.6 min. We observed a significant improvement in VAS score at 6 months, with differences relative to preoperative scores as follows, for: dysmenorrhea (-3.6, P = 0.004), dyspareunia (-2.4, P = 0.006), diarrhea (-3.0, P = 0.006), constipation (-3.0, P = 0.002), dyschezia (-3.2, P = 0.003), false urge to defecate (-3.3, P = 0.007), posterior pelvic pain (-3.8, P = 0.002) and asthenia (-3.8, P = 0.002). There was also a significant improvement in the SF-36 score, with an increase at 6 months relative to the preoperative score in both the physical component summary (+ 9.3%, P = 0.002) and mental component summary (+ 10.9%, P = 0.017). No major complications occurred during or after any procedure.

CONCLUSIONS

TR-HIFU therapy for posterior DIE is feasible. If its efficacy and safety are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

[The correlation of PSA-nadir PS recurrence after total HIFU-ablation in patients with localized prostate cancer]

OBJECTIVE

To study the survival rate of patients without biochemical recurrence according to the Stuttgart and Phoenix criteria in terms of their correlation with four different PSA nadir values as predictors of clinical recurrence in patients with localized prostate cancer who underwent total HIFU prostate ablation.

MATERIAL AND METHODS

The object of the study was patients with morphologically proven localized RP by biopsy results, who were treated with prostate cancer by HIFU ablation on the Ablatherm Integrated Imaging apparatus (EDAP TMS, France). The study included 658 patients in whom HIFU ablation was used as primary treatment of localized prostate cancer (stages T1 - T2) without previous use of other methods (hormonal, radiation therapy) For the analysis, a continuous sample of patients was selected, which were divided into four groups depending on the PSA nadir level: less or equal 0.2 ng / ml (1 group), 0.21-0.5 ng / ml (group 2), 0.51-1 ng / ml (group 3) and> 1 ng / ml (group 4). sensitivity, specificity, predictive value, and 5-year biochemical relapse-free survival according to the Stuttgart definition and the Phoenix definition in the PSA nadir groups.

RESULTS

The median (range) of the observation period for the patients was 5.3 (3-7) years, the mean time to reaching PSA nadir was 14.5+/-2.6 weeks. PSA nadirs less or equal 0.2, 0.21-0.5, 0.51-1.0 and > 1 ng/ml were achieved in 231 (35.1%), 132 (20.0%), 105 (15, 9%) and 190 (28.8%) patients, respectively. Survival without biochemical relapse in accordance with the Stuttgart definition in the four groups allocated for the PSA nadir was 82, 65, 43 and 32%, respectively (p<0.001), according to the Phoenix definition - 94, 74, 66 and 47% (p<0.001) respectively. According to the results of the control biopsy, 601 (91.3%) patients in the 1st and 2nd groups had a negative oncological status (approximately 85%).

CONCLUSION

This study confirms that PSA nadir after HIFU ablation predicts biochemical recurrence-free survival and is a reliable marker that is easy to integrate into routine clinical practice.

[Clinical, morphological and microcirculatory criteria of local recurrence of the prostate cancer after HIFU therapy]

AIM

to study the clinical, morphological and microcirculatory criteria for treatment efficiency and prognosis of local recurrence after HIFU.

MATERIALS AND METHODS

On the basis of the urological department of Clinical Hospital "Russian Railways - Medicine" in Barnaul (the clinical base of the Department of Urology and Andrology with a course of Specialized Surgery of FGBOU VO "Altai State Medical University") for the period 2011-2018, a comprehensive examination and treatment of 240 patients with prostate cancer (PCa) by means of HIFU using "Ablatherm" was performed following transurethral resection of the prostate (TURP). The indication for HIFU was morphologically-proven PCa (stage T2a-cN0M0) in patients with contraindications due to comorbidities or those who refused from radical prostatectomy.

RESULTS

A decrease in PSA to 0.5 ng/ml or less was observed in 74% of patients. A stable PSA level for 3 years was observed in 76% of patients. PSA levels differed depending on the PCa risk group. In the low-risk PCa, negative biopsy was seen in 89.6% of cases, in comparison with 72.2% and 69.4% in intermediate and high-risk PCa, respectively. There was a significant decrease in the volume of the prostate in all patients with low-risk PCa. The largest decrease in prostate volume was observed 12 months after HIFU. Regarding recurrence-free survival after HIFU therapy, during follow-up of 3 years or more, 77% of patients didnt have any signs of recurrence. A 3-year overall survival after HIFU was 83%. In addition, an increase in postoperative PSA levels, change in parameters of Doppler study and laser Doppler flowmetry at the area of the prostate during the period of 6-36 months after HIFU was associated with a significant increase in the risk of recurrence of PCa at biopsy.

CONCLUSION

HIFU therapy is an effective treatment method for inducing prostate necrosis with minimal collateral damage to the surrounding tissue. The best results were achieved in patients with low-risk PCa. There were minimal adverse events after HIFU. In addition, in case of relapse after HIFU therapy, there is an opportunity for an early assessment of the efficiency and prognosis.

An Exploratory Study of Dose Escalation vs Standard Focal High-Intensity Focused Ultrasound for Treating Nonmetastatic Prostate Cancer

Objective: Analysis of treatment success regarding oncological recurrence rate between standard and dose escalation focal high-intensity focused ultrasound (HIFU) of prostate cancer. Materials and Methods: In this analysis of our prospectively maintained HIFU (Sonablate^® 500) database, 598 patients were identified who underwent a focal HIFU (Sonablate 500) between March 2007 and November 2016. Follow-up occurred with 3-monthly clinic visits and prostate specific antigen (PSA) testing in the first year. Thereafter, PSA was measured 6-monthly or annually at least. Routine and for-cause multiparametric MRI (mpMRI) was conducted with biopsy for MRI suspicion of recurrence. Treatments were delivered in a quadrant or hemiablation fashion depending on the gland volume as well as tumor volume and location. Before mid-2015, standard focal HIFU was used (two HIFU blocks); after this date, some urologists conducted dose escalation focal HIFU (three overlapping HIFU blocks). Propensity matching was used to ensure two matched groups, leading to 162 cases for this analysis. Treatment failure was defined by any secondary treatment (systemic therapy, cryotherapy, radiotherapy, prostatectomy, or further HIFU), metastasis from prostate cancer without further treatment, tumor recurrence with Gleason score ≥7 (≥3 + 4) on prostate biopsy without further treatment, or prostate cancer-related mortality. Complications and side-effects were also compared. Results: Median age was 64.5 years (interquartile range [IQR] 60-73.5) in the standard focal-HIFU group and 64.5 years (IQR 60-69) in the dose-escalation group. Median prostate volume was 37 mL (IQR 17-103) in the standard group and 47.5 mL (IQR 19-121) in the dose-escalation group. As tumor volume on mpMRI and Gleason score were major matching criteria, these were identical with 0.43 mL (IQR 0.05-2.5) and Gleason 3 + 3 = 6 in 1 out of 32 (3%), 3 + 4 = 7 in 27 out of 32 (84%), and 4 + 3 = 7 in 4 out of 32 (13%). Recurrence in treated areas was found in 10 out of 32 (31%) when standard treatment zones were applied, and in 6 out of 32 (19%) of dose-escalation focal HIFU (p = 0.007). Conclusion: This exploratory study shows that dose escalation focal HIFU may achieve higher rates of disease control compared with standard focal HIFU. Further prospective comparative studies are needed.

[Prognostic significance of prostate-specific antigen in defining indications for initial prostate biopsy]

Currently, prostate biopsy remains the main method used to diagnose prostate cancer (PCa). The indication for the procedure is an elevated level of the serum level of the total prostate-specific antigen (PSA). However, the PSA test is organ- but not cancer-specific, and patients may undergo an unnecessary biopsy, which is an invasive procedure associated with a risk of complications. Additional tests have been developed aimed to improve the diagnostic performance of PSA for detecting PCa. They include PSA derivatives such as free PSA fraction, -2proPSA, PSA density, PHI and the free /total PSA fraction.

AIM

To investigate the diagnostic accuracy of PSA and its derivatives in detecting benign and malignant diseases of the prostate after an initial prostate biopsy.

MATERIALS AND METHODS

The current study analyzed 65 initial biopsies performed due to an elevated serum PSA level and compared them with the results of extended PSA testing with the use of PSA derivatives.

RESULTS

The histological findings consistent with PCa were found in about 30% of initial biopsies performed due to elevated serum levels of total PSA. The incidence of histologically confirmed PCa increased with age, and 70-79 year old men were more likely to have it than 60-69 years old patients. PSA density in 85% of PCa cases exceeded that for benign prostatic hyperplasia (BPH). In all PCa patients, PHI and free /total PSA fraction were greater than 25 and less than 0.15, respectively. In most patients with BPH, the PHI and free /total PSA fraction did not exceed 25 and were greater than 0.15.

CONCLUSIONS

1. Initial biopsy triggered by elevated serum level of total PSA allows detection of PCa in about 30% of cases. 2. The age of 60 years and older should be regarded as a risk factor for PCa. The probability of malignant transformation of prostate epithelial cells in men over 70 years of age is greater than in 60-69-year-olds. 3. The density of PSA in men with morphologically verified PCa is statistically significantly greater than that in men with BPH and the threshold value in 85% of cases. 4. Determination of PHI and free/total PSA fraction can improve the accuracy of predicting malignant lesions of the prostate and adjust the indications for histological examination, reduce the number of unnecessary biopsies. 5. When defining indications for initial prostate biopsy in cases with serum PSA varying from 2 to 10 ng/ml, PSA derivatives should be used, including PSA density, prostate health index, and the free /total PSA fraction.

[Morphological evidence of the ischemic nature of the prostatic fibrosis in the classical chronic pelvic pain syndrome / IIIB chronic prostatitis]

AIM

To examine the structure of the prostate tissue in patients with III B chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS).

MATERIALS AND METHODS

The study analyzed transrectal fine-needle biopsy specimens of 10 patients with the verified diagnosis of chronic pelvic pain syndrome/category III B chronic prostatitis (CPPS/IIIB CP) according to the National Institutes of Health classification. Tissues were examined using light and electron microscopy, and immunohistochemical study of the expression of CD31, CD34, NSE and S-100 markers.

RESULTS

All biopsy specimens of all patients showed fibroplastic changes of the prostate tissue most markedly pronounced in the stroma and muscle fibers in the form of total fibrosis, myofibril atrophy, and extracellular lipofuscin deposition. The examination revealed a significant reduction in the density of microcirculatory bed vessels and arteriolar luminal stenosis, a reduction in the number of nerve fibers, and compression of their fibrous tissue. No inflammatory changes were found in the prostate.

DISCUSSION

In patients with CPPS/IIIB CP, the changes in the prostate at the microscopic and ultrastructural levels are characteristic of severe chronic tissue hypoxia, which leads to the development of fibrosis resulting in stenosis of microcirculatory bed vessels and degenerative changes in nerve fibers and cells. No signs of an inflammatory reaction in the examined tissue were established.

CONCLUSION

Changes in the prostate tissue in CPPS/IIIB CP suggest the presence of chronic pelvic ischemia and exclude its association with inflammation as the main pathological process.

Online Robust Projective Dictionary Learning: Shape Modeling for MR-TRUS Registration

Robust and effective shape prior modeling from a set of training data remains a challenging task, since the shape variation is complicated, and shape models should preserve local details as well as handle shape noises. To address these challenges, a novel robust projective dictionary learning (RPDL) scheme is proposed in this paper. Specifically, the RPDL method integrates the dimension reduction and dictionary learning into a unified framework for shape prior modeling, which can not only learn a robust and representative dictionary with the energy preservation of the training data, but also reduce the dimensionality and computational cost via the subspace learning. In addition, the proposed RPDL algorithm is regularized by using the norm to handle the outliers and noises, and is embedded in an online framework so that of memory and time efficiency. The proposed method is employed to model prostate shape prior for the application of magnetic resonance transrectal ultrasound registration. The experimental results demonstrate that our method provides more accurate and robust shape modeling than the state-of-the-art methods do. The proposed RPDL method is applicable for modeling other organs, and hence, a general solution for the problem of shape prior modeling.

High intensity focused ultrasound for Focal Therapy of prostate cancer

High Intensity Focused Ultrasound (HIFU) is a heat based energy source used for tissue ablation. HIFU has several clinical applications and prostate cancer ablation is one of the uses that have been explored for more than a decade. Focal therapy is an alternative treatment option for selected patients with low/intermediate PCa, that is based on complete ablation of tumor within the prostate with preservation of normal parenchyma and better preservation of Genitourinary functions. In spite of PCa being predominantly a multi-centric disease, it is postulated that a specific dominant (large volume) 'index lesion' dictates the biological behavior of the cancer and subsequent lethality of the disease. The use of HIFU for focal ablation of PCa, have demonstrated satisfactory cancer control with fewer morbidity and better preservation of continence and erection. The aim of this article is to present the readers with a brief review of the principles, devices available for clinical uses, published clinical experience and future directions and research opportunities in focal HIFU ablation of prostate cancer.

[QUALITY OF LIFE IN PATIENTS UNDERGOING PROSTATE CRYOABLATION]

Not long ago, survival rates were the primary outcome measures of surgical management of prostate cancer. Currently, more attention is paid to the quality of life, because even minor changes in the quality of life can lead to serious alterations in the psycho-emotional status and significantly reduce patients' self-esteem. Most experts believe that the quality of life of patients treated for prostate cancer, is mostly affected by urinary incontinence, erectile dysfunction, urethral stricture, and bowel dysfunction. Thanks to advances in the treatment of prostate cancer, the incidence of complications was reduced to a minimum. To some extent, this was due to the use of novel minimally invasive treatment for prostate cancer, such as cryoablation, interstitial brachytherapy and HIFU-therapy. The quality of life in 65 patients undergoing cryoablation of the prostate was evaluated using EORTC QLQ-C30 questionnaire. Analyzing the findings of the survey enabled us to estimate the patients' quality of life, as well as to identify the various components of the postoperative health problems.

Role of information in preparing men for transrectal ultrasound guided prostate biopsy: a qualitative study embedded in the ProtecT trial

BACKGROUND

The histological diagnosis of prostate cancer requires a prostate needle biopsy. Little is known about the relationship between information provided to prepare men for transrectal ultrasound guided biopsy (TRUS-Bx) and how men experience biopsy. The objectives were a) to understand men's experiences of biopsy as compared to their expectations; and b) to propose current evidence-based information for men undergoing TRUS-Bx.

METHODS

Between February 2006 and May 2008, 1,147 men undergoing a standardised 10-core transrectal ultrasound guided biopsy protocol under antibiotic cover following a PSA 3.0-19.9 ng/ml in the Prostate Testing for Cancer and Treatment (ProtecT) trial, completed questionnaires about biopsy symptoms. In this embedded qualitative study, in-depth interviews were undertaken with 85 men (mean age 63.6 yrs, mean PSA 4.5 ng/ml) to explore men's experiences of prostate biopsy and how the experience might be improved. Interview data were analysed thematically using qualitative research methods. Findings from the qualitative study were used to guide selection of key findings from the questionnaire study in developing a patient information leaflet preparing men for biopsy.

RESULTS

Although most men tolerated TRUS-Bx, a quarter reported problematic side-effects and anxiety. Side effects were perceived as problematic and anxiety arose most commonly when experiences deviated from information provided. Men who were unprepared for elements of TRUS-Bx procedure or its sequelae responded by contacting health professionals for reassurance and voiced frustration that pre-biopsy information had understated the possible severity or duration of pain/discomfort and bleeding. Findings from questionnaire and interview data were combined to propose a comprehensive, evidence-based patient information leaflet for TRUS-Bx.

CONCLUSIONS

Men reported anxiety associated with TRUS-Bx or its side-effects most commonly if they felt inadequately prepared for the procedure. Data from this qualitative study and the previous questionnaire study have been used to propose an updated, comprehensive evidence-based set of information for men undergoing TRUS-Bx.

[Treatment of prostate cancer using cryoablation: a prospective study]

Currently, the choice of tactics of treatment of the patient with prostate cancer (PCa) requires to take into account the degree of differentiation and stage of tumor, age of the patient and his somatic diseases, the risk of complications, as well as the patient's desire and physician's experience. Due to the progressive development of medical technology, interest in minimally invasive treatments for prostate cancer, such as cryoablation, interstitial brachytherapy and HIFU-therapy, has grown. Cryoablation of the prostate gland is a tissue ablation by local effects of very low temperatures and is minimally invasive, highly effective treatment for prostate cancer that can be used as the primary treatment, and in the case of tumor recurrence after radiotherapy. Focal cryoablation of the prostate allows to selectively destroy the known tumor with preservation of organ function and without reducing the quality of life of the patient. Focal therapy for prostate cancer is an alternative to radical treatment and active surveillance, occupying an intermediate position between them. Due to the lack of long-term results, focal cryoablation is an experimental type of treatment. First cryoablation of the prostate using modern equipment was carried out in Russia in March 2010, at the Department of Urology MSMSU. Since that time, we performed this procedure in 122 patients with prostate cancer; cryoablation was primary treatment in 110 patients and was used as salvage treatment in 12 patients. In most cases, the operation was performed under epidural or spinal anesthesia. According to the protocol, all the patients underwent 2 cycles of freezing and thawing under transrectal ultrasound guidance. A significant improvement of equipment for cryosurgery, the use of cryoneedles with smaller diameter, and the use of temperature sensors and catheters to warm the urethral mucosa have allowed to minimize the number of complications in comparison with other methods of treatment of prostate cancer and achieve a high disease-free survival. Our prospective study was aimed to analyze our own results cryoablation of the prostate gland.

The value of TRUS in the staging of rectal carcinoma before and after radiotherapy and comparison with the staging postoperative pathology

AIM

To compare the effectiveness of transrectal ultrasonography (TRUS) with that of postoperative pathological examination in staging rectal carcinoma before surgery and before and after radiotherapy.

MATERIALS AND METHODS

A prospective study was undertaken comprising 62 patients with stage T3 or T4 rectal carcinoma confirmed by endoscopic biopsy.

RESULTS

TRUS showed significant differences (p < 0.01) in tumour echogenicity and volume, border delineation, local invasion, and draining lymph node involvement before and after radiotherapy, and significant reduction in blood flow resistance index after radiotherapy but no difference (p > 0.05) in the classification of tumour blood flow. In ultrasonographic assessments, 53 of the 62 cases (85.5%) showed lower T stages after radiotherapy. TRUS showed an accuracy of 94.1% for T2 cases, 77.3% for T3 cases, and 83.3% for T4 cases, and an overall accuracy of 87.1% in comparison with the results of postoperative pathological examination.

CONCLUSION

TRUS is expected to play a vital role in the accurate preoperative staging of rectal carcinoma with the increasing utilization of adjuvant radiotherapy in rectal carcinoma and to contribute to the assessment of treatment.

Sonochemiluminescence observation and acoustic detection of cavitation induced by pulsed HIFU at a tissue-fluid interface

The aim of this study is to investigate the mechanism of the erosion process induced by 1.2 MHz pulsed high-intensity focused ultrasound (pulsed HIFU). By using Sonochemiluminescence (SCL) photograph, the initiation and maintenance of active cavitation were observed. In order to understand the role of both inertial cavitation and stable cavitation, a passive cavitation detection (PCD) transducer was used. Since the exposure variables of HIFU are important in the controlled ultrasound tissue erosion, the influence of pulse length (PL) and duty cycle (DC, Ton:Toff) has been examined. The results of tissue hole, SCL observation and acoustic detection revealed that the erosion was highly efficient for shorter PL. For higher DCs, the area of SCL increased with increasing PL. For lower DCs, the area of SCL increased with increasing PL from 10 to 20 μs and then kept constant. For all PLs, the intensity of SCL decreased with lower DC. For all DCs, the intensity of SCL per unit area (the ratio of SCL intensity to SCL area) also decreased with increasing PL from 10 to 80 μs, which suggested that the higher the intensity of SCL is, the higher the efficiency of tissue erosion is. At DC of 1:10, the position of the maximum pixel in SCL pictures was distant from the tissue-fluid interface with the increasing PL because of shielding effect. By the comparison of inertial cavitation dose (ICD) and the stable cavitation dose (SCD), the mechanisms associated with inertial cavitation are very likely to be the key factor of the erosion process.

Experience with high-intensity focused ultrasound therapy for management of organ-confined prostate cancer: critical evaluation of oncologic outcomes

OBJECTIVES

To assess the oncologic results of high-intensity focused ultrasound therapy (HIFU) as treatment for clinically localized prostate cancer.

METHODS

A total of 180 patients with clinically localized prostate cancer underwent HIFU and were retrospectively reviewed. Of those 171 patients primarily treated with HIFU were included in the analysis. They were stratified by prostatic volume, neoadjuvant hormonal ablation (NHA), and post-treatment PSA nadir. PSA level was monitored every month during the first 6 months after the treatment and every 3 months thereafter. According to the latest Phoenix criteria, biochemical failure was defined by a PSA rise of2 ng/ml or more above the PSA nadir. Seventy-six (44.4%) patients were offered preoperative NHA in median duration of 3 months (IQR: 3-5.75). Preoperative transurethral resection of the prostate (TURP) was performed in 56 (32.7%) patients having the calcification within the prostatic gland.

RESULTS

Mean patient age was 68.3 +/- 7.0. The median follow-up time was 43 months (IQR: 30-55). According to D'amico risk groups 52 (30.4%) patients were identified with low risk, 47 (27.5%) patients with intermediate risk, and 72 (42.1%) with high risk. The overall and cancer-specific survival rates at 5 years were 98.8% and 100%. The metastasis-free survival rate at 5 years was 99.4%. No significant differences were seen in biochemical failure-free survival when stratified according to preoperative prostatic volume and administration of preoperative NHA (p = 0.931 and p = 0.712, respectively). Regardless NHA administration, patients with smaller PSA nadir (0.2 ng/ml) achieved better biochemical failure-free survival ratio.

CONCLUSION

High-intensity focused ultrasound therapy provides sufficient oncologic control only in patients with low-risk prostate cancer. However, our data could be used to improve the selection of patients who are potential candidates for HIFU therapy.

[Diagnostic imaging of the prostate cancer]

Diagnosis of the prostate cancer is based on clinical, biochemical and histological examinations, as well as various imaging techniques. From the last listed group, magnetic resonance imaging (MRI) provides precise identification of focal areas and local staging of the cancer. It improves evaluation of the local extracapsular extension and involvement of regional lymph nodes, which has significant implications for a patient management. MRI, supplemented by dynamic contrast enhanced and diffusion-weighted imaging (DWI), is especially useful in detection of small focal lesions. MRI also plays an important role in the evaluation of a local recurrence and monitoring of the early and late response to treatment. Whole-body MRI should be performed in patients with a disseminated disease. In patients with an increased level of prostate specific antigen (PSA), small lesions, local recurrence and distant metastases, not detected by other imaging techniques, a positron emission tomography (PET) should be also performed. Computed tomography (CT) does not play a significant role in the diagnosis of the primary prostate cancer, however new CT scanners improve the accuracy of prostate cancer staging. Diagnostic imaging is also widely used in the screening process. Transrectal ultrasound (TRUS) examination of the organ is applied to obtain systematic core biopsies for a histological examination.