Quality of life following high-intensity focused ultrasound for the treatment of localized prostate cancer: a prospective study

Oncological and Functional Outcomes of Whole-Gland HIFU as the Primary Treatment for Localized Prostate Cancer: A Systematic Review

INTRODUCTION

High-intensity focused ultrasound (HIFU) is regarded as a promising alternative treatment option for localized prostate cancer (PCa) as it has been proposed to offer similar oncologic control to the standard of care, but with significantly reduced treatment-related side effects. This systematic literature review assesses the available evidence of whole-gland HIFU as primary treatment for localized PCa.

METHODS

MEDLINE (PubMed) was searched for studies investigating oncological and functional outcomes following whole-gland HIFU as primary treatment for localized PCa. Our primary outcomes for the review were biochemical disease-free survival rates (BDFS), overall and PCa-specific survival rates as well as negative biopsy rates. Our secondary outcomes were functional results and complications of the treatment.

RESULTS

A total of 375 articles were identified, of which 35 were included in the present review. All 35 articles were prospective or retrospective case series. Mean/median duration of follow-up across studies was 10.9 to 94 months, and 6618 patients were included in the review. The BDFS rate varied greatly across studies from 21.7% to 89.2% during follow-up. The 10-year PCa-specific survival rate following HIFU was 90%, 99%, and 100% in 3 studies. Negative biopsy rates post-HIFU ranged from 20% to 92.7% across studies. Common side effects to HIFU included urinary incontinence (grade 1: 0%-22.7%), erectile dysfunction (11.6%-77.1%), urinary tract infections (1.5%-47.9%), and bladder outlet obstruction mainly as urethral strictures (7%-41.2%).

CONCLUSION

Great variation in oncological and functional outcomes was seen across studies. More prospective trials are needed before whole-gland HIFU can be considered as a treatment option for localized PCa.

Evaluation of post-ablation mpMRI as a predictor of residual prostate cancer after focal high intensity focused ultrasound (HIFU) ablation

PURPOSE

To evaluate the performance of multiparametric magnetic resonance imaging (mpMRI) and PSA testing in follow-up after high intensity focused ultrasound (HIFU) focal therapy for localized prostate cancer.

METHODS

A total of 73 men with localized prostate cancer were prospectively enrolled and underwent focal HIFU followed by per-protocol PSA and mpMRI with systematic plus targeted biopsies at 12 months after treatment. We evaluated the association between post-treatment mpMRI and PSA with disease persistence on the post-ablation biopsy. We also assessed post-treatment functional and oncological outcomes.

RESULTS

Median age was 69 years (Interquartile Range (IQR): 66-74) and median PSA was 6.9 ng/dL (IQR: 5.3-9.9). Of 19 men with persistent GG ≥ 2 disease, 58% (11 men) had no visible lesions on MRI. In the 14 men with PIRADS 4 or 5 lesions, 7 (50%) had either no cancer or GG 1 cancer at biopsy. Men with false negative mpMRI findings had higher PSA density (0.16 vs. 0.07 ng/mL², P = 0.01). No change occurred in the mean Sexual Health Inventory for Men (SHIM) survey scores (17.0 at baseline vs. 17.7 post-treatment, P = 0.75) or International Prostate Symptom Score (IPSS) (8.1 at baseline vs. 7.7 at 24 months, P = 0.81) after treatment.

CONCLUSIONS

Persistent GG ≥ 2 cancer may occur after focal HIFU. mpMRI alone without confirmatory biopsy may be insufficient to rule out residual cancer, especially in patients with higher PSA density. Our study also validates previously published studies demonstrating preservation of urinary and sexual function after HIFU treatment.

Development and future prospective of treatment for localized prostate cancer with high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) was experimentally used for focal therapy for anti-cancer effects in prostate cancer (PC). Focal therapy is a diagnosis-based investigational treatment option for localized PC that cures clinically significant PC (csPC) while preserving the anatomical structures related to urinary and sexual function based on its spread observed using multi-parametric magnetic resonance imaging (mpMRI). The European Association of Urology indicated that the current status of focal therapy for localized PC was an investigational modality and encouraged prospective recording of outcomes and recruitment of suitable patients in 2018. During the last few years, large-population multi- and single-center prospective studies have investigated focal therapy as a treatment strategy for localized PC. In a multicenter prospective study with 5-year follow-up, failure-free survival, which was defined as avoidance of local salvage therapy (surgery or radiotherapy), systemic therapy, metastases, and prostate cancer-specific death, was 88%. In the previous studies, there was no significant influence on urinary function before and at 3 months after the treatment, although transient impairment was reported 1 month after the treatment. Pad- and leak-free continence was preserved in 80-100% of the patients after treatment. Erectile function was significantly impaired in the initial 3 months after treatment compared to the pretreatment values, but it improved 6 months after the focal therapy in the previous reports. Paired comparison studies and cohort studies with long-term follow-up will contribute to verifying this treatment's clinical outcomes for patients with localized PC.

Effectiveness of Telenursing for Postoperative Complications in Patients with Prostate Cancer

Objective:

This study is addressing the question of whether a telenursing system using information and communication technology is effective for improving postoperative complications and quality of life (QOL) in patients with prostate cancer.

Methods:

Using a tablet computer, the participants were asked to provide information on various items, including urinary frequency, number of incontinence pads used, and presence of sexual desire and erections. Both the participants and researchers monitored automatically graphed time-dependent changes in symptoms, and the researchers could propose concrete measures to reduce patients' complications. The primary endpoint was an improved score on the expanded prostate cancer index composite (EPIC) and improved urinary incontinence based on a positive stress test. The secondary endpoint was an evaluation of self-care responses to the Functional Assessment of Cancer Therapy-General (FACT-G) instrument.

Results:

This study asked 33 patients who met all inclusion criteria to participate in the study, 30 of whom agreed. We compared the scores of EPIC, FACT-G, and stress test for prostate cancer patients 1 month and 3 months after surgery. The scores of urinary incontinence and urinary bother for both groups were significantly higher in 3 months after surgery than in 1 month after surgery, showing improvement in symptoms. The amount of urine left in the bladder after stress test increased showing the improvement in urinary incontinence (P = 0.001).

Conclusions:

The relationship between prostate cancer patients' complications after surgery and QOL showed that their physical well-being improved as they found relief from their symptoms. Telenursing was shown to be effective for symptom management of patients with chronic diseases including cancer.

Current status and future prospective of focal therapy for localized prostate cancer: development of multiparametric MRI, MRI-TRUS fusion image-guided biopsy, and treatment modalities

Multiparametric magnetic resonance imaging (mpMRI) has been increasingly used to diagnose clinically significant prostate cancer (csPC) because of its usefulness in combination with anatomic and functional data. MRI-targeted biopsy, such as MRI-transrectal ultrasound (TRUS) fusion image-guided prostate biopsy, has high accuracy in the detection and localization of csPC. This novel diagnostic technique contributes to the development of tailor-made medicine as focal therapy, which cures the csPC while preserving the anatomical structures related to urinary and sexual function. In the early days of focal therapy, TRUS-guided systematic biopsy was used for patient selection, and treatment was performed for patients with low-risk PC. With the introduction of mpMRI and mapping biopsy, the treatment range is now determined based on individualized cancer localization. In recent prospective studies, 87.4% of treated patients had intermediate- and high-risk PC. However, focal therapy has two main limitations. First, a randomized controlled trial would be difficult to design because of the differences in pathological features between patients undergoing focal therapy and radical treatment. Therefore, pair-matched studies and/or historical controlled studies have been performed to compare focal therapy and radical treatment. Second, no long-term (≥ 10-year) follow-up study has been performed. However, recent prospective studies have encouraged the use of focal therapy as a treatment strategy for localized PC because it contributes to high preservation of continence and erectile function.

A case of immunoglobulin G4-related inflammatory pseudotumor mimicking renal cell carcinoma

In a 69-year-old woman with a history of Mikulicz's disease, a hypoechoic solitary renal mass was identified on routine ultrasound examination. Based on the findings of computed tomography (CT) and magnetic resonance imaging (MRI), renal cell carcinoma was a possible diagnosis. Subsequent partial nephrectomy revealed a mass characterized by an increased number of blood vessels, internal hemorrhage, and a thick fibrous capsule. Immunohistochemically, the mass comprised of tubulointerstitial nephritis with increased immunoglobulin (Ig)G4-positive plasma cells and fibrosis. Generally, diagnosis of IgG4-related kidney disease (IgG4-RKD) is not difficult when the kidney is involved together with other systemic involvements. However, diagnosis becomes harder when a solitary renal mass appears as a single-organ involvement. On precise review of our imaging findings, MRI signals were markedly affected by hemorrhage, so the mass showed hypointensity on both T1- and T2-weighted imaging, and the signal of in-phase images decreased. Dynamic MRI showed no apparent enhancement of the mass, while CT showed an apparent enhancement effect. Capsule formation was another key finding for IgG4-RKD and was recognized as a gradually enhancing boundary zone surrounding the mass on both CT and MRI. When a solitary renal mass is associated with hemorrhage and thick capsule formation, inflammatory pseudotumor should be considered as differential diagnosis.

Current status and progress of focal therapy in Asia

PURPOSE OF REVIEW

With the increasing incidence of low-to-intermediate risk of prostate cancer (PCa) by the introduction of prostate-specific antigen (PSA) screening, focal therapy has become one of the promising treatment options in the world. In Asia, same movement are occurring using several technologies including cryoablation, high-intensity focused ultrasound, brachytherapy and irreversible electroporation. However, these are still not common strategies to treat organ-confined PCa. The purpose of this review is to summarize the most updated experience and future direction of focal therapy in Asian countries.

RECENT FINDINGS

The prevalence and diagnosis of PCa are increasing in Asian countries. This increase is related to various factors including the widespread implementation of PSA testing and lifestyle changes to more Westernized diets. With the increasing detection rate of early stage PCa, overdetection and overtreatment are recognized even in Asia. In this setting, accumulating data on multiparametric MRI and MRI-targeted biopsy as well as MRI-transrectal ultrasound (TRUS) fusion biopsy suggest the potential in improving the detection of clinically significant PCa in Asia. Furthermore, targeted focal therapy has emerged as a promising treatment strategy aiming for both providing oncological outcome and maintaining functional preservation in many Asian countries.

SUMMARY

At present, focal therapy is not a current standard choice for the treatment of localized PCa in Asian countries. However, with the increase of localized PCa and patient's preference for less invasive treatment with preservation of organ-function, focal therapy should become a definite treatment option for localized PCa in Asia.

Cryotherapy versus high-intensity focused ultrasound for treating prostate cancer: Oncological and functional results

CONTEXT AND OBJECTIVE

The increasingly early diagnosis of prostate cancer requires a search for therapeutic alternatives with good oncological results that in turn facilitate a good long-term quality of life. This review analyses 2 minimally invasive therapies for treating localised prostate cancer in terms of oncological and functional results, as well as the complications resulting from the therapies.

ACQUISITION OF EVIDENCE

A systematic literature review was conducted of the treatment of localised prostate cancer with 2 ablative techniques as the primary therapy: cryosurgery or cryotherapy and high intensity focused ultrasound (HIFU). We included patients who underwent procedures that included the entire gland, with hemiablation or focal therapy, which were indicated for low to intermediate-risk prostate cancer according to the D'Amico criteria. We excluded patients with high-risk prostate cancer and those who underwent any prior treatment for prostate cancer.

SYNTHESIS OF THE EVIDENCE

After conducting the literature search and excluding the studies that did not meet the protocol criteria, we reviewed a total of 14 studies, with a total of 350 patients treated using cryotherapy and 1107 treated with HIFU. All studies were either prospective or retrospective and were not randomised. The patients' mean age was younger than 75 years. Overall, the rate of disease recurrence in the patients treated with cryotherapy varied between 13.2% and 26%, while the rate for those treated with HIFU varied between 7.3% and 67.9%. The overall demonstrated continence at 12 months was 97.6-100% for cryotherapy and 96-100% for HIFU. In terms of sexual potency rates, cryotherapy showed complete potency at 12 months for 86-100% of the patients treated with focal cryotherapy and slightly lower rates for hemiablation (76.9-100%) and total therapy (39%). HIFU showed potency rates of 89%, 52-80% and 33-78% for focal therapy, hemiablation and total therapy, respectively.

CONCLUSIONS

Both techniques have comparable functional results, although the somewhat poorer oncological results for HIFU reflect a steeper learning curve, which could lead to its use in centres with high volumes of patients.

Patient-reported outcomes after treatment for clinically localized prostate cancer: A systematic review and meta-analysis

BACKGROUND

The aim of this systematic review is to assess the impact of primary treatments with curative intention in patients with localized prostate cancer, measured with Patient-Reported Outcomes (PROs), and to examine differences among modalities within treatments.

METHODS

We conducted a systematic literature search for January 2005-March 2017 following PRISMA guidelines, including longitudinal studies measuring disease-specific PROs in localized prostate cancer patients with a follow-up from pre- to post-treatment (≥1 year). Two reviewers independently extracted data and assessed risk of bias. The study is registered in PROSPERO: CRD42015019747.

RESULTS

Of 148 identified studies, 60 were included in the meta-analyses. At the 1st year, radical prostatectomy patients showed small urinary irritative-obstructive improvement (0.37SD 95%CI 0.30, 0.45), but large deterioration for sexual function and incontinence with high heterogeneity (I² = 77% and 93%). Moderate worsening in external radiotherapy patients for sexual function (-0.46SD 95%CI -0.55, -0.36), small urinary incontinence (-0.16SD 95%CI -0.23, -0.09) and bowel impairment (-0.31SD 95%CI -0.39, -0.23). Brachytherapy patients presented small deterioration in urinary incontinence (-0.29SD 95%CI -0.39, -0.19), irritative obstructive symptoms (-0.35SD 95%CI -0.47, -0.23), sexual function (-0.12SD 95%CI -0.24, -0.002), and bowel bother (-0.27SD 95%CI -0.42, -0.11). These patterns persisted up to the 5th year. High-intensity focused ultrasound and active surveillance only have results at 1st year, showing no statistically significant worsening.

CONCLUSIONS

No remarkable differences in PRO appeared between modalities within each treatment. Nowadays, available evidence supports brachytherapy as possible alternative to radical prostatectomy for patients seeking an attempted curative treatment limiting the risk for urinary incontinence and sexual dysfunction.

A comparison of time taken to return to baseline erectile function following focal and whole gland ablative therapies for localized prostate cancer: A systematic review

OBJECTIVES

To systematically review erectile function (EF) outcomes following primary whole gland (WG) and focal ablative therapies for localized prostate cancer to ascertain whether the treatment modality or intended treatment volume affects the time taken to recover baseline EF.

METHOD AND MATERIALS

A systematic review was performed according to the preferred reporting items for systematic review and meta-analysis statement. Inclusion criteria were men with localized prostate cancer treated with primary, ablative therapy. Primary outcome was the return to baseline EF measured with objective, validated symptoms scores. Secondary outcome was use of phosphodiesterase inhibitors or erectile aids. Meta-analysis was not performed owing to heterogenous outcome measures.

RESULTS

Of 222 articles identified in February 2017, 55 studies which reported EF after ablative therapy were identified but only 17 used validated outcome measures and met inclusion criteria. WG cryotherapy was used in 2 studies, WG high-intensity focused ultrasound (HIFU) in 5, focal cryotherapy in 2, focal HIFU in 3, focal phototherapy or laser therapy in 4, vascular-targeted photodynamic therapy in 3, and irreversible electroporation in 2. WG cryotherapy was associated with a significant decline in EF at 6 months with minimal improvement at 36 months. Baseline IIEF-15 of patients undergoing focal HIFU fell 30 points at 1 month but returned to baseline by 6 months. The remaining focal therapies demonstrated minimal or no effect on EF, but the men in these studies had small foci of disease. The review is limited by lack of randomized studies and heterogenous outcome measures.

CONCLUSIONS

Most studies assessing the outcomes of focal therapy on sexual function were not of high quality, used heterogenous outcomes, and had relatively short follow up, highlighting the need for more robustly designed studies using validated patient reported outcome measures  for comparison. However, FT in general resulted in less effect on EF than WG ablation.

Quality of life and functional outcome after infravesical desobstruction and HIFU treatment for localized prostate cancer

Background

To evaluate quality of life, functional and oncological outcome after infravesical desobstruction and HIFU treatment for localized prostate cancer.

Methods

One hundred thirty-one patients, treated with TURP and HIFU in a single institution were followed up for oncological and functional outcome. Oncological outcome was quantified by biochemical recurrence free survival using the Stuttgart and Phoenix criteria. Quality of life was assessed by usage of standardized QLQ-C30 and QLQ-PR25 questionnaires. In addition, functional questionnaires such as IPSS and IIEF-5 were used. Complications were assessed by the Clavien-Dindo classification.

Results

One hundred thirty-one patients with a mean age of 72.8 years (SD: 6.0) underwent HIFU for prostate cancer (29.0% low risk, 58.8% intermediate risk, 12.2% high risk). PSA nadir was 0.6 ng/ml (SD: 1.2) after a mean of 4.6 months (SD: 5.7). Biochemical recurrence free survival defined by Stuttgart criteria was 73.7%, 84.4% and 62.5% for low-, intermediate- and high-risk patients after 22.2 months. Complications were grouped according to Clavien-Dindo and occurred in 10.7% (grade II) and 11.5% (grade IIIa) of cases. 35.1% of patients needed further treatment for bladder neck stricture. Regarding incontinence, 14.3%, 2.9% and 0% of patients had de novo urinary incontinence grade I°, II° and III° and 3.8% urge incontinence due to HIFU treatment. Patients were asked for the ability to have intercourse: 15.8%, 58.6% and 66.7% of patients after non-, onesided and bothsided nervesparing procedure were able to obtain sufficient erection for intercourse, respectively. Regarding quality of life, mean global health score according to QLQ-C30 was 69.4%.

Conclusion

HIFU treatment for localized prostate cancer shows acceptable oncological safety. Quality of life after HIFU is better than in the general population and ranges within those of standard treatment options compared to literature. HIFU seems a safe valuable treatment alternative for patients not suitable for standard treatment.

Comparisons of oncological and functional outcomes among radical retropubic prostatectomy, high dose rate brachytherapy, cryoablation and high-intensity focused ultrasound for localized prostate cancer

PURPOSE

To conduct a retrospective, single institutional and comparative study for radical retropubic prostatectomy (RRP), high dose rate brachytherapy (HDRBT), cryoablation and high-intensity focused ultrasound (HIFU) in localized prostate cancer with respect to oncological and functional outcomes.

METHODS

We reviewed 97, 161, 114 and 120 patients of RRP, HDRBT, cryoablation and HIFU respectively for localized prostate cancer from May 2008 to December 2013. PSA biochemical recurrence, salvage treatment-free rate, metastasis-free rate, and biochemical recurrence-free survival were analyzed for oncological outcomes. Functional outcomes included complications and serial IIEF-5 scores, IPSS and related QoL scores.

RESULTS

During nearly 3 years of follow-up, the patients of HDRBT experienced higher PSA biochemical recurrence rate overall (54.7%), as well as D'Amico intermediate-risk (34.4%) and high-risk (61.8%) groups, lower salvage treatment-free rate (46.7%), and metastasis-free rate (90.7%). Besides, the patients of RRP demonstrated higher urethral stricture (29.9%) and urinary incontinence (11.3%). The patients of HIFU revealed lower de novo erectile dysfunction rate at 1 year (65.6%), higher serial IIEF-5 scores, lower IPSS and related QoL scores.

CONCLUSIONS

The patients of HDRBT demonstrated worse oncological outcomes in D'Amico intermediate and high-risk groups. Besides, the patients of RRP had more complications rate in urethral stricture and urinary incontinence. Moreover, the patients of HIFU experienced better urinary function improvement and more possible sexual function preservation. In consideration of trifecta, HIFU may provide equivalent cancer control and better quality of life for patients of localized prostate cancer.

Ablative therapy for people with localised prostate cancer: a systematic review and economic evaluation

BACKGROUND

For people with localised prostate cancer, active treatments are effective but have significant side effects. Minimally invasive treatments that destroy (or ablate) either the entire gland or the part of the prostate with cancer may be as effective and cause less side effects at an acceptable cost. Such therapies include cryotherapy, high-intensity focused ultrasound (HIFU) and brachytherapy, among others.

OBJECTIVES

This study aimed to determine the relative clinical effectiveness and cost-effectiveness of ablative therapies compared with radical prostatectomy (RP), external beam radiotherapy (EBRT) and active surveillance (AS) for primary treatment of localised prostate cancer, and compared with RP for salvage treatment of localised prostate cancer which has recurred after initial treatment with EBRT.

DATA SOURCES

MEDLINE (1946 to March week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (29 March 2013), EMBASE (1974 to week 13, 2013), Bioscience Information Service (BIOSIS) (1956 to 1 April 2013), Science Citation Index (1970 to 1 April 2013), Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2013), Cochrane Database of Systematic Reviews (CDSR) (issue 3, 2013), Database of Abstracts of Reviews of Effects (DARE) (inception to March 2013) and Health Technology Assessment (HTA) (inception to March 2013) databases were searched. Costs were obtained from NHS sources.

REVIEW METHODS

Evidence was drawn from randomised controlled trials (RCTs) and non-RCTs, and from case series for the ablative procedures only, in people with localised prostate cancer. For primary therapy, the ablative therapies were cryotherapy, HIFU, brachytherapy and other ablative therapies. The comparators were AS, RP and EBRT. For salvage therapy, the ablative therapies were cryotherapy and HIFU. The comparator was RP. Outcomes were cancer related, adverse effects (functional and procedural) and quality of life. Two reviewers extracted data and carried out quality assessment. Meta-analysis used a Bayesian indirect mixed-treatment comparison. Data were incorporated into an individual simulation Markov model to estimate cost-effectiveness.

RESULTS

The searches identified 121 studies for inclusion in the review of patients undergoing primary treatment and nine studies for the review of salvage treatment. Cryotherapy [3995 patients; 14 case series, 1 RCT and 4 non-randomised comparative studies (NRCSs)], HIFU (4000 patients; 20 case series, 1 NRCS) and brachytherapy (26,129 patients; 2 RCTs, 38 NRCSs) studies provided limited data for meta-analyses. All studies were considered at high risk of bias. There was no robust evidence that mortality (4-year survival 93% for cryotherapy, 99% for HIFU, 91% for EBRT) or other cancer-specific outcomes differed between treatments. For functional and quality-of-life outcomes, the paucity of data prevented any definitive conclusions from being made, although data on incontinence rates and erectile dysfunction for all ablative procedures were generally numerically lower than for non-ablative procedures. The safety profiles were comparable with existing treatments. Studies reporting the use of focal cryotherapy suggested that incontinence rates may be better than for whole-gland treatment. Data on AS, salvage treatment and other ablative therapies were too limited. The cost-effectiveness analysis confirmed the uncertainty from the clinical review and that there is no technology which appears superior, on the basis of current evidence, in terms of average cost-effectiveness. The probabilistic sensitivity analyses suggest that a number of ablative techniques are worthy of further research.

LIMITATIONS

The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.

CONCLUSIONS

The findings indicate that there is insufficient evidence to form any clear recommendations on the use of ablative therapies in order to influence current clinical practice. Research efforts in the use of ablative therapies in the management of prostate cancer should now be concentrated on the performance of RCTs and the generation of standardised outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002461.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Effects of Focal Therapy for Prostate Cancer on Sexual Function: A Combined Analysis of Three Prospective Trials

BACKGROUND

Tissue preservation by means of focal therapy offers some men with clinically significant prostate cancer an alternative to standard care that appears to confer favourable genito-urinary outcomes. The precise estimates of these outcomes have so far been based on small series.

OBJECTIVE

This analysis pools the sexual domain related patient reported outcomes from three prospective, registered studies that represent a range of inclusion criteria.

DESIGN, SETTING, AND PARTICIPANTS

One-hundred and eighteen men with localised prostate cancer (prostate specific antigen ≤ 15ng/ml, Gleason ≤ 4+3, stage ≤ T3aN0M0) treated in a tissue-preserving manner using high intensity focused ultrasound from three registered studies were included. Data on International Index of Erectile Function (IIEF-5) scores and use of phosphodiesterase-5-inhibitors were collected at baseline, and 1 mo, 3 mo, 6 mo, 9 mo, and 12 mo postoperatively. The IIEF-15 total and individual domain scores were used to assess overall sexual function. Urinary function was assessed with the International Prostate Symptom Score (IPSS), IPSS quality-of-life, and UCLA-Expanded Prostate Cancer Index Composite continence questionnaires. General health status was derived by means of the Charlson score. Multiple linear regression was used to assess whether age, grade, stage, qualitative scores (IIEF, IPSS, Expanded Prostate Cancer Index Composite, Charlson), or focal therapy type duration were associated with IIEF-5 and IIEF-15 scores at 12 mo.

RESULTS AND LIMITATIONS

Median age was 63 yr (interquartile range [IQR] 52-70 yr). Median IIEF-erectile score at baseline was 23 (IQR 11-28). This declined significantly to 9 (IQR 3-22, p<0.01) at 1 mo, but improved to 20 (IQR 9-29, p=0.30) at 1 yr posttreatment. Changes in total IIEF and other IIEF domains were only significantly different from preoperative values at 1 mo and 3 mo postoperatively. In the same period, the proportion of men using phosphodiesterase-5-inhibitors was 10% preoperatively, reaching 43% and 42% at 6 mo and 9 months before declining to 37% at 1 yr. The only baseline determinants of postoperative erectile function were total IIEF and IIEF-erectile function scores (p=0.002). The primary limitation of our study is the relatively short follow-up of 1 yr.

CONCLUSION

Men who received a range of tissue preserving therapies from the three pertinent studies experienced small decreases in total IIEF, erectile, and individual sexual domain scores that are not significantly different to those recorded at baseline. The only determinant of erectile dysfunction after tissue preserving therapy was preoperative erectile dysfunction status. Tissue preservation confers a high probability of maintaining erectile function that appears independent of all perioperative factors with the exception of baseline status.

PATIENT SUMMARY

In this report, the largest prospectively collected and published set of patients with erectile dysfunction outcomes post-focal therapy for prostate cancer, we have found a return to baseline International Index of Erectile Function-erectile and total International Index of Erectile Function scores by 6 mo post-focal therapy which was maintained at 1 yr, with the majority of patients not on any form of medical treatment for their erectile dysfunction at that point. Focal therapy may represent a suitable alternative for men of any age or comorbidity wishing to maintain erectile function.

IgG4-related kidney disease--an update

Purpose of review

IgG4-related disease (IgG4-RD) is a recently recognized systemic inflammatory disorder that can affect most organs/tissues such as sarcoidosis. The kidney is a frequently affected organ with tubulointerstitial nephritis (TIN), the representative lesion of IgG4-RD. This review focuses on the latest knowledge of IgG4-related kidney disease (IgG4-RKD).

Recent findings

A wide range of renal manifestations of IgG4-RD, that is TIN, membranous glomerulonephritis (MGN) and other glomerular lesions, and pyelitis, are collectively referred to as IgG4-RKD. Clinically, decreased renal function, or characteristic imaging findings such as multiple low-density lesions on contrast-enhanced computed tomography or diffuse thickening of the renal pelvic wall, are typical presenting features. Although a rapid response to corticosteroid therapy is a very important feature of IgG4-TIN, in cases in which renal function is moderately to severely decreased before therapy, only partial recovery of renal function is obtained.

Summary

TIN with characteristic imaging findings is a typical manifestation of IgG4-RKD in the interstitium, while MGN is a representative manifestation of the glomerular lesions. Although IgG4 is a central feature of IgG4-RD, the recent discovery of IgG4-negative IgG4-RD raises questions about the causative role of the IgG4 molecule in this context.

Salvage HIFU for biopsy confirmed local prostate cancer recurrence after radical prostatectomy and radiation therapy: Case report and literature review

High-intensity focused ultrasound (HIFU) is a treatment option for low- and intermediate-risk prostate cancer and more recently has been used as salvage therapy after failed radiation therapy. We present a case of local recurrence with biochemical failure after radical prostatectomy and salvage external beam radiation therapy with salvage HIFU without biochemical recurrence at 20 months.

Systematic Review of the Efficacy and Safety of High-intensity Focussed Ultrasound for Localised Prostate Cancer

CONTEXT

High-intensity focussed ultrasound (HIFU) has been used for 10 yr to treat localised prostate cancer (PCa).

OBJECTIVE

To evaluate systematically the evidence on the efficacy and side effects of HIFU in the primary treatment of localised PCa.

EVIDENCE ACQUISITION

We performed a critical review and appraisal of Medline (Ovid), PreMedline, Embase, and Cochrane Database of Systematic Reviews publications on HIFU up to May 2013. One systematic review and 18 primary studies, all case series, were eligible.

EVIDENCE SYNTHESIS

Outcomes were summarised and evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluation methodology. Low-quality evidence suggests an overall survival rate after Ablatherm HIFU ranging from 80% to 89% for >5 yr. The PCa survival rate ranges from 97% to 99% for >5 yr. Effect of HIFU on quality of life remains undetermined. Erectile dysfunction was the most frequent adverse event reported from zero but up to 74% of patients. Adverse events affecting the urinary tract occurred in 0.7-31% of patients, bladder outlet obstruction in 4-51.5%, and they were more frequent in patients who had transurethral resection of the prostate the same day or within 2 d of HIFU. Outcomes vary for low- and high-risk categories.

CONCLUSIONS

Good quality evidence on the efficacy of HIFU treatment for localised PCa is lacking.

PATIENT SUMMARY

We reviewed all the data on treatment with high-intensity focussed ultrasound (HIFU) for localised prostate cancer (PCa). The quality of the evidence is very low because the information is based on a series of patients who received HIFU treatment with no comparison with active surveillance or radical treatment. Case series suggest an overall survival rate up to 89% and a PCa survival rate up to 99% after 5 yr, but these numbers vary according to the patient's risk category. Longer term and effects on quality of life are unknown.

Racial Disparities in Sexual Dysfunction Outcomes After Prostate Cancer Treatment: Myth or Reality?

Among diverse subject areas in the field of prostate cancer management, treatment-related sexual dysfunction complications persist today as a significant potential problem for all men receiving treatment for this disease. The conjecture that African-American men are disproportionately affected by this problem among ethnic groups is not trivial and warrants attention in view of the possibility that its risk profile, whether real or perceived, may influence clinical management decisions impacting survival outcomes in this high-prostate cancer-risk population. A literature review was performed to define the occurrence and significance of sexual dysfunction after prostate cancer treatment in African-American men, with an emphasis on clinically localized treatment. Data retrieved from population-based as well as single-center investigations are conflicting with regard to the extent and quality of life relevance of sexual dysfunction following prostate cancer treatments in African-American men, relative to that of ethnically different counterparts. Some reports suggest a relatively greater trend in African-American men than other ethnic groups toward obtaining clinical management for sexual dysfunction and experiencing psychosocial effects from it, lending additional support for the possibly greater effect of this problem in African-American men. Although further studies are needed to define sexual dysfunction after prostate cancer treatment and ascertain its bother and impact on quality of life in African-American men, survivorship care that encompasses sexual dysfunction management should proceed with appropriate attention given to cultural, educational, and psychosocial variables.

IgG4-Related Systemic Disease Can Be Easily Mistaken as a Uroepithelial Tumor

Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized systemic syndrome characterized by elevated serum IgG4 concentrations and tumefaction or tissue infiltration by IgG4-positive plasma cells. We experienced a case of IgG4-RD involving multiple organs in a 64-year-old female who was referred for a suspected uroepithelial tumor. A mass biopsy confirmed dense lymphoplasmacytic infiltration with an increased number of IgG4-positive plasma cells. We discuss this case and review the literature to bring IgG4-RD to the attention to clinicians because it responds dramatically well to steroid therapy and should be kept in mind as a differential diagnosis to avoid unnecessary surgery.

Opportunities for targeted focal treatment in Japan

PURPOSE OF REVIEW

Widespread prostate-specific antigen screening has led to an increase in prostate cancer diagnoses in Asian populations, reflecting changes in socioeconomic status and epidemiological features in these countries. In this setting, the present review explores opportunities for target focal therapy in Japan.

RECENT FINDINGS

Our review examines several topics relating to focal therapy in Asia, and discusses the current status of prostate cancer diagnosis and treatment in that region. First, we summarize the prevalence of prostate cancer in Asian populations. Second, we examine prostate cancer diagnosis and treatment options such as mapping biopsy and MRI fusion biopsy in Japan. Third, we review treatment strategies for localized prostate cancer, especially robotic-assisted surgery, active surveillance, and high-intensity focused ultrasound. Lastly, we discuss the potential for focal therapy in Japan.

SUMMARY

The number of localized prostate cancer patients is expected to increase in Asia. Accordingly, the need for precise diagnosis in terms of localization of prostate cancer foci will also expand. MRI fusion target biopsies are being performed in Asia, particularly in some Japanese academic institutions, but as pilot studies. In recent years, an increase in robotic-assisted surgery in East Asia has yielded new options in prostate cancer treatment. Although active surveillance is a practical choice for low-risk prostate cancer in some Asian countries, focal therapy is expected to see increasing interest as another alternative in Japan.

High-intensity focused ultrasound for the treatment of prostate cancer: A prospective trial with long-term follow-up

OBJECTIVE

High-intensity focused ultrasound (HIFU) is a minimally invasive treatment for prostate cancer. Data from the literature show promising oncological outcomes with a favourable side-effect profile. The aim of this study was to re-evaluate and bring up to date the follow-up of a previously published, prospective trial on HIFU as the primary treatment for prostate cancer.

MATERIALS AND METHODS

Between 2004 and 2007, 163 consecutive men with T1-T3N0M0 prostate cancer underwent HIFU with the Sonablate 500. Follow-up included prostate-specific antigen (PSA) tests every 3 months after treatment and a random prostate biopsy at 6 months. Failure was defined according to positive findings at the 6 month biopsy and biochemical failure was defined according to the Phoenix criteria. Biochemical-free survival, metastasis-free survival and cancer-specific survival were calculated by Kaplan-Meier curves.

RESULTS

Median follow-up was 72.0 months. Of the 160 evaluable patients, 104 (65%) were biochemically disease free; in low- to intermediate-risk disease, on Kaplan-Meier analysis the 8 year biochemical-non-evidence of disease (bNED), metastasis-free survival and cancer-specific survival rates were 69.6%, 81.3%, 100% and 40.5%, 60.6%, 100%, respectively. A PSA nadir below 0.40 ng/ml and risk stratification have an independent predictive value for bNED and metastasis-free survival.

CONCLUSIONS

A long-term favourable outcome of HIFU is associated with careful patient selection, with low- to intermediate-risk disease being the ideal case. A low postoperative PSA nadir is a predictor of long-term bNED.

Development, characteristics and validity of the EORTC QLQ-PR25 and the FACT-P for assessment of quality of life in prostate cancer patients

This review aims to compare and contrast the development, characteristics and validity of two widely used quality of life assessment tools in patients with prostate cancers: the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-PR25) and Functional Assessment of Chronic Illness Therapy (FACT-P). Both questionnaires present several strengths as well as some limitations in measuring the quality of life of prostate cancer patients. Each tool may be selected accordingly based on study design and needs.

IgG4-related tubulointerstitial nephritis accompanied with cystic formation

Background

An immunoglobulin G4 (IgG4)-related disease is important disease in differential diagnosis of tumors in kidney, pancreas, lung and other organs. The imaging findings of IgG4-related kidney diseases are usually expressed as defect contrast region, while cystic formation in kidney is extremely rare. Here, we report a case of IgG4-related tubulointerstitial nephritis with renal cystic change caused by the narrowing or obstruction of collecting duct in renal medulla.

Case presentation

Abdominal contrasted CT scan showed a 31 × 24 mm cystic tumor at the upper pole of the right kidney and multiple low-attenuation areas in the left kidney. ¹⁸ F-fluorodeoxyglucose (FDG)-PET/CT scan showed moderate FDG accumulation of cystic tumor in marginal lesion. In addition, FDG-PET/CT scan also showed moderate FDG accumulation in the pancreatic body. Laparoscopic right nephrectomy was performed. Histological examination was revealed lymphoplasmacytic infiltrate with focal fibrosis and severe narrowing or obstruction of lumen of collecting duct in renal medulla. Furthermore, the IgG4 positive plasma cells infiltrated exceeding 10 cells per one high-power field in renal medulla. The ratio of IgG4-plasma cells to IgG-positive plasma cells was about 50%. The serum level of IgG4 was also elevated (218 mg/dl). Based on these findings, we finally diagnosed IgG4-related tubulointerstitial nephritis with renal cystic change.

Conclusion

IgG4-related kidney disease might cause cystic formation by severe narrowing and obstruction of collecting duct.

Prostate swelling and shift during high intensity focused ultrasound: implication for targeted focal therapy

PURPOSE

We quantified prostate swelling and the intraprostatic point shift during high intensity focused ultrasound using real-time ultrasound.

MATERIALS AND METHODS

The institutional review board approved this retrospective study. Whole gland high intensity focused ultrasound was done in 44 patients with clinically localized prostate cancer. Three high intensity focused ultrasound sessions were required to cover the entire prostate, including the anterior zone (session 1), middle zone (session 2) and posterior zone (session 3). Computer assisted 3-dimensional reconstructions based on 3 mm step-section images of intraoperative transrectal ultrasound were compared before and after each session.

RESULTS

Most prostate swelling and intraprostatic point shifts occurred during session 1. The median percent volume increase was 18% for the transition zone, 9% for the peripheral zone and 13% for the entire prostate. The volume percent increase in the transition zone (p <0.001), peripheral zone (p = 0.001) and entire prostate (p = 0.001) statistically depended on the volume of each area measured preoperatively. The median 3-dimensional intraprostatic shift was 3.7 mm (range 0.9 to 13) in the transition zone and 5.5 mm (range 0.2 to 14) in the peripheral zone. A significant negative linear correlation was found between the preoperative presumed circle area ratio, and the percent increase in prostate volume (p = 0.001) and shift (p = 0.01) during high intensity focused ultrasound.

CONCLUSIONS

We quantified significant prostate swelling and shift during high intensity focused ultrasound. Smaller prostates and a smaller preoperative presumed circle area ratio were associated with greater prostate swelling and intraprostatic shifts. Real-time intraoperative adjustment of the treatment plan impacts the achievement of precise targeting during high intensity focused ultrasound, especially in prostates with a smaller volume and/or a smaller preoperative presumed circle area ratio.

A case of intraperitoneal immunoglobulin G4-related inflammatory pseudotumor

The term inflammatory pseudotumor (IPT) has been used to describe inflammatory and fibrosing tumoral processes of an undetermined cause that may involve a variety of organ system. IgG4-related disease is a newly recognized fibroinflammatory condition characterized by IgG4-producing plasma cell expansion in affected organs and, often but not always, elevated serum IgG4 concentrations. IgG4-related IPTs, a subtype of IPT, are characterized by dense infiltration of IgG4-positive plasma cells and stromal fibrosis. The association between inflammatory pseudotumor and IgG4 was first reported with a regard to sclerosing pancreatitis. Despite there are many reports on intraperitoneal IPTs including both cellular and lymphoplasmacytic type, only a few cases have been confirmed to be IgG4-related. We experienced a case of intraperitoneal IgG4-related inflammatory pseudotumor in an 83-year-old woman presenting with epigastric pain and malaise. Surgical specimens revealed an IgG4-related inflammatory pseudotumor.

Targeting accuracy of transcranial magnetic resonance-guided high-intensity focused ultrasound brain therapy: a fresh cadaver model

OBJECT

This work aimed at evaluating the accuracy of MR-guided high-intensity focused ultrasound (MRgHIFU) brain therapy in human cadaver heads.

METHODS

Eighteen heads of fresh human cadavers were removed with a dedicated protocol preventing intracerebral air penetration. The MR images allowed determination of the ultrasonic target: a part of the thalamic nucleus ventralis intermedius implicated in essential tremor. Osseous aberrations were corrected with simulation-based time reversal by using CT data from the heads. The ultrasonic session was performed with a 512-element phased-array transducer system operating at 1 MHz under stereotactic conditions with thermometric real-time MR monitoring performed using a 1.5-T imager.

RESULTS

Dissection, imaging, targeting, and planning have validated the feasibility of this human cadaver model. The average temperature elevation measured by proton resonance frequency shift was 7.9°C ± 3°C. Based on MRI data, the accuracy of MRgHIFU is 0.4 ± 1 mm along the right/left axis, 0.7 ± 1.2 mm along the dorsal/ventral axis, and 0.5 ± 2.4 mm in the rostral/caudal axis.

CONCLUSIONS

Despite its limits (temperature, vascularization), the human cadaver model is effective for studying the accuracy of MRgHIFU brain therapy. With the 1-MHz system investigated here, there is millimetric accuracy.

Prostatic cancer surveillance following whole-gland high-intensity focused ultrasound: comparison of MRI and prostate-specific antigen for detection of residual or recurrent disease

OBJECTIVE

This retrospective study compares dynamic contrast-enhanced (DCE) MRI with the serial prostate-specific antigen (PSA) measurement for detection of residual disease following whole-gland high-intensity focused ultrasound (HIFU) therapy of prostate cancer.

METHODS

Patients in whom post-HIFU DCE-MRI was followed within 3 months by ultrasound-guided transrectal biopsy were selected from a local database. 26 patients met the study inclusion criteria. Serial PSA levels following HIFU and post-HIFU follow-up MRI were retrieved for each patient. Three radiologists unaware of other investigative results independently assessed post-HIFU MRI studies for the presence of cancer, scoring on a four-point scale (1, no disease; 2, probably no disease; 3, probably residual disease; and 4, residual disease). Sensitivity, specificity and receiver operating characteristic (ROC) analysis were performed for each reader, post-HIFU PSA nadir and pre-biopsy PSA level thresholds of >0.2 and >0.5 ng ml(-1).

RESULTS

The sensitivity of DCE-MRI for detection of residual disease for the three readers ranged between 73% and 87%, and the specificity between 73% and 82%. There was good agreement between readers (κ = 0.69-0.77). The sensitivity and specificity of PSA thresholds was 60-87% and 73-100%, respectively. The area under the ROC curve was greatest for pre-biopsy PSA (0.95).

CONCLUSION

DCE-MRI performed following whole-gland HIFU has similar sensitivity and specificity and ROC performance to serial PSA measurements for detection of residual or recurrent disease.

High-intensity focused ultrasound therapy for prostate cancer

Recent advances in high-intensity focused ultrasound, which was developed in the 1940s as a viable thermal tissue ablation approach, have increased its popularity. High-intensity focused ultrasound is currently utilized the most in Europe and Japan, but has not yet been approved by the Food and Drug Administration, USA, for this indication. The purpose of the present report is to review the scientific foundation of high-intensity focused ultrasound technology and the clinical outcomes achieved with commercially available devices. Recently published articles were reviewed to evaluate the current status of high-intensity focused ultrasound as a primary or salvage treatment option for localized prostate cancer. Improvements in the clinical outcome as a result of technical, imaging and technological advancements are described herein. A wide range of treatment options for organ-confined prostate cancer is available. However, high-intensity focused ultrasound is an attractive choice for men willing to choose less invasive options, although establishing the efficacy of high-intensity focused ultrasound requires longer follow-up periods. Technological advances, together with cultural and economic factors, have caused a dramatic shift from traditional open, radical prostatectomy to minimally invasive techniques. High-intensity focused ultrasound is likely to play a significant role in the future of oncology practice.

Inflammatory pseudotumors of the kidney and the lung presenting as immunoglobulin G4-related disease: a case report

Introduction

It has been reported that immunoglobulin G4-related systemic disease can spread to nearly every organ, and often presents as an inflammatory mass or masses at those sites. In the kidney, this disease is often diagnosed after a radical or partial nephrectomy following the discovery of an inflammatory mass which is often suspected to be a malignant tumor. Here, we present a rare case of inflammatory pseudotumors of the kidney and the lung presenting as immunoglobulin G4-related disease, which were diagnosed by computed tomography-guided biopsies.

Case presentation

A 54-year-old Japanese man was referred to our hospital with suspected bilateral renal cancer, multiple lung metastases and autoimmune pancreatitis. His serum immunoglobulin G4 level was high. We used computed tomography-guided biopsies and histopathological examinations of the biopsied specimens to diagnose the tumors as immunoglobulin G4-related bilateral renal and lung inflammatory pseudotumors. Our patient was treated with oral prednisolone, and after one month of treatment, contrast-enhanced computed tomography demonstrated a general improvement, as noted by a reduction in size of the masses.

Conclusion

Renal masses that are formed due to immunoglobulin G4-related disease require comprehensive diagnosis to prevent unnecessary surgical resections from being performed. Further consideration should be paid to immunoglobulin G4-related diseases in the future.

Proposal for diagnostic criteria for IgG4-related kidney disease

BACKGROUND

IgG4-related disease has attracted wide attention recently. It is characterized by a high level of serum IgG4 and dense infiltration of IgG4-positive plasma cells into multiple organs, with the kidney being one representative target. Although several sets of diagnostic criteria for autoimmune pancreatitis (AIP) are available and renal lesion is recognized as an extra-pancreatic manifestation of AIP, it is difficult to differentiate IgG4-related tubulointerstitial nephritis (TIN) without AIP from other types of TIN. To clarify the entity of IgG4-related kidney disease (IgG4-RKD) and support in-depth studies, the Japanese Society of Nephrology has established a working group to prepare diagnostic criteria for IgG4-RKD.

METHOD

The working group analyzed 41 patients with IgG4-RKD, and collected the following data to devise a diagnostic algorithm and diagnostic criteria for IgG4-RKD: clinical features including extra-renal organ involvement, urinalysis and serological features including serum IgG4 levels, imaging findings demonstrated by computed tomography (CT), renal histology with IgG4 immunostaining, and response to steroid therapy.

RESULTS

The conditions for criteria are as follows. (1) Presence of some kidney damage, as manifested by abnormal urinalysis or urine marker(s) and/or decreased kidney function with either elevated serum IgG level, hypocomplementemia, or elevated serum IgE level. (2) Kidney imaging studies showing abnormal renal imaging findings, i.e., multiple low density lesions on enhanced CT, diffuse kidney enlargement, hypovascular solitary mass in the kidney, and hypertrophic lesion of the renal pelvic wall without irregularity of the renal pelvic surface. (3) Serum IgG4 level exceeding 135 mg/dl. (4) Renal histology showing two abnormal findings: (a) dense lymphoplasmacytic infiltration with infiltrating IgG4-positive plasma cells >10/high power field (HPF) and/or ratio of IgG4-positive plasma cells/IgG positive plasma cells >40%. (b) Characteristic 'storiform' fibrosis surrounding nests of lymphocytes and/or plasma cells. (5) Extra-renal histology showing dense lymphoplasmacytic infiltration with infiltrating IgG4-positive plasma cells >10/HPF and/or ratio of IgG4-positive plasma cells/IgG-positive plasma cells >40%. The diagnosis is classified into 3 stages of definite, probable and possible according to the combinations of the above conditions. Thirty-nine cases (95.1%) were diagnosed with IgG4-RKD according to the criteria.

CONCLUSION

The provisional criteria and algorithm appear to be useful for clarifying the entity of IgG4-RKD and seeking underlying IgG4-RKD cases; however, further experience is needed to confirm the validity of these criteria.

Health-related quality of life after salvage high-intensity focused ultrasound (HIFU) treatment for locally radiorecurrent prostate cancer

OBJECTIVE

To evaluate health-related quality of life (HRQOL) after salvage high-intensity focused ultrasound (HIFU) for locally radiorecurrent prostate cancer (PCa).

METHODS

Since June 2006 we have treated 61 patients consecutively by salvage HIFU. All patients were offered the University of California, Los Angeles Prostate Cancer Index (UCLA-PCI) questionnaire at baseline and at follow-up. Scores ranged from 0 (worst) to 100 (best). Clinically significant changes were defined as a minimum difference of 10 points between the baseline score and the score at follow-up.

RESULTS

  Fifty-seven patients (93%) had evaluable data at baseline, compared with 46 (75%) after treatment. The mean time lapse between HIFU treatment and questionnaire response was 17.5 months (range 6-29 months). The mean score for urinary function decreased from 79.7 ± 12.1 prior to HIFU to 67.4 ± 17.8 after HIFU (P < 0.001). The mean score for sexual function decreased from 32.1 ± 24.1 prior to HIFU to 17.2 ± 17.0 after HIFU (P < 0.001). There were no significant effects on bowel function. There was a significant reduction in the mean score for Physical HRQOL, but the mean score for Mental HRQOL was did not change significantly.

CONCLUSION

Treatment of localized radiorecurrent PCa by salvage HIFU is associated with clinically significant reductions in urinary and sexual function domains after a mean follow-up of 17.5 months.