Partial Salvage Cryoablation of the Prostate for Recurrent Prostate Cancer After Radiotherapy Failure

Salvage Cryoablation for Recurrent Prostate Cancer Following Radiation-A Comprehensive Review

The treatment options for prostate cancer typically entail active surveillance, surgery, radiation, or a combination of the above. Disease recurrence remains a concern, with a wide range of recurrence rates having been reported in the literature. In the setting of recurrence, the salvage treatment options include salvage prostatectomy, salvage high-intensity focused ultrasound (HIFU), stereotactic body radiotherapy (SBRT), salvage brachytherapy, and salvage cryoablation. In this review, we analyze the currently available data related to salvage cryoablation for recurrent prostate cancer following radiation.

Salvage Cryoablation for Recurrent Prostate Cancer Following Primary External Beam Radiotherapy or Primary Cryotherapy: A Propensity Score Matched Analysis of Mid-term Oncologic and Functional Outcomes

INTRODUCTION

Local prostate cancer recurrence following radiotherapy (XRT) or cryoablation (CRYO) may be addressed with salvage cryotherapy (SCT), although little is known about how the primary treatment modality affects SCT results. Oncologic and functional outcomes of patients who underwent SCT after primary XRT (XRT-SCT) or cryoablation (CRYO-SCT) were studied.

METHODS

Data was collected using the Duke Prostate Cancer database and the Cryo On-Line Data (COLD) registry. The primary outcome was biochemical progression-free survival (BPFS).  Urinary incontinence, rectourethral fistula, and erectile dysfunction were secondary outcomes. The Kaplan-Meier log-rank test and univariable/multivariable Cox proportional hazards (CPH) models were utilized to evaluate BPFS between groups.

RESULTS

419 XRT-SCT and 63 CRYO-SCT patients met inclusion criteria, that was reduced to 63 patients in each cohort after propensity matching. There was no difference in BPFS at 2 and 5 years both before (P = .5 and P = .7) and after matching (P = .6 and P = .3). On multivariable CPH, BPFS was comparable between treatment groups (CRYO-SCT, HR=1.1, [0.2-2.2]).  On the same analysis, BPFS was lower in D'Amico high-risk (HR 3.2, P < .01) and intermediate-risk (HR 1.95, P < .05) categories compared to low-risk. There was no significant difference in functional outcomes between cohorts.

CONCLUSION

Following primary cryotherapy, salvage cryoablation provides comparable intermediate oncological outcomes and functional outcomes compared to primary radiotherapy.

Focal therapy for primary and salvage prostate cancer treatment: a narrative review

Despite innovations in surgical technology and advancements in radiation therapy, radical treatments for clinically localized prostate cancer are associated with significant patient morbidity, including both urinary and sexual dysfunction. This has created a vital need for therapies and management strategies that provide an acceptable degree of oncologic efficacy while mitigating these undesirable side effects. Successful developments in screening approaches and advances in prostate imaging have allowed clinicians to identify, localize, and more precisely target early cancers. This has afforded urologists with an important opportunity to develop and employ focal ablation techniques that selectively destroy tumors while preserving the remainder of the gland, thus avoiding detrimental treatment effects to surrounding sensitive structures. A lack of high-level evidence supporting such an approach had previously hindered widespread adoption of focal treatments, but there are now numerous published clinical trials which have sought to establish benchmarks for safety and efficacy. As the clinical evidence supporting a potential role in prostate cancer treatment begins to accumulate, there has been a growing acceptance of focal therapy in the urologic oncology community. In this narrative review article, we describe the techniques, advantages, and side effect profiles of the most commonly utilized focal ablative techniques and analyze published clinical trial data supporting their evolving role in the prostate cancer treatment paradigm.

Minimally invasive strategies for the treatment of prostate cancer recurrence after radiation therapy: a systematic review

INTRODUCTION

The aim of this review was to conduct a comprehensive analysis of the role of minimally invasive salvage modalities in radio-recurrent prostate cancer and the associated clinical outcomes and toxicity profiles.

EVIDENCE ACQUISITION

A systematic review of the current literature was conducted through the Medline and NCBI PubMed, Scopus databases in January 2020. All papers published after 2000, concerning studies conducted on humans for radio-recurrent prostate cancer were considered for the review.

EVIDENCE SYNTHESIS

Overall, 545 studies were identified. After duplicate exclusion, initial screening, and eligibility evaluation, a total of 80 studies were included in the qualitative analysis, corresponding to a cohort of 6681 patients. The median age at initial diagnosis ranged from 59 to 75.5. Pre-treatment PSA ranged from 6.2 to 27.4 ng/mL. All patients underwent primary radiotherapy for localized prostate cancer. Cryotherapy, Brachytherapy, EBRT, HIFU were the minimally invasive options mostly used as salvage therapy. They showed to be promising approaches for recurrent prostate cancer (PCa) control, with acceptable toxicities.

CONCLUSIONS

Minimally invasive therapeutic options offer promising results in terms of biochemical control in the local recurrence setting. Unfortunately, the absence of high quality and comparative studies makes it difficult to establish which method is the best in terms of oncological and safety outcomes.

A systematic review of salvage focal therapies for localised non-metastatic radiorecurrent prostate cancer

Although radiotherapy to the prostate for cancer is effective, recurrence occurs in 10-15% within 5 years. Traditional salvage treatments for men with radiorecurrent prostate cancer comprise of watchful waiting (WW) with or without androgen deprivation therapy (ADT) or radical prostatectomy (RP). Neither strategy provides ideal therapeutic ratios. Salvage focal ablation is an emerging option. We performed a systematic review of the Medline and Embase databases for studies reporting outcomes of focal salvage brachytherapy (sBT), cryotherapy (sCT) or high-intensity focused ultrasound (sHIFU) for radiorecurrent prostate cancer (conception to April 2019). Results were screened for inclusion against predetermined eligibility criteria. Certain data were extracted, including rates of biochemical disease-free survival (BDFS), metastasis, conversion to second-line therapies and adverse events. Of a total 134 articles returned from the search, 15 studies (14 case series and 1 comparative study) reported outcomes after focal sBT [5], sCT [7] and sHIFU [3]. Cohort size varied depending on intervention, with eligible studies of sBT being small case series. Median follow-up ranged from 10 to 56 months. Although pre-salvage demographics were similar [median age range, 61-75 years; prostate-specific antigen (PSA) range, 2.8-5.5 ng/mL], there was heterogeneity in patient selection, individual treatment protocols and outcome reporting. At 3 years, BDFS ranged from 61% to 71.4% after sBT, 48.1-72.4% after sCT and 48% after sHIFU. Only studies of sCT reported 5-year BDFS, which ranged from 46.5% to 54.4%. Rates of metastasis were low after all salvage modalities, as were conversion to second-line therapies (although this was poorly reported). Grade 3 adverse events were rare. This systematic review indicates that salvage focal ablation of radiorecurrent prostate cancer provides acceptable oncological outcomes and is well tolerated. Unfortunately, there is heterogeneity in the study design of existing evidence. Level 1 research comparing salvage focal therapies to existing whole-gland strategies is needed to further establish the role of these promising treatments.

Salvage Focal Cryotherapy Offers Similar Short-term Oncologic Control and Improved Urinary Function Compared With Salvage Whole Gland Cryotherapy for Radiation-resistant or Recurrent Prostate Cancer

BACKGROUND

We compared the short-term oncologic and functional outcomes of salvage focal cryotherapy (SFC) with those of salvage total cryotherapy (STC) for radiotherapy (RT)-persistent/recurrent prostate cancer.

MATERIALS AND METHODS

We queried the Cryo On-Line Database registry for men who had undergone SFC and STC of the prostate for RT-persistent or recurrent disease. Propensity score weighting was used to match age at treatment, presalvage therapy prostate-specific antigen level, Gleason sum, and presalvage cryotherapy androgen deprivation therapy status. The primary outcome was progression-free survival.

RESULTS

A total of 385 men with biopsy-proven persistent or recurrent prostate cancer after primary RT were included in the present study. The median follow-up, age, prostate-specific antigen, and Gleason sum before salvage cryotherapy was 24.4 months (first and third quartile, 9.8 and 60.3), 70 years (first and third quartile, 66 and 74 years), 4 ng/dL (first and third quartile, 2.7 and 5.6 ng/dL), and 7 (first and third quartile, 6 and 8), respectively. After propensity score weighting, the difference in progression-free survival was not statistically significant between the patients who had undergone STC and those who had undergone SFC (79.8% vs. 76.98%; P = .11 on weighted log-rank test). SFC was associated with a lower probability of post-treatment transient urinary retention (5.6% vs. 22.4%; P < .001). No significant differences were found in the incidence of rectal fistula (1.4% vs. 3.8; P = .30), new-onset urinary incontinence within 12 months (9.3% vs. 15.1%; P = .19), or new-onset erectile dysfunction within 12 months (52.6% vs. 59.6%; P = .47) between the SFC and STC groups, respectively.

CONCLUSIONS

STC resulted in similar 2-year oncologic outcomes compared with SFC in the RT-persistent/recurrent disease population. However, the patients who had undergone SFC had a lower urinary retention rate compared with those who had undergone STC.

Focal Salvage MR Imaging-Guided Cryoablation for Localized Prostate Cancer Recurrence after Radiotherapy: 12-Month Follow-up

PURPOSE

To evaluate safety, quality of life (QoL), and local cancer control after focal salvage MR imaging-guided cryoablation in patients with local recurrence of prostate cancer (PCa) after radiotherapy.

MATERIALS AND METHODS

A retrospective, single-center study was performed in 62 patients with radiorecurrent PCa who underwent MR imaging-guided cryoablation since May 2011 with a follow-up ≥12 months in December 2017. Rates and descriptions of adverse events were reported. Ablation complications were classified according to the Clavien and SIR systems. Validated questionnaires were used to observe functional outcomes and QoL before therapy and 6 and 12 months after therapy. Cancer control was defined as no biochemical failure according to Phoenix criteria and no other clinical evidence for local or metastatic disease.

RESULTS

All procedures were technically feasible. The number of complications requiring major therapy (Clavien grade 3b/4 or SIR grade D/E/F) was low (2 [3.2%] and 1 [1.6%], respectively). After 12 months, the International Consultation of Incontinence Questionnaire-Short Form (P < .001) and 5-item International Index of Erectile Function (P = .001) scores became significantly worse, indicating increased symptoms of incontinence and diminished erectile function, without compromising QoL. Six patients developed metastases within 6 months. After 12 months, 36 patients (63%) were disease-free.

CONCLUSIONS

Focal salvage MR imaging-guided cryoablation is safe and is associated with a high technical success rate, preservation of QoL, and local PCa control. This treatment can be a reasonable alternative to salvage radical prostatectomy in properly selected patients with low morbidity and preservation of QoL; however, longer follow-up is needed.

Nonsurgical Salvage Local Therapies for Radiorecurrent Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Different nonsurgical therapeutic strategies can be adopted for intraprostatic relapse of prostate cancer after primary radiotherapy, including re-irradiation (with brachytherapy [BT] or external beam radiotherapy [EBRT]), high-intensity focused ultrasound (HIFU), and cryotherapy. The main issues to consider when choosing nonsurgical salvage local therapies are local tumor control and significant genitourinary toxicity.

OBJECTIVE

To conduct a systematic review and meta-analysis of the role of nonsurgical salvage modalities in patients with radiorecurrent prostate cancer and associated clinical outcomes and toxicity profiles.

EVIDENCE ACQUISITION

We performed a critical review of the Medline, Scopus, and ClinicalKey databases from January 1, 2000 through February 1, 2018 according to the Preferred Reporting Items and Meta-Analyses statement. To assess the overall quality of the literature reviewed, we used a modified Delphi tool for case-series studies.

EVIDENCE SYNTHESIS

A total of 64 case-series studies were included, corresponding to a cohort of 5585 patients. The modified Delphi checklist evidenced high methodological quality overall (mean quality score of 80.6%). Biochemical control rates were lowest for patients treated with HIFU (58%, 95% confidence interval [CI] 47-68%) and highest for patients treated with BT (69%, 95% CI 62-76%) and EBRT (69%, 95% CI 53-83%). The lowest prevalence of incontinence was for patients treated with BT (3%, 95% CI 0-6%; I²=63.4%) and the highest was among patients treated with HIFU (28%, 95% CI 19-38%; I²=89.7%).

CONCLUSIONS

Nonsurgical therapeutic options, especially BT, showed good outcomes in terms of biochemical control and tolerability in the local recurrence setting.

PATIENT SUMMARY

The current analysis demonstrated that nonsurgical salvage local therapies offer a chance of a curative local approach in radiorecurrent prostate cancer. However, high-quality data from prospective trials are needed to validate long-term outcomes from nonsurgical strategies for the treatment of intraprostatic recurrence after previous radiotherapy.

[Salvage cryotherapy of prostate cancer after failed external radiotherapy and brachytherapy: Morbidity and mid-term oncological results]

OBJECTIVE

To study the oncologic and functional results of salvage cryotherapy after failure of external radiotherapy and brachytherapy.

MATERIALS AND METHODS

Patients treated by total salvage cryotherapy (3rd generation) in 2 centers (Groupe Hospitalier Saint-Joseph in Paris and Clinique Jule-Verne Nantes) in between January 2008 and April 2016 were included. The biochemical recurrence-free survival (BRFS) was calculated using the Phoenix criteria (PSA>nadir+2ng/mL). The functional results were assessed clinically.

RESULTS

Ninety-seven patients with an average follow up of 39.4months were evaluated retrospectively. The 5-year biochemical recurrence-free survival (5y-BRFS) among all patients was 58.1% (IC à 95% [45.9-68.5]). Low and intermediate risk patients (d'Amico classification) were less prone to biochemical recurrence than high risk (81.05% (IC à 95% [64.1-90.5]) 5y-BRFS as opposed to 35.09% (IC à 95% [20.1-50.4]) respectively) (P<0.0001). As were patients with a Gleason score≤7 75.35% (IC à 95% [59.7-85.6]) compared to 32.31% (IC à 95% [16.5-49.2]) for higher Gleason (>7 scores [P=0.0002]). A Gleason score>7 (OR=6.9; P=0.002), PSA nadir>1ng/mL (OR=25.8; P=0.0026) and peri-urethral invasion (OR=35.8; P<0.001) were major risk factors for local recurrence in univariate analysis. In multivariate analysis, only PSA nadir>1ng/mL (OR=12.9; P=0.042) and peri-urethral invasion (OR=21.6; P=0.0003) remain major risk factors for recurrence. About 13 (16.46%) patients were incontinent of which 3 (3.79%) required placement of an artificial urinary sphincter. Erectile dysfunction was present in 66 (83.5%) patients. Recto-urethral fistula was uncommon in 1 patient (1.27%).

CONCLUSION

Salvage cryotherapy after failure of external radiotherapy and brachytherapy is a reliable and reproducible technique with promising oncological and functional results. Study of prognostic factors will help better select eligible patients in the future.

LEVEL OF EVIDENCE

4.

Dual-timing PSA as a biomarker for patients with salvage intensity modulated radiation therapy for biochemical failure after radical prostatectomy

We investigated the outcomes and the associated clinical-pathological factors in patients with prostate cancer (PCa) undergoing salvage intensity modulated radiation therapy (IMRT) for post-radical-prostatectomy (RP) biochemical failure. We report clinical outcomes of post-RP salvage IMRT, and describe chronic toxicity in these patients.Fifty patients with PCa underwent post-RP salvage IMRT. The median dose of IMRT was 70 Gy to the prostatic and seminal vesicle bed. Clinical-pathological and toxicity information were collected. The prostate cancer-specific survival (PCSS), disease-free survival (DFS), and biochemical-failure-free survival (BFFS) were calculated. Prognostic factors were analyzed for their association with disease control.The median follow-up time was 74 months. The 5-year PCSS, DFS, and BFFS after salvage IMRT were 95%, 88%, and 60%, respectively. Two patients (4%) experienced late gastrointestinal toxicity ≥ grade 3, and 5 patients (10%) had late genitourinary toxicity ≥ grade 3. On multivariate analysis, post-RP prostate-specific antigen (PSA) nadir ≤0.1 ng/ml (P=0.018) and PSA ≤0.5 ng/ml at salvage IMRT (P=0.016) were independent factors predicting better BFFS. Patients with both post-RP PSA nadir ≤0.1 ng/ml and PSA ≤0.5 ng/ml at salvage IMRT had a 5-year BFFS of 83% as compared with 43% in other patients (P=0.001).In conclusion, with hormonal therapy in most PCa patients, the addition of salvage IMRT for post-RP biochemical failure can achieve a good outcome with low toxicity. Patients with a post-RP PSA nadir ≤0.1 ng/ml and PSA ≤0.5 ng/ml at salvage IMRT could benefit the most from salvage IMRT.

[SALVAGE CRYOABLATION TARGETING RECURRENT LESIONS AFTER DEFINITIVE RADIOTHERAPY FOR PROSTATE CANCER: IMPACT OF POST CRYOABLATION CHANGE IN URINARY AND SEXUAL FUNCTION]

(Purpose) To describe our initial experience in salvage cryoablation targeting recurrent lesions after definitive irradiation for prostate cancer. (Methods) Eligible patients for this treatment were those who developed biochemical failure after definitive radiotherapy for localized prostate cancer, but without distant metastasis, and with solid lesions identifiable on multiparametric magnetic resonance imaging (mpMRI). Histological proof of recurrence with mapping biopsy covering corresponding sites was obtained. Two to four cryoprobes were inserted transperineally into the prostate under general anesthesia with extensive lithotomy position. The rapid expansion of argon gas cryogen through a small opening within the cryoprobe cools itself to make an ice ball and the quick exchange to helium gas induces an active thawing phase. Entire procedure is monitored and guided with the use of transrectal ultrasonography. Postoperative follow-up included patient interview, digital rectal examination, prostate specific antigen (PSA) testing and quality of life (QOL) monitoring using IPSS and IIEF-5 at 1, 3, 6 and 12 months postoperatively. Changes of mpMRI findings with time, particularly at one month, were used to judge immediate treatment impact. (Results) Five patients underwent salvage cryoablation between October 2015 and September 2016. No grade 3/4 complications such as rectal fistula or urethral stenosis were experienced. Mean and maximal percent decline of PSA from baseline levels at 1, 3, 6 and 12 months following cryoablation were 72.2 and 94.7%, 79.4% and 93.9%, 78.2% and 92.1%, 79.6% and 90.9%, respectively. Posttreatment IPSS showed temporary worsening with average changes in score of 1.8, 1.5, 1.6, and 1.0 times over baseline levels, respectively. IPSS score returned to the baseline in one at six months and two at 12 months. Two of 5 patients were sexually active prior to therapy and thus evaluable. Both showed significant decline in IIEF score by 95% at 12 months. No patients showed any signs of recurrence. mpMRI at one month following cryoablation confirmed complete disappearance of visible lesions in all cases. (Conclusions) Salvage cryoablation for recurrent lesions of prostate cancer after definitive radiotherapy is feasible with minimal morbidity. Both oncological outcome and adverse events should be monitored carefully with longer follow up.

Whole-Gland Prostate Cancer Cryoablation with Magnetic Resonance Imaging Guidance: One-Year Follow-Up

PURPOSE

Patients who develop prostate cancer after prior abdominal perineal resection are poor surgical candidates, and have limited treatment options. Therefore, our goal is to present results from a single institutional experience of four patients who underwent whole gland MRI-guided cryoablation with a history complicated by prior abdominoperineal resection.

MATERIALS AND METHODS

Four MRI-guided cryoablative treatments (mean age 64, range 59-69 years) for primary and locally recurrent prostate adenocarcinoma were retrospectively reviewed in patients with prior abdominal perineal resection for colorectal cancer (3) and juvenile polyposis (1). Average prostate volume prior to ablation was 23 cc, with an average PSA of 5.6 ng/mL. For each gland, 7-10 cryoprobes were placed approximately 0.5 cm apart in the prostate gland under MRI guidance by a transperineal approach with 3-4 freeze-thaw cycles performed. Each patient had follow up imaging and PSA measurements out to 12 months post ablation.

RESULTS

All four patient's PSA dropped below 0.1 ng/mL at 3-6 month post-ablation and remained at these levels at 12 months. Three of the 4 patients had PSA measurements to 33 months post-ablation, with no evidence of recurrence. No patient developed urinary incontinence due to the whole gland cryoablation.

CONCLUSION

With all four patients in our study having undetectable PSAs 12 months post ablation, and with no patient developing urinary incontinence due to the cryoablation, MRI-guided cryoablation appears to be a promising treatment option in patients who are poor surgical candidates due to prior pelvic surgery and/or radiation.

[Evaluation and results of ablative therapies in prostate cancer]

OBJECTIVE

To perform a state of the art about methods of evaluation and present results in ablative therapies for localized prostate cancer.

METHODS

A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of keywords. Publications obtained were selected based on methodology, language and relevance. After selection, 102 articles were analysed.

RESULTS

Analyse the results of ablative therapies is presently difficult considering the heterogeneity of indications, techniques and follow-up. However, results from the most recent and homogeneous studies are encouraging. Oncologically, postoperative biopsies (the most important criteria) are negative (without any tumor cells in the treated area) in 75 to 95%. Functionally, urinary and sexual pre-operative status is spared (or recovered early) in more than 90% of the patients treated. More and more studies underline also the correlation between the results and the technique used considering the volume of the gland and, moreover, the "index lesion" localization.

CONCLUSION

The post-treatment pathological evaluation by biopsies (targeted with MRI or, perhaps in a near future, with innovative ultrasonography) is the corner stone of oncological evaluation of ablative therapies. Ongoing trials will allow to standardize the follow-up and determine the best indication and the best techniques in order to optimize oncological and functional results for each patient treated.

Percutaneous MR-guided focal cryoablation for recurrent prostate cancer following radiation therapy: retrospective analysis of iceball margins and outcomes

OBJECTIVES

To evaluate iceball margins after magnetic resonance (MR)-guided focal salvage prostate cryoablation and determine the correlation with local outcome.

METHODS

A retrospective review was performed on 47 patients that underwent percutaneous MR-guided focal cryoablation for biopsy-proven locally recurrent prostate cancer after primary radiotherapy. Preprocedural diagnostic and intraprocedural MR images were analysed to derive three-directional iceball margins. Local tumour progression after cryoablation was defined as evident tumour recurrence on follow-up MRI, positive MR-guided biopsy or biochemical failure without radiological evidence of metastatic disease.

RESULTS

Mean iceball margins were 8.9 mm (range -7.1 to 16.2), 10.1 mm (range 1.1-20.3) and 12.5 mm (range -1.5 to 22.2) in anteroposterior, left-right and craniocaudal direction respectively. Iceball margins were significantly smaller for tumours that were larger (P = .008) or located in the posterior gland (P = .047). Significantly improved local progression-free survival at 1 year post focal cryoablation was seen between patients with iceball margin >10 mm (100%), 5-10 mm (84%) and <5 mm (15%) (P < .001).

CONCLUSIONS

Iceball margins appear to correlate with local outcome following MR-guided focal salvage prostate cryoablation. Our initial data suggest that freezing should be applied at minimum 5 mm beyond the border of an MR-visible recurrent prostate tumour for successful ablation, with a wider margin appearing desirable.

KEY POINTS

• Shortest iceball margin most often occurred in anteroposterior direction • Margins were smaller in tumours that were larger or posteriorly located • Minimum iceball margin was a predictor of early local tumour progression • A minimum 5-mm margin seems required for effective cryoablation of recurrent PCa.

Comparative cost-effectiveness of focal and total salvage 125I brachytherapy for recurrent prostate cancer after primary radiotherapy

PURPOSE

Focal salvage (FS) iodine 125 (125I) brachytherapy could be an effective treatment for locally radiorecurrent prostate cancer (PCa). Toxicity is often reduced compared to total salvage (TS) while cancer control can be maintained, which could increase cost-effectiveness. The current study estimates the incremental cost per quality-adjusted life year (QALY) of FS compared to TS.

MATERIAL AND METHODS

A decision analytic Markov model was developed, which compares costs and QALYs associated with FS and TS. A 3-year time horizon was adopted with six month cycles, with a hospital perspective on costs. Probabilities for genitourinary (GU) and gastrointestinal (GI) toxicity and their impact on health-related quality of life (SF-36) were derived from clinical studies in the University Medical Center Utrecht (UMCU). Probabilistic sensitivity analysis, using 10,000 Monte Carlo simulations, was performed to quantify the joint decision uncertainty up to the recommended maximum willingness-to-pay threshold of €80,000/QALY.

RESULTS

Focal salvage dominates TS as it results in less severe toxicity and lower treatment costs. Decision uncertainty is small, with a 97-100% probability for FS to be cost-effective compared to TS (€0-€80,000/QALY). Half of the difference in costs between FS and TS was explained by higher treatment costs of TS, the other half by higher incidence of severe toxicity. One-way sensitivity analyses show that model outcomes are most sensitive to utilities and probabilities for severe toxicity.

CONCLUSIONS

Focal salvage 125I brachytherapy dominates TS, as it has lower treatment costs and leads to less toxicity in our center. Larger comparative studies with longer follow-up are necessary to assess the exact influence on (biochemical disease free) survival and toxicity.

Focal salvage therapy for local prostate cancer recurrences after primary radiotherapy: a comprehensive review

Background/Aim

Patients with locally recurrent prostate cancer after primary radiotherapy can be eligible for salvage treatment. Whole-gland salvage techniques carry a high risk of toxicity. A focal salvage approach might reduce the risk of adverse events while maintaining cancer control in carefully selected patients. The aim of this review was to evaluate current literature to assess whether focal salvage leads to a comparable or favourable recurrence rate and less toxicity compared to whole-gland salvage.

Methods

A literature search was performed using PubMed, Embase and the Cochrane Library. A total of 3015 articles were screened and assessed for quality. Eight papers [on focal cryoablation (n = 3), brachytherapy (n = 3) and high-intensity focused ultrasound (n = 2)] were used to report outcomes.

Results

One-, 2-, 3- and 5-year biochemical disease-free survival (BDFS) ranges for focal salvage are, respectively, 69–100, 49–100, 50–91 and 46.5–54.5 %. Severe genitourinary, gastrointestinal and sexual function toxicity rates are 0–33.3 %. One study directly compares focal to whole-gland salvage cryotherapy, showing 5-year BDFS of, respectively, 54.4 and 86.5 % with lower toxicity rates for focal salvage patients.

Conclusion

Provisional data suggest that BDFS rates of focal salvage are in line with those of whole-gland approaches. There is evidence that focal salvage could decrease severe toxicity and preserve erectile function.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-016-1811-9) contains supplementary material, which is available to authorized users.

Comparative Oncologic and Toxicity Outcomes of Salvage Radical Prostatectomy Versus Nonsurgical Therapies for Radiorecurrent Prostate Cancer: A Meta-Regression Analysis

CONTEXT

In the absence of randomised controlled trials comparing the oncologic, toxicity, and functional outcomes of salvage radical prostatectomy (SRP), salvage high-intensity focused ultrasound (SHIFU), salvage brachytherapy (SBT), and salvage cryotherapy (SCT), controversy exists as to the optimal salvage modality in radiorecurrent prostate cancer.

OBJECTIVE

We carried out a meta-regression analysis to determine whether there is a difference in oncologic, toxicity, and functional outcomes using data from original publications of salvage modalities in the postradiation setting.

EVIDENCE ACQUISITION

We performed a systematic review of PubMed/Medline citations according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. We included 63 articles in the analysis (25 on SRP, 8 on SHIFU, 16 on SCT, 14 on SBT).

EVIDENCE SYNTHESIS

Median values of the following variables were extracted from each study: patient age, length of follow-up, prostate-specific antigen (PSA) before radiotherapy (RT), PSA before salvage therapy, Gleason score before RT, and time interval between RT and salvage therapy. Functional, toxicity, and oncologic outcomes were measured according to rates of impotence, incontinence, fistula formation, urethral strictures, and biochemical recurrence. Meta-regression adjusting for confounders found no significant difference in oncologic outcomes between SRP and nonsurgical salvage modalities. SBT, SCT, and SHIFU appeared to have better continence outcomes than SRP. No significant difference in toxicity outcomes between modalities was found, although limitations such as reporting, selection, and publication bias and between-study heterogeneity must also be considered with these conclusions.

CONCLUSIONS

Oncologic outcomes are comparable for SRP and all three nonsurgical salvage modalities. We found no significant differences in toxicity outcomes among modalities; however, SRP appears to be associated with worse rates of urinary incontinence than SBT, SCT, and SHIFU.

PATIENT SUMMARY

We performed a meta-regression analysis to compare oncologic, functional, and toxicity outcomes between salvage radical prostatectomy and nonsurgical salvage modalities. Oncologic and toxicity outcomes appear to be similar; however, all nonsurgical salvage modalities may be associated with better continence outcomes.

Is whole gland salvage cryotherapy effective as palliative treatment of haematuria in patients with locally advanced prostate cancer? Results of a preliminary case series

OBJECTIVES

Locally advanced prostate cancer may cause several complications such as haematuria, bladder outlet obstruction, and renal failure due to the ureteral obstruction. Various treatments have been suggested, including radiotherapy, antifibrinolytics, bladder irrigation with alum solution, transurethral surgery and angioembolization, none of which have proven effectiveness. In the last years cryoablation has become a valid therapeutic option for prostate cancer. In our experience we used this 'new' technique as haemostatic therapy.

METHODS

We selected four patients with gross haematuria affected by locally advanced hormone refractory prostate cancer, who had already been treated with primary radiotherapy. We used third-generation cryotherapy: under ultrasonographic guidance, we inserted six cryoprobes, two in each of the vascular pedicles reaching at least -60°C, and three thermometers. We then induced two freeze-thaw cycles.

RESULTS

After the operation the haematuria stopped in all patients and at 9-month follow up we observed a mean of four red cells (range three to five) in the urinary sediment with no evidence of bacteriuria. Prostate volume, prostate-specific antigen and postmicturition residue were significantly reduced. Qmax improved significantly too.

CONCLUSION

Our experience has given us good results with minimal intra- and postoperative complications. We think that haemostatic cryotherapy as a palliative approach for locally advanced prostate cancer could represent a valid treatment option and more consideration could be given to its use.

Focal cryotherapy of localized prostate cancer: a systematic review of the literature

Radical/whole gland treatment for prostate cancer has significant side-effects. Therefore focal treatments such as cryotherapy have been used to treat localized lesions whilst aiming to provide adequate cancer control with minimal side-effects. We performed a systematic review of Pubmed/Medline and Cochrane databases' to yield 9 papers for primary focal prostate cryotherapy and 2 papers for focal salvage treatment (radio-recurrent). The results of 1582 primary patients showed biochemical disease-free survival between 71-93% at 9-70 months follow-up. Incontinence rates were 0-3.6% and ED 0-42%. Recto-urethral fistula occurred in only 2 patients. Salvage focal cryotherapy had biochemical disease-free survival of 50-68% at 3 years. ED occurred in 60-71%. Focal cryotherapy appears to be an effective treatment for primary localized prostate cancer and compares favorably to radical/whole gland treatments in medium-term oncological outcomes and side-effects. Although more studies are needed it is also effective for radio-recurrent cancer with a low complications rates.

Salvage radical prostatectomy after external beam radiation therapy: a systematic review of current approaches

BACKGROUND

Radical external beam radiotherapy (EBRT) is a standard treatment for prostate cancer patients. Despite this, the rate of intraprostatic relapses after primary EBRT is still not negligible. There is no consensus on the most appropriate management of these patients after EBRT failure. For these patients, local salvage therapy such as radical prostatectomy, cryotherapy, and brachytherapy may be indicated.

OBJECTIVE

The objectives of this review were to analyze the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method.

METHODS

A review of the literature was performed to identify studies of local salvage therapy for patients who had failed primary EBRT for localized prostate cancer.

RESULTS

Most studies demonstrated that local salvage therapy after EBRT may provide long-term local control in appropriately selected patients, although toxicity is often significant.

CONCLUSIONS

Our results suggest that for localized prostate cancer recurrence after EBRT, the selection of a local treatment modality should be made on a patient-by-patient basis. An improvement in selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological outcome and least comorbidity.

Urethral strictures and the cancer survivor

PURPOSE OF REVIEW

Urethral stricture disease is poorly understood in prostate cancer survivors who have undergone radiation or ablative treatments. We review the cause and incidence of urethral strictures (excluding bladder neck contracture) in this setting, as well as risk factors and treatment options.

RECENT FINDINGS

Stricture rates differ for various modalities of radiation therapy, with the highest rate in high-dose-rate brachytherapy. Risk factors include higher dose of radiation delivered to prostate apex, radiation delivered per treatment, and prior transurethral resection of prostate. Cryoablation and high-intensity focused ultrasound of the prostate also carry high risk of urethral stricture formation, particularly in the salvage setting. Dilation or direct vision incision of the urethra can be utilized as a temporizing technique, with frequent recurrence. Urethral stenting is also an option; however, this is associated with a high rate of incontinence. Urethroplasty has durable outcomes for radiation-induced strictures, with a preference for excision and primary anastomosis because of the bulbomembranous location and relatively short length of these strictures. Salvage radical prostatectomy has been described in a small series as treatment for posterior urethral strictures and bladder neck contractures resulting from ablative therapies.

SUMMARY

Prostate cancer survivors treated with radiation or ablative therapies are at risk for urethral stricture formation. Urethroplasty is a feasible and durable treatment option and should be considered in the appropriate patient.

Salvage focal prostate cryoablation for locally recurrent prostate cancer after radiotherapy: initial results from the cryo on-line data registry

BACKGROUND

Several investigators have tried to apply salvage focal prostate cryoablation to small numbers of patients with biopsy-proven unilateral recurrent prostate cancer (PCa) after radiotherapy with the aim of decreasing complications of salvage cryoablation. We report contemporary outcomes of salvage focal cryoablation for locally recurrent PCa after radiotherapy within the Cryo On-Line Data (COLD) Registry.

METHODS

We queried the COLD Registry to identify patients diagnosed as locally recurrent PCa after radiotherapy and treated with salvage focal cryoablation. Patients with hormone ablation after cryotherapy were excluded. The biochemical disease-free survival and morbidities were analyzed. Biochemical failure was defined using the Phoenix definition.

RESULTS

From 2002 to 2012, 91 patients with biopsy-proven radio-recurrent PCa underwent salvage focal cryoablation with curative intent. The biochemical disease-free survival rates were 95.3%, 72.4%, and 46.5% at 1, 3, and 5 years, respectively. Positive biopsies after salvage focal cryoablation were observed in four of 14 patients who underwent biopsy (28.6%). Rectourethral fistula was observed in three cases (3.3%). Urinary retention was observed in six cases (6.6%). Incontinence (requiring pad use) was reported in five cases (5.5%). Intercourse was reported in 10 of 20 patients (50%) who reported potency before salvage focal cryoablation.

CONCLUSIONS

The outcomes from this observational study indicate that salvage focal cryoablation can be an effective treatment with encouraging potency preservation for patients with locally recurrent PCa after radiotherapy. However, other morbidity including rectourethral fistula and incontinence are not clearly lower than for patients treated with salvage whole gland cryoablation. Studies with longer follow-up, more patients, and direct comparison to salvage whole gland cryoablation are needed before recommending salvage focal cryoablation as a standard treatment option for these patients.

Salvage of locally recurrent prostate cancer after definitive radiotherapy

Although a significant proportion of patients with localized prostate cancer are cured after definitive radiotherapy, solitary local recurrence is observed in a subset of patients and poses a management challenge. Curative-intent treatment options include prostatectomy, reirradiation, cryotherapy, and high-intensity-focused ultrasound. Outcomes data after any of these options are relatively limited. The 5-year biochemical progression-free survival rate is approximately 50% after salvage prostatectomy. However, the morbidity rate of the procedure is significantly higher compared with that observed in previously untreated patients. The likelihood of cure after low dose rate brachytherapy is similar to that observed after salvage prostatectomy, and the morbidity, although significant is less. Although cryotherapy and high-intensity-focused ultrasound may be less morbid than a prostatectomy, the probability of cure is probably lower.

Cryotherapy in prostate cancer

Review objectives:

Cryotherapy use has increased due to technological advances. A review of the literature was performed to evaluate the efficacy and outcomes of whole gland, salvage and targeted focal cryotherapy in the management of prostate cancer.

Review findings:

Cryotherapy use has increased significantly over the last 10 years with a trend towards focal ablation. Whole gland cryotherapy, salvage cryotherapy and focal cryotherapy biochemical recurrence rates appear to be comparable to other treatment modalities for low risk disease, however biochemical failure remains difficult to compare across studies due to a lack of consensus regarding appropriate end points for evaluation of cryotherapy. Short-term focal cryotherapy outcomes are encouraging. Side effect profiles for cryotherapy have significantly improved with fourth generation systems while salvage cryotherapy continues to carry a slightly higher risk of incontinence than primary whole gland cryotherapy. The incidence of erectile dysfunction after focal cryotherapy is dramatically lower than that for whole gland ablation.

Conclusions:

Cryotherapy continues to have an active role in the primary and salvage treatment of prostate cancer. Targeted focal cryotherapy is a promising treatment with minimal morbidity. Further long-term data is needed to support targeted therapy in addition to direct comparison with other treatment modalities.

Focal salvage iodine-125 brachytherapy for prostate cancer recurrences after primary radiotherapy: a retrospective study regarding toxicity, biochemical outcome and quality of life

PURPOSE

Whole-gland salvage for recurrent prostate cancer (PCa) shows high failure and toxicity rates. Early and adequate localization of recurrences enables focal salvage, thereby potentially improving functional outcomes, while maintaining cancer control.

MATERIALS AND METHODS

Retrospective analysis yielded 20 focal salvage I125 brachytherapy patients for locally recurrent PCa after primary radiotherapy. Tumor was defined by multiparametric MRI and correspondence with transrectal biopsies. Dose data were obtained intra-operatively. The tumor was prescribed ⩾144 Gy. Toxicity was scored by the Common Terminology Criteria for Adverse Events version 4 (CTCAE-4). Biochemical failure (BF) was defined using the Phoenix criteria (PSA-nadir + 2.0 ng/ml). Quality of life (QoL) was measured by SF-36 Health Survey and European Organization of Research and Treatment of Cancer (EORTC) C30+3 and PR25 questionnaires.

RESULTS

With a median follow-up of 36 months (range 10-45), six patients experienced BF, of which three had no initial response. Grade 3 genitourinary (GU) toxicity occurred in one patient (a urethral stricture). The five previously potent patients retained erectile function. QoL remained decreased with regard to urinary symptoms.

CONCLUSION

Focal salvage I125 brachytherapy showed one grade 3 GU toxicity in the 20 treated patients. Biochemical response and QoL were acceptable.

[Focal therapy and prostate cancer]

The International Task Force on Prostate Cancer defines focal therapy (FT) for prostate cancer (PCa) as the therapy that "selectively ablates known disease and preserves existing functions, with the overall objective of minimizing lifetime morbidity without compromising life expectancy". FT for the treatment of PCa has been called the "male lumpectomy", an analogue to women's breast lumpectomy for the treatment of breast cancer. Radical prostatectomy continues to be the most frequently performed treatment for localized PCa, as anatomic knowledge and several technical advances, i.e. the introduction of robotic assisted surgery, have led to successful oncological outcome and lower rates of post-treatment morbidity. However, a proportion of patients still experiences a no negligible sexual, urinary, and bowel morbidity. Although the rationale of active surveillance for low-risk PCa (PSA <10 ng/mL, Gleason grade 6 or less, and clinical stage T1c-T2a) is sound, only few of newly diagnosed patients elect this approach. Thus, in the recent years the concept of a "subtotal therapy" gained the interest of some urological schools. The aim of this paper is to review the existing literature in order to provide the status of art on FT for PCa. The manuscript will focus on the characteristics of the target population, on the pre-operative evaluation to localise disease, as well as on perioperative, functional, and disease-control following focal therapy.

EAU guidelines on prostate cancer. Part II: Treatment of advanced, relapsing, and castration-resistant prostate cancer

OBJECTIVE

To present a summary of the 2013 version of the European Association of Urology (EAU) guidelines on the treatment of advanced, relapsing, and castration-resistant prostate cancer (CRPC).

EVIDENCE ACQUISITION

The working panel performed a literature review of the new data (2011-2013). The guidelines were updated, and levels of evidence and/or grades of recommendation were added to the text based on a systematic review of the literature that included a search of online databases and bibliographic reviews.

EVIDENCE SYNTHESIS

Luteinising hormone-releasing hormone (LHRH) agonists are the standard of care in metastatic prostate cancer (PCa). LHRH antagonists decrease testosterone without any testosterone surge, and they may be associated with an oncologic benefit compared with LHRH analogues. Complete androgen blockade has a small survival benefit of about 5%. Intermittent androgen deprivation results in noninferior oncologic efficacy when compared with continuous androgen-deprivation therapy (ADT) in well-selected populations. In locally advanced and metastatic PCa, early ADT does not result in a significant survival advantage when compared with delayed ADT. Relapse after local therapy is defined by prostate-specific antigen (PSA) values >0.2 ng/ml following radical prostatectomy (RP) and >2 ng/ml above the nadir and after radiation therapy (RT). Therapy for PSA relapse after RP includes salvage RT (SRT) at PSA levels <0.5 ng/ml and SRP or cryosurgical ablation of the prostate in radiation failures. Endorectal magnetic resonance imaging and 11C-choline positron emission tomography/computed tomography (PET/CT) are of limited importance if the PSA is <1.0 ng/ml; bone scans and CT can be omitted unless PSA is >20 ng/ml. Follow-up after ADT should include analysis of PSA and testosterone levels, and screening for cardiovascular disease and metabolic syndrome. Treatment of CRPC includes sipuleucel-T, abiraterone acetate plus prednisone (AA/P), or chemotherapy with docetaxel at 75mg/m(2) every 3 wk. Cabazitaxel, AA/P, enzalutamide, and radium-223 are available for second-line treatment of CRPC following docetaxel. Zoledronic acid and denosumab can be used in men with CRPC and osseous metastases to prevent skeletal-related complications.

CONCLUSIONS

The knowledge in the field of advanced, metastatic, and castration-resistant PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice. A full version is available at the EAU office or at www.uroweb.org.

PATIENT SUMMARY

We present a summary of the 2013 version of the European Association of Urology guidelines on treatment of advanced, relapsing, and castration-resistant prostate cancer (CRPC). Luteinising hormone-releasing hormone (LHRH) agonists are the standard of care in metastatic prostate cancer (PCa). LHRH antagonists decrease testosterone without any testosterone surge, and they might be associated with an oncologic benefit compared with LHRH analogues. Complete androgen blockade has a small survival benefit of about 5%. Intermittent androgen deprivation results in noninferior oncologic efficacy when compared with continuous androgen-deprivation therapy (ADT) in well-selected populations. In locally advanced and metastatic PCa, early ADT does not result in a significant survival advantage when compared with delayed ADT. Relapse after local therapy is defined by prostate-specific antigen (PSA) values >0.2 ng/ml following radical prostatectomy (RP) and >2 ng/ml above the nadir and after radiation therapy. Therapy for PSA relapse after RP includes salvage radiation therapy at PSA levels <0.5 ng/ml and salvage RP or cryosurgical ablation of the prostate in radiation failures. Multiparametric magnetic resonance imaging and 11C-choline positron emission tomography/computed tomography (PET/CT) are of limited importance if the PSA is <1.0 ng/ml; bone scans, and CT can be omitted unless PSA is >20 ng/ml. Follow-up after ADT should include analysis of PSA and testosterone levels, and screening for cardiovascular disease and metabolic syndrome. Treatment of castration-resistant CRPC includes sipuleucel-T, abiraterone acetate plus prednisone (AA/P), or chemotherapy with docetaxel 75 mg/m(2) every 3 wk. Cabazitaxel, AA/P, enzalutamide, and radium-223 are available for second-line treatment of CRPC following docetaxel. Zoledronic acid and denosumab can be used in men with CRPC and osseous metastases to prevent skeletal-related complications. The guidelines reported should be adhered to in daily routine to improve the quality of care in PCa patients. As we have shown recently, guideline compliance is only in the area of 30-40%.

Salvage focal and salvage total cryoablation for locally recurrent prostate cancer after primary radiation therapy

OBJECTIVES

To present the oncological and functional outcomes of salvage focal (SFC) and salvage total (STC) cryoablation for recurrent prostate cancer (PCa) after failed primary radiotherapy.

PATIENTS AND METHODS

From March 2003 to August 2010, 50 men with biopsy-proven unilateral (n = 25) or bilateral (n = 25) radio-recurrent PCa underwent SFC or STC, respectively. Patients were assessed after treatment by prostate-specific antigen (PSA) testing, transrectal ultrasonography, biopsy and questionnaires. Biochemical failure (BF) was defined using the Phoenix criteria (PSA nadir + 2 mg/mL). Data were prospectively collected and retrospectively analysed.

RESULTS

The median pre-cryoablation PSA level and Gleason score were, respectively, 2.8 ng/mL and 7 for SFC, and 3.9 ng/mL and 7 for STC. The median follow-up was 31 and 53 months (P = 0.004) for SFC and STC, respectively. Oncological outcomes were as follows: no patient died; one patient who underwent STC developed bone metastases; eight patients who underwent SFC and three who underwent STC had BF and the 5-year BF-free survival rates were 54 and 86%, respectively. In those patients without BF, the mean PSA decreased by 86% for SFC and 90% for STC within the first year and remained stable. Functional outcomes were as follows: new onset urinary incontinence occurred in three (13%) patients in the STC group, whereas no patient in the SFC group developed incontinence (P = 0.10); Two of seven patients in the SFC group retained postoperative potency, but none of the four potent patients in the STC group recovered potency postoperatively (P = 0.48); one (4%) patient in the STC group developed a recto-urethral fistula, but none occurred in the SFC group (P = 0.48).

CONCLUSIONS

SFC and STC are feasible and safe with acceptable mid-term oncological outcomes. For carefully selected patients, SFC is an option that could be associated with lower treatment-related morbidity compared with STC. Although longer follow-up and more patient numbers are needed, our initial oncological and functional outcomes of SFC and STC are encouraging.

Focal therapy for prostate cancer: rationale and treatment opportunities

Focal therapy is an emerging treatment modality for localised prostate cancer that aims to reduce the morbidity seen with radical therapy, while maintaining cancer control. Focal therapy treatment strategies minimise damage to non-cancerous tissue, with priority given to the sparing of key structures such as the neurovascular bundles, external sphincter, bladder neck and rectum. There are a number of ablative technologies that can deliver energy to destroy cancer cells as part of a focal therapy strategy. The most widely investigated are cryotherapy and high-intensity focussed ultrasound. Existing radical therapies, such as brachytherapy and external beam radiotherapy, also have the potential to be applied in a focal manner. The functional outcomes of focal therapy from several phase I and II trials have been encouraging, with low rates of urinary incontinence and erectile dysfunction. Robust medium- and long-term cancer control outcomes are currently lacking. Controversies in focal therapy remain, notably treatment paradigms based on the index lesion hypothesis, appropriate patient selection for focal therapy and how the efficacy of focal therapy should be assessed. This review articles discusses the current status of focal therapy, highlighting controversies and emerging strategies that can influence treatment outcomes for the future.

The role of focal therapy in the management of localised prostate cancer: a systematic review

CONTEXT

The incidence of localised prostate cancer is increasing worldwide. In light of recent evidence, current, radical, whole-gland treatments for organ-confined disease have being questioned with respect to their side effects, cancer control, and cost. Focal therapy may be an effective alternative strategy.

OBJECTIVE

To systematically review the existing literature on baseline characteristics of the target population; preoperative evaluation to localise disease; and perioperative, functional, and disease control outcomes following focal therapy.

EVIDENCE ACQUISITION

Medline (through PubMed), Embase, Web of Science, and Cochrane Review databases were searched from inception to 31 October 2012. In addition, registered but not yet published trials were retrieved. Studies evaluating tissue-preserving therapies in men with biopsy-proven prostate cancer in the primary or salvage setting were included.

EVIDENCE SYNTHESIS

A total of 2350 cases were treated to date across 30 studies. Most studies were retrospective with variable standards of reporting, although there was an increasing number of prospective registered trials. Focal therapy was mainly delivered to men with low and intermediate disease, although some high-risk cases were treated that had known, unilateral, significant cancer. In most of the cases, biopsy findings were correlated to specific preoperative imaging, such as multiparametric magnetic resonance imaging or Doppler ultrasound to determine eligibility. Follow-up varied between 0 and 11.1 yr. In treatment-naïve prostates, pad-free continence ranged from 95% to 100%, erectile function ranged from 54% to 100%, and absence of clinically significant cancer ranged from 83% to 100%. In focal salvage cases for radiotherapy failure, the same outcomes were achieved in 87.2-100%, 29-40%, and 92% of cases, respectively. Biochemical disease-free survival was reported using a number of definitions that were not validated in the focal-therapy setting.

CONCLUSIONS

Our systematic review highlights that, when focal therapy is delivered with intention to treat, the perioperative, functional, and disease control outcomes are encouraging within a short- to medium-term follow-up. Focal therapy is a strategy by which the overtreatment burden of the current prostate cancer pathway could be reduced, but robust comparative effectiveness studies are now required.

MR imaging-guided focal cryoablation in patients with recurrent prostate cancer

PURPOSE

To assess the feasibility of magnetic resonance (MR) imaging-guided focal cryoablation in patients with locally recurrent prostate cancer after radiation therapy.

MATERIALS AND METHODS

This was a prospective study, and informed consent was obtained from all patients. Ten consecutive patients with histopathologically proved recurrent prostate cancer after radiation therapy, without evidence of distant metastases, were treated while under general anesthesia in a 1.5-T MR unit. A urethral warmer was inserted. Cryoneedles were transperineally inserted under real-time MR imaging. Then, a rectal warmer was inserted. Ice ball growth was continuously monitored under MR imaging guidance. Two freeze-thaw cycles were performed. Follow-up consisted of a visit to the urologist, measurement of prostate-specific antigen level, and multiparametric MR imaging at 3, 6, and 12 months. Potential complications were recorded.

RESULTS

All patients were successfully treated. In one patient, the urethral warmer could not be inserted and the procedure was cancelled. Two months later, the procedure was successfully repeated. Another patient had urinary retention. Follow-up data were available for all patients. A local recurrence or remnant tumor was found in two patients after 6 months and in another patient after 12 months. These three patients underwent successful retreatment with MR imaging-guided focal cryoablation.

CONCLUSION

MR imaging-guided focal cryoablation of recurrent prostate cancer after radiation therapy is feasible and safe. Initial results are promising; however, longer follow-up is needed and more patients must be studied.

MR imaging of treated prostate cancer

Many management options are available to patients with newly diagnosed prostate cancer. Magnetic resonance (MR) imaging plays an important role in initial staging of prostate cancer, but it also aids in tumor detection when there is clinical or biochemical suspicion of residual or recurrent disease after treatment. The purpose of this review is to describe the normal appearances of the prostatic region after different kinds of treatment for prostate cancer and to discuss how these appearances differ from those of recurrent and residual disease. Several MR imaging techniques used in evaluating patients with prostate cancer are described, including conventional MR imaging sequences (mainly T1- and T2-weighted sequences), MR spectroscopic imaging, diffusion-weighted imaging, and dynamic contrast agent-enhanced MR imaging. Clinical considerations, together with the different approaches for interpreting serum prostate-specific antigen values in the posttreatment setting, are also presented. All forms of treatment alter the MR imaging features of the prostatic region to a greater or lesser extent, and it is important to be able to recognize expected posttreatment appearances and distinguish them from the features of recurrent or residual cancer to aid subsequent clinical management.

Focal salvage therapy for localized prostate cancer recurrence after external beam radiotherapy: a pilot study

BACKGROUND

The objective of this study was to evaluate the safety, feasibility, side-effect profile, and proof of concept for focal salvage therapy using high-intensity focused ultrasound (HIFU).

METHODS

A registry-based analysis was conducted between 2004 and 2009 of 430 patients who underwent HIFU. Thirty-nine patients received focal salvage therapy for localized recurrence after external beam radiotherapy. Multiparametric magnetic resonance imaging studies combined with transperineal template prostate mapping biopsies or transrectal biopsies were used to localize disease. Validated questionnaires were used to assess functional outcomes. Biochemical failure was defined by using both Phoenix criteria (prostate-specific antigen [PSA] nadir plus 2 ng/mL) and Stuttgart criteria (PSA nadir plus 1.2 ng/mL).

RESULTS

The mean pre-HIFU PSA level was 4.6 ng/mL. The median follow-up was 17 months (interquartile range, 10-29 months). International Index of Erectile Function-5 scores decreased from a median ± standard deviation (SD) of 18 ± 16 to 13 ± 21 at 6 months, demonstrating worsening function. Scores on the University of California Los Angeles-Expanded Prostate Cancer Index Composite Urinary domain indicate that pad-free, leak-free continence status was 64%, and the pad-free rate was 87.2% at last follow-up. One rectourethral fistula occurred and spontaneously resolved with urinary and bowel diversion. The actuarial progression-free survival rate (including PSA nonresponders) was 69% at 1 year and 49% at 2 years according to Phoenix criteria. Excluding PSA nonresponders, these rates were 74% and 58%, respectively (Phoenix criteria).

CONCLUSIONS

The results from this study indicated that focal salvage therapy is a potential strategy for localized recurrence after radiotherapy that may reduce the harms resulting from whole-gland salvage therapies.

[EAU guidelines on prostate cancer. Part II: treatment of advanced, relapsing, and castration-resistant prostate cancer]

OBJECTIVES

Our aim is to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the treatment of advanced, relapsing, and castration-resistant prostate cancer (CRPC).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and the levels of evidence (LEs) and/or grades of recommendation (GR) were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

Luteinising hormone-releasing hormone (LHRH) agonists are the standard of care in metastatic prostate cancer (PCa). Although LHRH antagonists decrease testosterone without any testosterone surge, their clinical benefit remains to be determined. Complete androgen blockade has a small survival benefit of about 5%. Intermittent androgen deprivation (IAD) results in equivalent oncologic efficacy when compared with continuous androgen-deprivation therapy (ADT) in well-selected populations. In locally advanced and metastatic PCa, early ADT does not result in a significant survival advantage when compared with delayed ADT. Relapse after local therapy is defined by prostate-specific antigen (PSA) values > 0.2 ng/ml following radical prostatectomy (RP) and > 2 ng/ml above the nadir after radiation therapy (RT). Therapy for PSA relapse after RP includes salvage RT at PSA levels < 0.5 ng/ml and salvage RP or cryosurgical ablation of the prostate in radiation failures. Endorectal magnetic resonance imaging and 11C-choline positron emission tomography/computed tomography (CT) are of limited importance if the PSA is < 2.5 ng/ml; bone scans and CT can be omitted unless PSA is >20 ng/ml. Follow-up after ADT should include screening for the metabolic syndrome and an analysis of PSA and testosterone levels. Treatment of castration-resistant prostate cancer (CRPC) includes second-line hormonal therapy, novel agents, and chemotherapy with docetaxel at 75 mg/m(2) every 3 wk. Cabazitaxel as a second-line therapy for relapse after docetaxel might become a future option. Zoledronic acid and denusomab can be used in men with CRPC and osseous metastases to prevent skeletal-related complications.

CONCLUSION

The knowledge in the field of advanced, metastatic, and CRPC is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice. A full version is available at the EAU office or online at www.uroweb.org.

Salvage cryotherapy for radiation-recurrent prostate cancer: outcomes and complications

Potentially curative salvage options for radio-recurrent prostate cancer include prostatectomy, brachytherapy, high-intensity focused ultrasound, and cryotherapy. Salvage cryoablation technology, surgical technique, oncologic outcomes, and complication rates have improved dramatically over the past few decades, shifting this treatment modality from investigational status to an established therapeutic option. In this review, we focus on the most up-to-date oncologic and functional outcomes, as well as complications of salvage cryotherapy for radiation-recurrent prostate cancer.