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Windisch O, Valerio M. Re: Evaluation of Outcomes Following Focal Ablative Therapy for Treatment of Localised Clinically Significant Prostate Cancer in Patients >70 Years: A Multi-institute, Multi-energy 15-year Experience. Eur Urol 2024; 86:75. [PMID: 38538420 DOI: 10.1016/j.eururo.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/05/2024] [Indexed: 06/21/2024]
Affiliation(s)
- Olivier Windisch
- Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, Geneva University, Geneva, Switzerland.
| | - Massimo Valerio
- Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, Geneva University, Geneva, Switzerland
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Ladjevardi S, Ebner A, Femic A, Huebner NA, Shariat SF, Kraler S, Kubik-Huch RA, Ahlman RC, Häggman M, Hefermehl LJ. Focal high-intensity focused ultrasound therapy for localized prostate cancer: An interim analysis of the multinational FASST study. Eur J Clin Invest 2024; 54:e14192. [PMID: 38445798 DOI: 10.1111/eci.14192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/24/2024] [Accepted: 02/25/2024] [Indexed: 03/07/2024]
Abstract
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.
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Affiliation(s)
- Sam Ladjevardi
- Department of Urology, University of Uppsala, Uppsala, Sweden
| | - Anna Ebner
- Department of Urology, Cantonal Hospital Baden, Baden, Switzerland
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | | | - Nicolai A Huebner
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Working Group for Diagnostic imaging in Urology (ABDU), Austrian association of Urology (ÖGU), Vienna, Austria
- Department of urology, University of California Davis, Sacramento, California, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Division of Urology, Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
- Department of Urology, Weill Cornell Medical College, New York, New York, USA
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | | | | | - Michael Häggman
- Department of Urology, University of Uppsala, Uppsala, Sweden
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Light A, Mayor N, Cullen E, Kirkham A, Padhani AR, Arya M, Bomers JGR, Dudderidge T, Ehdaie B, Freeman A, Guillaumier S, Hindley R, Lakhani A, Pendse D, Punwani S, Rastinehad AR, Rouvière O, Sanchez-Salas R, Schoots IG, Sokhi HK, Tam H, Tempany CM, Valerio M, Verma S, Villeirs G, van der Meulen J, Ahmed HU, Shah TT. The Transatlantic Recommendations for Prostate Gland Evaluation with Magnetic Resonance Imaging After Focal Therapy (TARGET): A Systematic Review and International Consensus Recommendations. Eur Urol 2024; 85:466-482. [PMID: 38519280 DOI: 10.1016/j.eururo.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 11/29/2023] [Accepted: 02/04/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND AND OBJECTIVE Magnetic resonance imaging (MRI) can detect recurrences after focal therapy for prostate cancer but there is no robust guidance regarding its use. Our objective was to produce consensus recommendations on MRI acquisition, interpretation, and reporting after focal therapy. METHODS A systematic review was performed in July 2022 to develop consensus statements. A two-round consensus exercise was then performed, with a consensus meeting in January 2023, during which 329 statements were scored by 23 panellists from Europe and North America spanning urology, radiology, and pathology with experience across eight focal therapy modalities. Using RAND Corporation/University of California-Los Angeles methodology, the Transatlantic Recommendations for Prostate Gland Evaluation with MRI after Focal Therapy (TARGET) were based on consensus for statements scored with agreement or disagreement. KEY FINDINGS AND LIMITATIONS In total, 73 studies were included in the review. All 20 studies (100%) reporting suspicious imaging features cited focal contrast enhancement as suspicious for cancer recurrence. Of 31 studies reporting MRI assessment criteria, the Prostate Imaging-Reporting and Data System (PI-RADS) score was the scheme used most often (20 studies; 65%), followed by a 5-point Likert score (six studies; 19%). For the consensus exercise, consensus for statements scored with agreement or disagreement increased from 227 of 295 statements (76.9%) in round one to 270 of 329 statements (82.1%) in round two. Key recommendations include performing routine MRI at 12 mo using a multiparametric protocol compliant with PI-RADS version 2.1 standards. PI-RADS category scores for assessing recurrence within the ablation zone should be avoided. An alternative 5-point scoring system is presented that includes a major dynamic contrast enhancement (DCE) sequence and joint minor diffusion-weighted imaging and T2-weighted sequences. For the DCE sequence, focal nodular strong early enhancement was the most suspicious imaging finding. A structured minimum reporting data set and minimum reporting standards for studies detailing MRI data after focal therapy are presented. CONCLUSIONS AND CLINICAL IMPLICATIONS The TARGET consensus recommendations may improve MRI acquisition, interpretation, and reporting after focal therapy for prostate cancer and provide minimum standards for study reporting. PATIENT SUMMARY Magnetic resonance imaging (MRI) scans can detect recurrent of prostate cancer after focal treatments, but there is a lack of guidance on MRI use for this purpose. We report new expert recommendations that may improve practice.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Nikhil Mayor
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Emma Cullen
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alex Kirkham
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Anwar R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK
| | - Manit Arya
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Joyce G R Bomers
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Behfar Ehdaie
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alex Freeman
- Department of Pathology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Richard Hindley
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Amish Lakhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK; Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Surgery and Cancer, Imperial College London, London, UK
| | - Douglas Pendse
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | | | - Olivier Rouvière
- Department of Vascular and Urinary Imaging, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine, Université de Lyon, Lyon, France
| | | | - Ivo G Schoots
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Heminder K Sokhi
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK; Department of Radiology, The Hillingdon Hospitals NHS Foundation Trust, London, UK
| | - Henry Tam
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Clare M Tempany
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimo Valerio
- Department of Urology, Geneva University Hospitals, Geneva, Switzerland
| | - Sadhna Verma
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Geert Villeirs
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jan van der Meulen
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.
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Zhu A, Strasser MO, McClure TD, Gereta S, Cheng E, Pandit K, Hu JC. Comparative Effectiveness of Partial Gland Cryoablation Versus Robotic Radical Prostatectomy for Cancer Control. Eur Urol Focus 2024:S2405-4569(24)00060-9. [PMID: 38677913 DOI: 10.1016/j.euf.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/23/2024] [Accepted: 04/12/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND AND OBJECTIVE There is an absence of high-level evidence comparing oncologic endpoints for partial gland ablation, and most series use prostate-specific antigen (PSA) rather than biopsy endpoints. Our aim was to compare oncologic outcomes between partial gland cryoablation (PGC) and radical prostatectomy (RP) for prostate cancer. METHODS This was a retrospective, single-center analysis of subjects treated with PGC (n = 98) or RP (n = 536) between January 2017 and December 2022 as primary treatment for intermediate-risk (Gleason grade group [GG] 2-3) prostate cancer. Oncologic endpoints included surveillance biopsies per protocol after PGC in comparison to serial PSA testing after RP. The primary outcome was treatment failure, defined as a need for any salvage treatment or development of metastatic disease. Treatment failure and survival analyses were conducted using Cox proportional-hazard regression and Kaplan Meier survival curves. KEY FINDINGS AND LIMITATIONS After applying the inclusion/exclusion criteria, the PGC (n = 75) and RP (n = 298) groups were compared. PGC patients were significantly older (71 vs 64 yr; p < 0.001), but there were no differences in PSA, biopsy GG, or treatment year between the groups. The PGC group had higher rates of treatment failures at 24 mo (33% vs 11%; p < 0.001) and 48 mo (43% vs 14%; p < 0.001). One PGC patient (2.1%) and one RP patient (0.7%) developed metastases by 48-mo follow-up (p = 0.4). On adjusted analysis, PGC was associated with a higher risk of treatment failure (hazard ratio 4.6, 95% confidence interval 2.7-7.9; p < 0.001). Limitations include observational biases associated with the retrospective study design. CONCLUSIONS This is the first comparative effectiveness study of cancer control outcomes for PGC versus RP. The results demonstrate an almost fivefold higher risk of treatment failure with PGC during short-term follow-up. PATIENT SUMMARY We compared cancer control outcomes for patients with intermediate-risk prostate cancer treated with partial gland cryoablation versus radical prostatectomy. We found that partial gland cryoablation had an almost fivefold higher risk of treatment failure. Men with prostate cancer should be counseled regarding this difference in treatment failure.
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Affiliation(s)
- Alec Zhu
- Department of Urology, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Mary O Strasser
- Department of Urology, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Timothy D McClure
- Department of Urology, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Sofia Gereta
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Emily Cheng
- Department of Urology, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Kshitij Pandit
- Department of Urology, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Jim C Hu
- Department of Urology, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA.
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Chiu PKF, Chan CH, Yee CH, Lau SY, Teoh JYC, Wong HF, Lo KL, Yuen TY, Hung HY, Cho CCM, Ng CF. Transperineal Targeted Microwave Ablation (TMA) of localized prostate cancer guided by MRI-Ultrasound fusion and organ-based tracking: a pilot study. Prostate Cancer Prostatic Dis 2023; 26:736-742. [PMID: 35835844 DOI: 10.1038/s41391-022-00577-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND To investigate the efficacy of transperineal targeted microwave ablation (TMA) in treating localized prostate cancer (PCa). METHODS This is a single-centre prospective phase 2 trial recruiting men with low to intermediate-risk localized PCa to undergo transperineal TMA. TMA was performed with MRI-Ultrasound fusion guidance and organ-based tracking. A per-protocol 6-month MRI and biopsy were performed for all patients. The primary outcome was any cancer detected on biopsy of each ablated area. Secondary outcomes included per-patient analysis of positive biopsy, complications, urinary symptom score, erectile function and quality of life (QOL) scores. RESULTS In the first 15 men, 23 areas were being treated. The median age was 70 years, number of TMA ablations were 5 (range 2-8), and the total ablation time and operating time was 22 (IQR 14-28) and 75 (IQR 65-85) minutes, respectively. PSA level dropped from a median of 7.7 to 2.4 ng/mL. For the primary outcome, 91.3% (21/23) ablated area had no cancer in 6-month biopsy. In per-patient analysis, 33.3% (5/15) had in or out-of-field positive biopsy at 6 months. Among these five cases, four of them were amenable to active surveillance and 1 (6.7%) case with out-of-field ISUP grade group 2 cancer received radiotherapy. The urinary symptoms, uroflowmetry, erectile function, and QOL scores had no significant difference at 6 months. One patient (out of five patients with normal erection) in the cohort complained of significant worsening of erectile function after TMA. Grade 1 complications including hematuria (33.3%), dysuria (6.7%), and perineal discomfort (13.4%) were observed. CONCLUSIONS In this first pilot study, transperineal TMA guided by MRI-Ultrasound fusion guidance and organ-based tracking was shown to be effective, safe, and easily applicable in men with localized PCa.
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Affiliation(s)
- Peter Ka-Fung Chiu
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
| | - Chun-Hong Chan
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Chi-Hang Yee
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Sui-Yan Lau
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Jeremy Yuen-Chun Teoh
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Ho-Fai Wong
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Ka-Lun Lo
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Tsz-Yau Yuen
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hiu-Yee Hung
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Carmen Chi-Min Cho
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Chi-Fai Ng
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
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Parry MG, Sujenthiran A, Nossiter J, Morris M, Berry B, Nathan A, Aggarwal A, Payne H, van der Meulen J, Clarke NW. Prostate cancer outcomes following whole-gland and focal high-intensity focused ultrasound. BJU Int 2023; 132:568-574. [PMID: 37422679 DOI: 10.1111/bju.16122] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
OBJECTIVE To report the 5-year failure-free survival (FFS) following high-intensity focused ultrasound (HIFU). PATIENTS AND METHODS This observational cohort study used linked National Cancer Registry data, radiotherapy data, administrative hospital data and mortality records of 1381 men treated with HIFU for clinically localised prostate cancer in England. The primary outcome, FFS, was defined as freedom from local salvage treatment and cancer-specific mortality. Secondary outcomes were freedom from repeat HIFU, prostate cancer-specific survival (CSS) and overall survival (OS). Cox regression was used to determine whether baseline characteristics, including age, treatment year, T stage and International Society of Urological Pathology (ISUP) Grade Group were associated with FFS. RESULTS The median (interquartile range [IQR]) follow-up was 37 (20-62) months. The median (IQR) age was 65 (59-70) years and 81% had an ISUP Grade Group of 1-2. The FFS was 96.5% (95% confidence interval [CI] 95.4%-97.4%) at 1 year, 86.0% (95% CI 83.7%-87.9%) at 3 years and 77.5% (95% CI 74.4%-80.3%) at 5 years. The 5-year FFS for ISUP Grade Groups 1-5 was 82.9%, 76.6%, 72.2%, 52.3% and 30.8%, respectively (P < 0.001). Freedom from repeat HIFU was 79.1% (95% CI 75.7%-82.1%), CSS was 98.8% (95% CI 97.7%-99.4%) and OS was 95.9% (95% CI 94.2%-97.1%) at 5 years. CONCLUSION Four in five men were free from local salvage treatment at 5 years but treatment failure varied significantly according to ISUP Grade Group. Patients should be appropriately informed with respect to salvage radical treatment following HIFU.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Arunan Sujenthiran
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
- Flatiron, London, UK
| | - Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Arjun Nathan
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
- University College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Noel W Clarke
- Departments of Urology, The Christie and Salford Royal Hospitals, Manchester, UK
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7
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Jung G, Kim JK, Oh JJ, Lee S, Byun SS, Hong SK, Lee H. Partial gland ablation using high-intensity focused ultrasound versus robot-assisted radical prostatectomy: a propensity score-matched study. Prostate Int 2023; 11:134-138. [PMID: 37745903 PMCID: PMC10513903 DOI: 10.1016/j.prnil.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/10/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Background We compared the clinical outcomes of robot-assisted radical prostatectomy (RARP) and partial gland ablation (PGA) using high-intensity focused ultrasound (HIFU) in localized prostate cancer. Methods We analyzed 3,859 patients who had undergone RARP and PGA using HIFU. According to the propensity score for each treatment, 137 patients after PGA were matched to 3,722 patients after RARP at a 1:4 ratio using the nearest neighbor method. Results The matched cohort comprised 685 subjects (RARP, 548; PGA, 137), with a median follow-up period of 22 months. Treatment failures were identified in 13.9% and 9.1% of patients in the PGA and RARP groups, respectively, after a median follow-up of 36 months postoperatively. Kaplan-Meier analyses revealed significantly longer failure-free (P < 0.001) and salvage-free survival (P = 0.003) in the RARP group than in the PGA group. There was no significant difference in the postoperative urinary symptom score (P = 0.748), but the postoperative erectile function score was significantly higher in the PGA group (P < 0.001). The rate of urinary incontinence (any pad) was significantly lower in the PGA group than that in the RARP group (P < 0.001). Postoperative complications were more frequent in the PGA group (P = 0.003); however, there was no significant difference in high-grade complications (≥3) (P = 0.467). Conclusion PGA using HIFU showed statistically inferior oncological outcomes compared with RARP for failure-free survival and salvage-free survival. However, functional outcomes regarding postoperative incontinence and erectile dysfunction were more favorable in the PGA group.
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Affiliation(s)
- Gyoohwan Jung
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Kwon Kim
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Jin Oh
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sangchul Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Kyu Hong
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Hakmin Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
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8
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Javier-DesLoges J, Dall'Era MA, Brisbane W, Chamie K, Washington SL, Chandrasekar T, Marks LS, Nguyen H, Daneshvar M, Gin G, Kane CJ, Bagrodia A, Cooperberg MR. The state of focal therapy in the treatment of prostate cancer: the university of California collaborative (UC-Squared) consensus statement. Prostate Cancer Prostatic Dis 2023:10.1038/s41391-023-00702-1. [PMID: 37553435 DOI: 10.1038/s41391-023-00702-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/24/2023] [Accepted: 07/17/2023] [Indexed: 08/10/2023]
Affiliation(s)
| | - Marc A Dall'Era
- Department of Urology, University of California-Davis, Sacramento, CA, USA
| | - Wayne Brisbane
- Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Karim Chamie
- Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Samuel L Washington
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | | | - Leonard S Marks
- Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Hao Nguyen
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Michael Daneshvar
- Department of Urology, University of California-Irvine, Irvine, CA, USA
| | - Gregory Gin
- Department of Urology, University of California-Irvine, Irvine, CA, USA
| | - Christopher J Kane
- Department of Urology, University of California-San Diego, La Jolla, CA, USA
| | - Aditya Bagrodia
- Department of Urology, University of California-San Diego, La Jolla, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA.
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9
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Priester A, Fan RE, Shubert J, Rusu M, Vesal S, Shao W, Khandwala YS, Marks LS, Natarajan S, Sonn GA. Prediction and Mapping of Intraprostatic Tumor Extent with Artificial Intelligence. EUR UROL SUPPL 2023; 54:20-27. [PMID: 37545845 PMCID: PMC10403686 DOI: 10.1016/j.euros.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 08/08/2023] Open
Abstract
Background Magnetic resonance imaging (MRI) underestimation of prostate cancer extent complicates the definition of focal treatment margins. Objective To validate focal treatment margins produced by an artificial intelligence (AI) model. Design setting and participants Testing was conducted retrospectively in an independent dataset of 50 consecutive patients who had radical prostatectomy for intermediate-risk cancer. An AI deep learning model incorporated multimodal imaging and biopsy data to produce three-dimensional cancer estimation maps and margins. AI margins were compared with conventional MRI regions of interest (ROIs), 10-mm margins around ROIs, and hemigland margins. The AI model also furnished predictions of negative surgical margin probability, which were assessed for accuracy. Outcome measurements and statistical analysis Comparing AI with conventional margins, sensitivity was evaluated using Wilcoxon signed-rank tests and negative margin rates using chi-square tests. Predicted versus observed negative margin probability was assessed using linear regression. Clinically significant prostate cancer (International Society of Urological Pathology grade ≥2) delineated on whole-mount histopathology served as ground truth. Results and limitations The mean sensitivity for cancer-bearing voxels was higher for AI margins (97%) than for conventional ROIs (37%, p < 0.001), 10-mm ROI margins (93%, p = 0.24), and hemigland margins (94%, p < 0.001). For index lesions, AI margins were more often negative (90%) than conventional ROIs (0%, p < 0.001), 10-mm ROI margins (82%, p = 0.24), and hemigland margins (66%, p = 0.004). Predicted and observed negative margin probabilities were strongly correlated (R2 = 0.98, median error = 4%). Limitations include a validation dataset derived from a single institution's prostatectomy population. Conclusions The AI model was accurate and effective in an independent test set. This approach could improve and standardize treatment margin definition, potentially reducing cancer recurrence rates. Furthermore, an accurate assessment of negative margin probability could facilitate informed decision-making for patients and physicians. Patient summary Artificial intelligence was used to predict the extent of tumors in surgically removed prostate specimens. It predicted tumor margins more accurately than conventional methods.
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Affiliation(s)
- Alan Priester
- Department of Urology, David Geffen School of Medicine, Los Angeles, CA, USA
- Avenda Health, Inc., Culver City, CA, USA
| | - Richard E. Fan
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Mirabela Rusu
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sulaiman Vesal
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Wei Shao
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Yash Samir Khandwala
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Leonard S. Marks
- Department of Urology, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Shyam Natarajan
- Department of Urology, David Geffen School of Medicine, Los Angeles, CA, USA
- Avenda Health, Inc., Culver City, CA, USA
| | - Geoffrey A. Sonn
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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10
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Ong S, Chen K, Grummet J, Yaxley J, Scheltema MJ, Stricker P, Tay KJ, Lawrentschuk N. Guidelines of guidelines: focal therapy for prostate cancer, is it time for consensus? BJU Int 2023; 131:20-31. [PMID: 36083229 PMCID: PMC10087270 DOI: 10.1111/bju.15883] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To provide a summary and discussion of international guidelines, position statements and consensus statements in relation to focal therapy (FT) for prostate cancer (PCa). METHODS The European Association of Urology-European Association of Nuclear Medicine-European Society for Radiotherapy and Oncology-European Society of Urogential Radiology-International Society of Urological Pathology-International Society of Geriatric Oncology and American Urological Association-American Society for Radiation Oncology-Society of Urologic Oncology guidelines were interrogated for recommendations for FT. PubMed and Ovid Medline were searched for consensus statements. Only studies in English since 2015 were included. Reference lists of the included articles were also interrogated and a manual search for studies was also performed. RESULTS Our results showed a lack of long-term randomised data for FT. International Urological guidelines emphasised the need for more high-quality clinical trials with robust oncological and toxicity outcomes. Consensus and positions statements were heterogenous. CONCLUSION A globally accepted guideline for FT planning, technique and follow-up are still yet to be determined. Well-designed studies with long-term follow-up and robust clinical and toxicity endpoints are needed to improve our understanding of FT and create uniform guidelines to streamline management and follow-up.
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Affiliation(s)
- Sean Ong
- EJ Whitten Foundation Prostate Cancer Research Centre, Epworth HealthCare, Melbourne, Vic., Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic., Australia
| | - Kenneth Chen
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Vic., Australia.,Department of Urology, Singapore General Hospital, Singapore City, Singapore
| | - Jeremy Grummet
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Vic., Australia
| | - John Yaxley
- The University of Queensland, School of Medicine, Brisbane, QLD, Australia.,Wesley Urology Clinic, Wesley Hospital, Brisbane, QLD, Australia.,Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Matthijs J Scheltema
- St. Vincent's Prostate Cancer Research Centre, Darlinghurst, NSW, Australia.,Department of Urology, St Vincents Hospital and Campus, Sydney, NSW, Australia
| | - Phillip Stricker
- St. Vincent's Prostate Cancer Research Centre, Darlinghurst, NSW, Australia.,Department of Urology, St Vincents Hospital and Campus, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Kae Jack Tay
- Department of Urology, Singapore General Hospital, Singapore City, Singapore
| | - Nathan Lawrentschuk
- EJ Whitten Foundation Prostate Cancer Research Centre, Epworth HealthCare, Melbourne, Vic., Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic., Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Vic., Australia.,Department of Urology, Royal Melbourne Hospital, Melbourne, Vic., Australia
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11
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Wysock J, Thakker S, Rapoport E, Gogaj R, Lepor H. Two Year Functional Outcomes Stratified According to Baseline Erectile Function Following Partial Gland Cryo-Ablation. Urology 2023; 171:158-163. [PMID: 36272564 DOI: 10.1016/j.urology.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/20/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To critically evaluate time dependent sexual function following primary partial gland cryo-ablation (PGCA) stratified according to baseline erectile function. METHODS Between March 2017 and March 2022, all men undergoing primary PGCA by 2 surgeons were enrolled in an IRB approved outcomes registry. All subjects with PIRADS 2-5 lesion concordant with unilateral GGG 1-3 disease, no gross extra-prostatic extension on mpMRI, GGG >1 contralateral to the ROI, or distal apical disease on mpMRI were enrolled. Patients completed the Sexual Health Inventory for Men (SHIM) scale at baseline, 6, and 24 months. Men were stratified by baseline erectile function. Men with SHIM Score < 8 were excluded. Ability to sustain erection (aka "potency") was defined as a score of 3 or greater on question 2 of the SHIM index. Median SHIM scores and the proportion of men reporting "potency" at baseline, 6, and 24 months was recorded with comparisons between each timepoint. A univariate analysis was used to determine if clinical factors were associated with loss of "potency" at 24 months. RESULTS 106 men met the inclusion criteria. There was a statistically significant decrease in the mean SHIM scores for the entire cohort between baseline to 6 months and baseline to 24 months. SHIM scores increased significantly for the total cohort between 6 and 24 months. "Potency" was preserved in 70% at 24 months. CONCLUSION Those patients most likely to exhibit a decrease in sexual function have moderate ED at baseline. Only baseline ED was shown to predict preservation of "potency".
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12
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Nassiri N, Richardson S, Kuppermann D, Brisbane WG, Gonzalez S, Kwan L, Felker E, Wallner C, Marks LS. Partial Gland Ablation of Prostate Cancer: Effects of Repeat Treatment. Urology 2022; 170:161-167. [PMID: 35907484 DOI: 10.1016/j.urology.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/24/2022] [Accepted: 07/17/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the near-term clinical and pathological effects of repeat partial gland ablation (PGA) in men with intermediate-risk prostate cancer (PCa). MATERIALS AND METHODS One hundred seventy men with focal lesions of PCa (all GG2 or GG3) underwent PGA with high-intensity focused ultrasound (HIFU) or cryotherapy (CRYO) in prospective trials. Residual PCa in or near the ablation zone was found in 37 men after a first PGA; 30 went on to receive a second PGA and were the subjects of study. At 3 timepoints, baseline and 6 months after first and second ablations, quality-of-life (QOL) questionnaires (IIEF, IPSS) and MRI-guided biopsies (MRGB) were performed. Biopsies were targeted and systematic at baseline and in follow-up, comprehensively about the ablation zone. RESULTS All 30 patients completed QOL questionnaires and 26 had MRGB at the 3 timepoints. Mean QOL scores were not significantly different from the baseline after the first or second PGA. No operative complications were encountered; and "decisional regret" was reported in only 2/29 men after the repeat ablation. A decrease in semen volume was reported by 25% of patients. Repeat ablation was successful (absence of csPCa on MRGB) in 14/26 (53%) of men. PSA levels decreased and MRI lesions resolved after ablations, but neither was a reliable predictor of biopsy outcomes. CONCLUSION When initial PGA fails, repeat PGA is a reasonable consideration, because in near-term follow-up, secondary procedures appear to be safe, causing only minimal detriment to urinary and sexual function, with csPCa becoming undetectable by MRGB in approximately half the patients.
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Affiliation(s)
- Nima Nassiri
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Shannon Richardson
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David Kuppermann
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Wayne G Brisbane
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Samantha Gonzalez
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ely Felker
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Caroline Wallner
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Leonard S Marks
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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13
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Marra G, Soeterik T, Oreggia D, Tourinho-Barbosa R, Moschini M, Stabile A, Filippini C, van Melick HH, van den Bergh RC, Gontero P, Pasquali C, Macek P, Cathala N, Sanchez-Salas R, Cathelineau X. Focal High-Intensity Focused Ultrasound vs. Active Surveillance for ISUP Grade 1 Prostate Cancer: Medium-Term Results of a Matched-Pair Comparison. Clin Genitourin Cancer 2022; 20:592-604. [PMID: 35918262 DOI: 10.1016/j.clgc.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION/BACKGROUND Only 1 randomized controlled trial has compared focal therapy and active surveillance (AS) for the low-risk prostate cancer (PCa). We investigated whether focal HIFU (fHIFU) yields oncologic advantages over AS for low-risk PCa. MATERIALS AND METHODS We included 2 non-randomized prospective series of 132 (fHIFU) and 421 (AS) consecutive patients diagnosed with ISUP 1 PCa between 2008 and 2018. A matched pair analysis was performed to decrease potential bias. Study main outcomes were freedom from radical treatment (RT) or androgen-deprivation therapy (ADT), treatment-free survival (TFS), time to metastasis, and overall survival (OS). RESULTS Median fHIFU follow-up was 50 months (interquartile range, 29-84 months). Among matched variables, no major differences were recorded except for AS having more suspicious digital rectal examination findings (P = .0074) and recent enrollment year (P = .0005). Five-year intervention-free survival from RT or ADT was higher for the fHIFU cohort (67.4% vs. 53.8%; P = .0158). Time to treatment was approximately 10 months shorter for AS than for fHIFU (time to RT, P = .0363; time to RT or ADT, P = .0156; time to any treatment, P = .0319). No differences were found in any-TFS (fHIFU, 61.4% vs. AS, 53.8%; P = .2635), OS (fHIFU, 97% vs. AS, 97%; P = .9237), or metastasis (n = 0 in fHIFU and n = 2 in AS; P = .4981). Major complications (≥ Clavien 3) were rare (n = 4), although 36.4% of men experienced complications. No relevant changes were noted in continence (P = .3949). CONCLUSION At a 4-year median follow-up, fHIFU for mainly low-risk PCa (ISUP grade 1) is safe, may decrease the need for radical treatment or ADT and may allow longer time to treatment compared to AS. Nonetheless, no advantages are seen in PCa progression and/or death (OS).
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Affiliation(s)
- Giancarlo Marra
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France; Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin Italy; Department of Urology and Clinical Research Group on predictive onco-urology, APHP. Sorbonne University, Paris, France.
| | - Timo Soeterik
- Department of Urology, St. Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - Davide Oreggia
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Rafael Tourinho-Barbosa
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Marco Moschini
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Armando Stabile
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Claudia Filippini
- Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin Italy
| | - Harm He van Melick
- Department of Urology, St. Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | | | - Paolo Gontero
- Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin Italy
| | - Caio Pasquali
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Petr Macek
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Nathalie Cathala
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Rafael Sanchez-Salas
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Xavier Cathelineau
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
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14
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Anttinen M, Blanco Sequeiros R, Boström PJ, Taimen P. Evolving imaging methods of prostate cancer and the emergence of magnetic resonance imaging guided ablation techniques. Front Oncol 2022; 12:1043688. [DOI: 10.3389/fonc.2022.1043688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022] Open
Abstract
Established therapies for prostate cancer (PCa), surgery and radiotherapy, treat the entire gland regardless of the location of the cancerous lesion within the prostate. Although effective, these methods include a significant risk of worsening genitourinary outcomes. Targeted image-guided cancer therapy has gained acceptance through improved PCa detection, localization, and characterization by magnetic resonance imaging (MRI). Minimally-invasive ablative techniques aim to achieve comparable oncological outcomes to radical treatment while preserving genitourinary function. Transurethral ultrasound ablation (TULSA) and next-generation transrectal high-intensity focused ultrasound (HIFU) utilize MRI guidance to thermally ablate prostate tissue under real-time MRI monitoring and active temperature feedback control. Previous trials performed by our group and others, including a large multicenter study in men with localized favorable-risk disease, have demonstrated that TULSA provides effective prostate ablation with a favorable safety profile and low impact on quality of life. Recently, MRI-guided HIFU focal therapy was also shown as a safe and effective treatment of intermediate-risk PCa. Here we review the current literature on ablative techniques in the treatment of localized PCa with a focus on TULSA and HIFU methods.
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15
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Fujihara A, Ukimura O. Focal therapy of localized prostate cancer. Int J Urol 2022; 29:1254-1263. [PMID: 35996758 DOI: 10.1111/iju.14991] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 07/04/2022] [Indexed: 11/28/2022]
Abstract
In the treatment of localized prostate cancer, controlling the cancer and maintaining quality of life are important. Focal therapy of localized prostate cancer aims to treat the lesion/part of the prostate that includes the index lesion, which determines the prognosis. We performed a non-systematic review of novel studies on focal therapy of localized prostate cancer as primary treatment published between 2016 and 2021. For mainly intermediate-risk patients, therapeutic technology, such as cryoablation, brachytherapy, high-intensity focused ultrasound, photodynamic therapy, microwave-coagulation, electroporation, and laser ablation, etc., were performed. These procedures are minimally invasive and safe, and provide good functional outcome: a 94-100% pad-free rate against urinary incontinence and 47-86% erectile function, which is sufficient for sexual intercourse. Accurate three-dimensional mapping of the targeted lesion could be an essential navigation technique for therapeutic success. Intermediate- to short-term oncological outcomes were good, resulting in downstaging of the patient's status to no clinically significant cancer; however, transition to conventional whole-gland treatment was necessary in about 10-30% of patients. It is important to select appropriate patients by both multiparametric magnetic resonance imaging and targeted biopsy, and to follow-up postoperatively with methods such as active surveillance. Clinically significant prostate-specific antigen reduction, image response using preoperative and postoperative multiparametric magnetic resonance imaging, and histological analysis should be combined for follow-up.
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Affiliation(s)
- Atsuko Fujihara
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Ukimura
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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16
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Duan H, Iagaru A. The use of advanced imaging in guiding the further investigation and treatment of primary prostate cancer. Cancer Imaging 2022; 22:45. [PMID: 36057766 PMCID: PMC9441085 DOI: 10.1186/s40644-022-00481-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/05/2022] [Indexed: 11/10/2022] Open
Abstract
In the era of precision medicine, oncological imaging techniques are advancing at a rapid pace, particularly molecular imaging with promising new targets for prostate cancer (PC) such as gastrin releasing peptide receptors (GRPR) along the established and indispensable prostate specific membrane antigen (PSMA). As PC is characterized by heterogenous tumor biology ranging from indolent to aggressive disease, distinguishing clinically significant tumors from indolent disease is critical. Multiparametric MRI- and PET-targeted prostate biopsies mitigate the shortcomings and risks of standard systematic template biopsy by identifying more significant cancers.Focal treatment for localized disease is a minimally invasive approach that targets the index tumor - the lesion of the highest grade - while sparing the surrounding healthy tissue. Real-time MRI-guidance and thermal control with MR-thermometry, improves treatment accuracy and results in lower rates of functional side effects. PET imaging could be an useful tool to assess response to treatment compared to invasive prostate biopsies.In this comprehensive review, we focus on the image-guided detection and treatment of localized primary prostate cancer, its current status and future perspectives.
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Affiliation(s)
- Heying Duan
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Stanford University, Stanford, CA, USA
| | - Andrei Iagaru
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Stanford University, Stanford, CA, USA.
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17
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Applications of Focused Ultrasound in the Treatment of Genitourinary Cancers. Cancers (Basel) 2022; 14:cancers14061536. [PMID: 35326687 PMCID: PMC8945954 DOI: 10.3390/cancers14061536] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Cancer is a prevalent disease globally, and conventional treatment options have been associated with substantial morbidity for patients. The unique acoustic properties and biological effects of focused ultrasound have been investigated for use as an alternative treatment option for various forms of cancer with lower associated morbidity than standard treatments. The objective of our review was to assess the current state and various applications of focused ultrasound for the treatment of genitourinary cancers, including prostate, kidney, bladder, penile, and testicular malignancies. Current research demonstrates that focused ultrasound-based focal therapy shows promise for the treatment of localized prostate and kidney cancer, and the effect of ultrasound on cell membranes may increase the efficacy of chemotherapeutics and radiotherapy. Focused ultrasound-based treatment modalities should continue to be investigated as an alternative or complementary treatment option for cancer patients. Abstract Traditional cancer treatments have been associated with substantial morbidity for patients. Focused ultrasound offers a novel modality for the treatment of various forms of cancer which may offer effective oncological control and low morbidity. We performed a review of PubMed articles assessing the current applications of focused ultrasound in the treatment of genitourinary cancers, including prostate, kidney, bladder, penile, and testicular cancer. Current research indicates that high-intensity focused ultrasound (HIFU) focal therapy offers effective short-term oncologic control of localized prostate and kidney cancer with lower associated morbidity than radical surgery. In addition, studies in mice have demonstrated that focused ultrasound treatment increases the accuracy of chemotherapeutic drug delivery, the efficacy of drug uptake, and cytotoxic effects within targeted cancer cells. Ultrasound-based therapy shows promise for the treatment of genitourinary cancers. Further research should continue to investigate focused ultrasound as an alternative cancer treatment option or as a complement to increase the efficacy of conventional treatments such as chemotherapy and radiotherapy.
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18
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Peters I, Derlin K, Peperhove MJ, Hensen B, Pertschy S, Wolters M, von Klot CAJ, Wacker F, Hellms S. First experiences and results after cryoablation of prostate cancer with histopathological evaluation and imaging-based follow-up. Future Oncol 2022; 18:1705-1716. [PMID: 35255716 DOI: 10.2217/fon-2021-1146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To share our experience after 28 cryoablation treatments for prostate cancer (PCa) with histopathology, clinical data and MRI as the follow-up methods. Methods: Clinical follow-up comprised prostate specific antigen (PSA)-measurements, PSA-density and quality-of-life-parameters. multi-parametric (mp)MRI pre- and post-cryoablation were retrospectively re-analyzed in 23 cases using Likert scores. Follow-up-histopathology was performed via MRI/ultrasound fusion-guided and/or systematic biopsy. Receiver operating characteristic curve analysis was performed. Results: 17 PCa (61%) were diagnosed within 12-month post-cryotherapy (infield and out-of-field disease). PSA levels and PSA density were not significantly different between patients with or without PCa recurrence. mpMRI can characterize the decrease in prostate volume and necrosis. Area under the curve for the detection of PCa was 81% (global Likert scores), 74-87% (T2), 78% (diffusion weighted imaging) and 57-78% (dynamic contrast enhanced imaging; Youden-selected cutoff ≥3). Conclusion: Besides histopathological evaluation and control biopsy, MRI might have the potential to accurately detect PCa after cryotherapy. Clinical data and interdisciplinary communication are required for efficient monitoring after cryoablation treatments for PCa.
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Affiliation(s)
- Inga Peters
- Department of Urology & Urologic Oncology, Hannover Medical School, Carl-Neuberg Str. 1, Hannover, 30625, Germany
| | - Katja Derlin
- Institute for Diagnostic & Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, Hannover, 30625, Germany
| | - Matti Joonas Peperhove
- Institute for Diagnostic & Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, Hannover, 30625, Germany
| | - Bennet Hensen
- Institute for Diagnostic & Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, Hannover, 30625, Germany
| | - Stefanie Pertschy
- Institute for Diagnostic & Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, Hannover, 30625, Germany
| | - Mathias Wolters
- Department of Urology & Urologic Oncology, Hannover Medical School, Carl-Neuberg Str. 1, Hannover, 30625, Germany
| | | | - Frank Wacker
- Institute for Diagnostic & Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, Hannover, 30625, Germany
| | - Susanne Hellms
- Institute for Diagnostic & Interventional Radiology, Hannover Medical School, Carl-Neuberg Str. 1, Hannover, 30625, Germany
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19
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Focal prostate cancer therapy in the era of multiparametric MRI: a review of options and outcomes. Prostate Cancer Prostatic Dis 2022:10.1038/s41391-022-00501-0. [PMID: 35246609 DOI: 10.1038/s41391-022-00501-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/10/2022] [Accepted: 01/19/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The goal of prostate cancer focal therapy is to achieve oncologic control while reducing the rate of adverse events associated with whole-gland treatments. Numerous focal therapy modalities are currently available with early data demonstrating highly variable rates of cancer control and preservation of sexual/urinary function. METHODS All English language clinical trial publications evaluating various focal therapies for localized prostate cancer were reviewed. The literature search was limited to studies from the modern era of MRI-guided treatment, as MRI is hypothesized to improve tumor localization and targeting. Primary outcomes were post-treatment cancer-free rates, in-field/out-of-field recurrence rates, and rates of conversion to radical therapy. Secondary outcomes were related to functional status and adverse events. RESULTS Numerous focal therapies were identified with clinical data including high-intensity focused ultrasound, transurethral ultrasound ablation, focal laser ablation, focal cryotherapy, irreversible electroporation, and photodynamic therapy. Recurrence rates among all technologies were low to moderate (0-51%) and rates of freedom from radical treatment were highly variable (46-98%). Rates of erectile dysfunction and incontinence generally ranged from 0 to 44% and 0 to 12%, respectively, with variability between focal therapy modalities. Caution should be exercised when comparing studies as outcomes are strongly associated with patient selection. No individual focal therapy is currently recommended by society guidelines. Randomized controlled trials are ongoing in search of a standard of care. CONCLUSION For localized MRI-visible prostate cancer, early clinical trial data demonstrate that focal therapy can provide good to moderate cancer control while having preferable side effect profiles compared to whole-gland treatments. While current studies do not make head-to-head comparisons between technologies, early data suggest a potential for these technologies to provide adequate cancer control in a well-selected patient population. The oncologic outcomes of some focal therapies appear promising; however, longer-term follow-up data are needed to assess the durability of early outcomes.
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20
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Nyk Ł, Michalak W, Szempliński S, Woźniak R, Zagożdżon B, Krajewski W, Kryst P, Kamecki H, Poletajew S. High-Intensity Focused-Ultrasound Focal Therapy Versus Laparoscopic Radical Prostatectomy: A Comparison of Oncological and Functional Outcomes in Low- and Intermediate-Risk Prostate Cancer Patients. J Pers Med 2022; 12:jpm12020251. [PMID: 35207739 PMCID: PMC8877347 DOI: 10.3390/jpm12020251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 12/04/2022] Open
Abstract
To compare oncological and functional outcomes of high-intensity focused-ultrasound (HIFU) focal therapy (FT) versus laparoscopic radical prostatectomy (LRP) in patients treated for low- or intermediate-risk prostate cancer (PCa), we retrospectively analyzed data of consecutive patients comprising 30 men, who underwent HIFU-FT, and 96 men who underwent LRP, in an academic center. Oncological outcomes were assessed based on the follow-up prostate-specific antigen values. We used the International Index of Erectile Function short form score to assess erectile function (EF). Urinary continence status was defined based on the number of pads used per day. Median follow-up was 12.5 and 19.1 months in the LRP and HIFU-FT groups, respectively. The effects were computed after propensity score matching and expressed as average treatment effect (ATE). Compared to LRP, HIFU-FT was associated with increased risk of treatment failure (ATE 0.103–0.164, depending on definition, p < 0.01) and lower risk of urinary incontinence (ATE −0.808 at 12 months, p < 0.01). Risk of erectile dysfunction was higher in the LRP group (ATE 5.092, p < 0.01). Our results demonstrate that HIFU-FT may be a reasonable treatment option in selected PCa patients, willing to preserve their EF and urinary continence yet accepting a higher risk of treatment failure.
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Affiliation(s)
- Łukasz Nyk
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (Ł.N.); (W.M.); (S.S.); (B.Z.); (P.K.); (S.P.)
| | - Wojciech Michalak
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (Ł.N.); (W.M.); (S.S.); (B.Z.); (P.K.); (S.P.)
| | - Stanisław Szempliński
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (Ł.N.); (W.M.); (S.S.); (B.Z.); (P.K.); (S.P.)
| | - Rafał Woźniak
- Chair of Statistics and Econometrics, Faculty of Economic Sciences, University of Warsaw, 00-241 Warsaw, Poland;
| | - Bartłomiej Zagożdżon
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (Ł.N.); (W.M.); (S.S.); (B.Z.); (P.K.); (S.P.)
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wrocław Medical University, 50-556 Wrocław, Poland;
| | - Piotr Kryst
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (Ł.N.); (W.M.); (S.S.); (B.Z.); (P.K.); (S.P.)
| | - Hubert Kamecki
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (Ł.N.); (W.M.); (S.S.); (B.Z.); (P.K.); (S.P.)
- Correspondence: ; Tel.: +48-22-710-3049
| | - Sławomir Poletajew
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (Ł.N.); (W.M.); (S.S.); (B.Z.); (P.K.); (S.P.)
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Cancer Control Outcomes Following Focal Therapy Using High-intensity Focused Ultrasound in 1379 Men with Nonmetastatic Prostate Cancer: A Multi-institute 15-year Experience. Eur Urol 2022; 81:407-413. [DOI: 10.1016/j.eururo.2022.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 12/04/2021] [Accepted: 01/05/2022] [Indexed: 12/21/2022]
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22
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Marks LS. Prostate Cancer: a comparison of focal therapy and radical prostatectomy. Prostate Cancer Prostatic Dis 2022; 25:381-382. [PMID: 35087221 DOI: 10.1038/s41391-021-00334-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 12/21/2020] [Accepted: 01/20/2021] [Indexed: 11/09/2022]
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23
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Matsuoka Y, Uehara S, Toda K, Fukushima H, Tanaka H, Yoshida S, Yokoyama M, Yoshimura R, Kihara K, Fujii Y. Focal brachytherapy for localized prostate cancer: 5.7-year clinical outcomes and a pair-matched study with radical prostatectomy. Urol Oncol 2021; 40:161.e15-161.e23. [PMID: 34895818 DOI: 10.1016/j.urolonc.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/09/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To report experience with focal brachytherapy (FB) and compare its clinical outcomes with those of radical prostatectomy (RP) in localized prostate cancer. METHODS Fifty-one patients with low- to intermediate-risk prostate cancer underwent low-dose-rate FB. Survival rates free from biochemical failure (BF), additional treatment (AT) including re-FB, and whole-gland or systemic salvage therapy (ST) were calculated and oncological risk factors were investigated. Patient-reported outcomes on genitourinary function were also assessed. Using propensity scoring, 51 pair-matched RP patients were selected. Oncological control, urinary continence, and ejaculation status after FB and RP were compared. RESULTS During a median 5.7-year follow-up, BF, AT, and ST occurred in 12 (24%), 10 (20%), and 4 FB patients (8%), respectively. 6 of 10 AT patients were managed with re-FB alone. In the RP cohort, 3 patients (6%) underwent ST. 5-year BF-free survival rate after FB was 79%. Compared to 5-year ST-free survival rate of 94% after RP, ST-free and AT-free survival rates after FB were 93% (P = 0.813) and 87% (P = 0.049), respectively. Multivariate analyses of FB-treated patients showed that time to PSA nadir was negatively associated with BF and AT (hazard ratio 0.84 and 0.83, respectively, P <0.001 for each). The difference in oncological outcomes between low- and intermediate-risk categories was not significant. At 2 years after FB and RP, pad-free continence rates were 100% and 81%, respectively (P = 0.001). Ejaculation was preserved in 67% and 0% of patients who had been capable of ejaculation at baseline, respectively (P <0.001). CONCLUSION In low- to intermediate-risk prostate cancer, FB-treated patients achieved superior genitourinary function compared to pair-matched RP patients. The need for ST was not substantially different between the 2 treatment cohorts. Over half of patients requiring AT could be managed by re-focal treatment rather than whole-gland ST. Early PSA nadir may predict poor oncological control after FB.
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Affiliation(s)
- Yoh Matsuoka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Sho Uehara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuma Toda
- Department of Radiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroshi Fukushima
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hajime Tanaka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minato Yokoyama
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryoichi Yoshimura
- Department of Radiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazunori Kihara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
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Dudderidge TJ. Multiparametric magnetic resonance imaging - a crucial imaging tool for considering and planning prostate cancer focal therapy. BJU Int 2021; 128:125-126. [PMID: 34318981 DOI: 10.1111/bju.15442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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van Son MJ, Peters M, Reddy D, Shah TT, Hosking-Jervis F, Robinson S, Lagendijk JJW, Mangar S, Dudderidge T, McCracken S, Hindley RG, Emara A, Nigam R, Persad R, Virdi J, Lewi H, Moore C, Orczyk C, Emberton M, Arya M, Ahmed HU, van der Voort van Zyp JRN, Winkler M, Falconer A. Conventional radical versus focal treatment for localised prostate cancer: a propensity score weighted comparison of 6-year tumour control. Prostate Cancer Prostatic Dis 2021; 24:1120-1128. [PMID: 33934114 DOI: 10.1038/s41391-021-00369-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/14/2021] [Accepted: 04/15/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND For localised prostate cancer, focal therapy offers an organ-sparing alternative to radical treatments (radiotherapy or prostatectomy). Currently, there is no randomised comparative effectiveness data evaluating cancer control of both strategies. METHODS Following the eligibility criteria PSA < 20 ng/mL, Gleason score ≤ 7 and T-stage ≤ T2c, we included 830 radical (440 radiotherapy, 390 prostatectomy) and 530 focal therapy (cryotherapy, high-intensity focused ultrasound or high-dose-rate brachytherapy) patients treated between 2005 and 2018 from multicentre registries in the Netherlands and the UK. A propensity score weighted (PSW) analysis was performed to compare failure-free survival (FFS), with failure defined as salvage treatment, metastatic disease, systemic treatment (androgen deprivation therapy or chemotherapy), or progression to watchful waiting. The secondary outcome was overall survival (OS). Median (IQR) follow-up in each cohort was 55 (28-83) and 62 (42-83) months, respectively. RESULTS At baseline, radical patients had higher PSA (10.3 versus 7.9) and higher-grade disease (31% ISUP 3 versus 11%) compared to focal patients. After PSW, all covariates were balanced (SMD < 0.1). 6-year weighted FFS was higher after radical therapy (80.3%, 95% CI 73.9-87.3) than after focal therapy (72.8%, 95% CI 66.8-79.8) although not statistically significant (p = 0.1). 6-year weighted OS was significantly lower after radical therapy (93.4%, 95% CI 90.1-95.2 versus 97.5%, 95% CI 94-99.9; p = 0.02). When compared in a three-way analysis, focal and LRP patients had a higher risk of treatment failure than EBRT patients (p < 0.001), but EBRT patients had a higher risk of mortality than focal patients (p = 0.008). CONCLUSIONS Within the limitations of a cohort-based analysis in which residual confounders are likely to exist, we found no clinically relevant difference in cancer control conferred by focal therapy compared to radical therapy at 6 years.
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Affiliation(s)
- Marieke J van Son
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK. .,Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK. .,Department of Radiotherapy, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Max Peters
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Deepika Reddy
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Urology, Sunderland Royal Hospital, City Hospital Foundation Trust, Sunderland, UK
| | - Feargus Hosking-Jervis
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Stephen Robinson
- Division of Clinical Oncology, Department of Radiotherapy, Charing Cross Hospital, Imperial College London Healthcare NHS Trust, London, UK
| | - Jan J W Lagendijk
- Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen Mangar
- Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Stuart McCracken
- Department of Urology, Sunderland Royal Hospital, City Hospital Foundation Trust, Sunderland, UK
| | - Richard G Hindley
- Department of Urology, Hampshire Hospitals & Ain Shams University Hospitals, Basingstoke, UK
| | - Amr Emara
- Department of Urology, Hampshire Hospitals & Ain Shams University Hospitals, Basingstoke, UK
| | - Raj Nigam
- BMI Mount Alvernia Hospital, Guildford, Surrey, UK
| | - Raj Persad
- Department of Urology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jaspal Virdi
- Department of Urology, Princes Alexandra Hospital NHS Trust, Harlow, UK.,Rivers Hospital, Essex, UK
| | | | - Caroline Moore
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Mark Emberton
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Manit Arya
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK.,Department of Urology, Princes Alexandra Hospital NHS Trust, Harlow, UK.,Rivers Hospital, Essex, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Matt Winkler
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Alison Falconer
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
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