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Ghai S, Finelli A, Corr K, Lajkosz K, McCluskey S, Chan R, Gertner M, van der Kwast TH, Incze PF, Zlotta AR, Kucharczyk W, Perlis N. MRI-guided Focused Ultrasound Focal Therapy for Intermediate-Risk Prostate Cancer: Final Results from a 2-year Phase II Clinical Trial. Radiology 2024; 310:e231473. [PMID: 38441092 DOI: 10.1148/radiol.231473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Background MRI-guided focal therapy (FT) allows for accurate targeting of localized clinically significant prostate cancer (csPCa) while preserving healthy prostate tissue, but the long-term outcomes of this approach require more study. Purpose To assess the 2-year oncological and functional outcomes of men with intermediate-risk prostate cancer (PCa) treated with targeted FT. Materials and Methods In this single-center prospective phase II trial, men with localized unifocal intermediate-risk PCa underwent transrectal MRI-guided focused ultrasound between July 2016 and July 2019. Planned ablation volumes included 10-mm margins when possible. Data regarding adverse events were collected and quality-of-life questionnaires were completed by participants at 6 weeks and at 5, 12, 18, and 24 months after treatment. Multiparametric MRI and targeted and systematic biopsies were performed at 24 months. Ablation volumes were determined by manual contouring of nonperfused volumes on immediate contrast-enhanced images. Generalized estimating equations were used to model trends in quality-of-life measures. Results Treatment was successfully completed in the 44 participants (median age, 67 years; IQR, 62-70 years; 36 patients with grade group [GG] 2; eight patients with GG 3). No major adverse events from treatment were recorded. One participant refused biopsy at 24 months. After 2 years, 39 of 43 participants (91%) had no csPCa at the treatment site and 36 of 43 (84%) had no cancer in the entire gland. No changes in International Index of Erectile Function-15 score or International Prostate Symptom Score were observed during 2-year follow-up (P = .73 and .39, respectively). Conclusion The majority of men treated with MRI-guided focused ultrasound for intermediate risk PCa had negative results for csPCa at biopsy 2 years after treatment. Additionally, there was no significant decline in quality of life per the validated questionnaires. Clinical trial registration no. NCT02968784 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Woodrum in this issue.
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Affiliation(s)
- Sangeet Ghai
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Antonio Finelli
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Kateri Corr
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Katherine Lajkosz
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Stuart McCluskey
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Rosanna Chan
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Mark Gertner
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Theodorus H van der Kwast
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Peter F Incze
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Alexandre R Zlotta
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Walter Kucharczyk
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Nathan Perlis
- From the Joint Department of Medical Imaging, University Health Network-Mount Sinai Hospital-Women's College Hospital, University of Toronto, Toronto General Hospital, 585 University Ave, 1PMB-292, Toronto, ON, Canada M5G 2N2 (S.G., K.C., R.C., M.G., W.K.); Division of Urology, Department of Surgical Oncology (A.F., A.R.Z., N.P.), Department of Anesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network, University of Toronto, Toronto, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada (K.L.); and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
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Ahn H, Hwang SI, Lee HJ, Kim SY, Cho JY, Lee H, Hong SK, Byun SS, Kim TM. Diagnostic Performance of MRI for Prediction of Recurrent Prostate Cancer after High-intensity Focused Ultrasound: A Systematic Review and Meta-analysis. Prostate Int 2022. [DOI: 10.1016/j.prnil.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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3
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Diagnostic value of multiparametric MRI in detecting residual or recurrent prostate cancer after high-intensity focused ultrasound. Prostate Cancer Prostatic Dis 2022:10.1038/s41391-022-00531-8. [DOI: 10.1038/s41391-022-00531-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/04/2022] [Accepted: 03/23/2022] [Indexed: 11/08/2022]
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Mäkelä P, Anttinen M, Suomi V, Steiner A, Saunavaara J, Sainio T, Horte A, Taimen P, Boström P, Blanco Sequeiros R. Acute and subacute prostate MRI findings after MRI-guided transurethral ultrasound ablation of prostate cancer. Acta Radiol 2021; 62:1687-1695. [PMID: 33251811 DOI: 10.1177/0284185120976931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI)-guided transurethral ultrasound ablation (TULSA) is an emerging method for treatment of localized prostate cancer (PCa). TULSA-related subacute MRI findings have not been previously characterized. PURPOSE To evaluate acute and subacute MRI findings after TULSA treatment in a treat-and-resect setting. MATERIAL AND METHODS Six men with newly diagnosed MRI-visible and biopsy-concordant clinically significant PCa were enrolled and completed the study. Eight lesions classified as PI-RADS 3-5 were focally ablated using TULSA. One- and three-week follow-up MRI scans were performed between TULSA and robot-assisted laparoscopic prostatectomy. RESULTS TULSA-related hemorrhage was detected as a subtle T1 hyperintensity and more apparent T2 hypointensity in the MRI. Both prostate volume and non-perfused volume (NPV) markedly increased after TULSA at one week and three weeks after treatment, respectively. Lesion apparent diffusion coefficient values increased one week after treatment and decreased nearing the baseline values at the three-week MRI follow-up. CONCLUSION The optimal timing of MRI follow-up seems to be at the earliest at three weeks after treatment, when the post-procedural edema has decreased and the NPV has matured. Diffusion-weighted imaging has little or no added diagnostic value in the subacute setting.
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Affiliation(s)
- Pietari Mäkelä
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Mikael Anttinen
- Department of Urology, Turku University Hospital, Turku, Finland
| | - Visa Suomi
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Aida Steiner
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Jani Saunavaara
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Teija Sainio
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Antero Horte
- Department of Urology, Turku University Hospital, Turku, Finland
| | - Pekka Taimen
- Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Pathology, Turku University Hospital, Turku, Finland
| | - Peter Boström
- Department of Urology, Turku University Hospital, Turku, Finland
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Schaudinn A, Michaelis J, Franz T, Ho-Thi P, Horn LC, Blana A, Hadaschik B, Stumpp P, Stolzenburg JU, Schlemmer HP, Denecke T, Busse H, Ganzer R, Linder N. High-intensity focused ultrasound (HIFU) hemiablation of the prostate: Late follow-up MRI findings in non-recurrent patients. Eur J Radiol 2021; 144:109957. [PMID: 34601322 DOI: 10.1016/j.ejrad.2021.109957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/30/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Focal therapy with high-intensity focused ultrasound (HIFU) is an emerging option for the treatment of prostate cancer and often followed up by MRI. Image assessment of treatment failure, however, requires proper knowledge about typical procedure-related changes in prostate MRI, which is sparse, in particular for unilateral HIFU treatment and late follow up (beyond 6 months). The goal of this study was therefore to compile the type and frequency of such MRI findings in selected patients without recurrent cancer 12 months after prostate hemiablation. METHODS Data from a prospective multicenter trial on HIFU hemiablation were reviewed retrospectively. Trial patients have had a late follow-up by MRI (at around 12 months) and either MRI/transrectal ultrasound (TRUS) fusion or standard TRUS-guided biopsy. This work deliberately included patients with non-recurrent cancer in the treated prostate lobe in per-protocol biopsy leaving 30 men with initial International Society of Urological Pathology (ISUP) Grade Group of 1 or 2. Six categories of potential HIFU-related MRI features were assessed by an expert committee and then evaluated by two readers in consensus: 1. shrinkage of the treated lobe, 2. residual prostate tissue, 3. fluid-filled cavity, 4. fibrosis, 5. hematoma residuals (in the prostate or seminal vesicles) and 6. contrast enhancement of the ablated area. RESULTS Shrinkage of the ablated lobe was seen in 93% of the cases with an average percent volume change of -37% (range: -70% to +108%). In the contralateral lobe, the volume remained practically the same (-2% on average, p = 0.804). In the ablated lobe, the frequency of fibrosis was 97%. Residual prostate tissue was seen in 93% of the cases. The frequency for fluid-filled cavities was 97%, with the wide majority (90%) contiguous with the urethra. Hematoma residuals in the prostate and in seminal vesicles were found in 47% and 10% of the patients, respectively. Contrast enhancement was both rim-like (50%) as well as diffuse (33%) within the ablated area. CONCLUSION In our case series of HIFU hemiablation in the prostate, shrinkage, residual prostate tissue, fluid-filled cavities contiguous with the urethra and fibrosis were very common late MRI findings of the ablated lobe in non-recurrent patients. Rim-like contrast enhancement or diffuse one within the ablated area were less frequent.
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Affiliation(s)
- Alexander Schaudinn
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Jakob Michaelis
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Toni Franz
- Department of Urology, University Hospital Leipzig, Leipzig, Germany
| | - Phuc Ho-Thi
- Department of Urology, University Hospital Leipzig, Leipzig, Germany
| | | | - Andreas Blana
- Department of Urology, Fürth Hospital, Fürth, Germany
| | - Boris Hadaschik
- Department of Urology, University Hospital Essen, Essen, Germany; Department of Urology, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrick Stumpp
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | | | | | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Harald Busse
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Roman Ganzer
- Department of Urology, Asklepios Hospital Bad Tölz, Bad Tölz, Germany
| | - Nicolas Linder
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany.
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6
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Bass EJ, Pantovic A, Connor M, Gabe R, Padhani AR, Rockall A, Sokhi H, Tam H, Winkler M, Ahmed HU. A systematic review and meta-analysis of the diagnostic accuracy of biparametric prostate MRI for prostate cancer in men at risk. Prostate Cancer Prostatic Dis 2021; 24:596-611. [PMID: 33219368 DOI: 10.1038/s41391-020-00298-w] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/14/2020] [Accepted: 10/19/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Multiparametric magnetic resonance imaging (mpMRI), the use of three multiple imaging sequences, typically T2-weighted, diffusion weighted (DWI) and dynamic contrast enhanced (DCE) images, has a high sensitivity and specificity for detecting significant cancer. Current guidance now recommends its use prior to biopsy. However, the impact of DCE is currently under debate regarding test accuracy. Biparametric MRI (bpMRI), using only T2 and DWI has been proposed as a viable alternative. We conducted a contemporary systematic review and meta-analysis to further examine the diagnostic performance of bpMRI in the diagnosis of any and clinically significant prostate cancer. METHODS A systematic review of the literature from 01/01/2017 to 06/07/2019 was performed by two independent reviewers using predefined search criteria. The index test was biparametric MRI and the reference standard whole-mount prostatectomy or prostate biopsy. Quality of included studies was assessed by the QUADAS-2 tool. Statistical analysis included pooled diagnostic performance (sensitivity; specificity; AUC), meta-regression of possible covariates and head-to-head comparisons of bpMRI and mpMRI where both were performed in the same study. RESULTS Forty-four articles were included in the analysis. The pooled sensitivity for any cancer detection was 0.84 (95% CI, 0.80-0.88), specificity 0.75 (95% CI, 0.68-0.81) for bpMRI. The summary ROC curve yielded a high AUC value (AUC = 0.86). The pooled sensitivity for clinically significant prostate cancer was 0.87 (95% CI, 0.78-0.93), specificity 0.72 (95% CI, 0.56-0.84) and the AUC value was 0.87. Meta-regression analysis revealed no difference in the pooled diagnostic estimates between bpMRI and mpMRI. CONCLUSIONS This meta-analysis on contemporary studies shows that bpMRI offers comparable test accuracies to mpMRI in detecting prostate cancer. These data are broadly supportive of the bpMRI approach but heterogeneity does not allow definitive recommendations to be made. There is a need for prospective multicentre studies of bpMRI in biopsy naïve men.
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Affiliation(s)
- E J Bass
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK. .,Imperial Urology, Division of Cancer, Cardiovascular Medicine and Surgery, Imperial College Healthcare NHS Trust, London, UK.
| | - A Pantovic
- Centre of Research Excellence in Nutrition and Metabolism, Institute for Medical Research, Belgrade, Serbia
| | - M Connor
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Division of Cancer, Cardiovascular Medicine and Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - R Gabe
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - A R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, London, UK
| | - A Rockall
- Division of Cancer, Department of Surgery and Cancer,Faculty of Medicine, Imperial College London, London, UK
| | - H Sokhi
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, London, UK.,Department of Radiology, Hillingdon Hospitals NHS Foundation Trust, London, UK
| | - H Tam
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
| | - M Winkler
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Division of Cancer, Cardiovascular Medicine and Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - H U Ahmed
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Division of Cancer, Cardiovascular Medicine and Surgery, Imperial College Healthcare NHS Trust, London, UK
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Ghai S, Finelli A, Corr K, Chan R, Jokhu S, Li X, McCluskey S, Konukhova A, Hlasny E, van der Kwast TH, Incze PF, Zlotta AR, Hamilton RJ, Haider MA, Kucharczyk W, Perlis N. MRI-guided Focused Ultrasound Ablation for Localized Intermediate-Risk Prostate Cancer: Early Results of a Phase II Trial. Radiology 2021; 298:695-703. [PMID: 33529137 DOI: 10.1148/radiol.2021202717] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background To reduce adverse effects of whole-gland therapy, participants with localized clinically significant prostate cancer can undergo MRI-guided focal therapy. Purpose To explore safety and early oncologic and functional outcomes of targeted focal high-intensity focused ultrasound performed under MRI-guided focused ultrasound for intermediate-risk clinically significant prostate cancer. Materials and Methods In this prospective phase II trial, between February 2016 and July 2019, men with unifocal clinically significant prostate cancer visible at MRI were treated with transrectal MRI-guided focused ultrasound. The primary end point was the 5-month biopsy (last recorded in December 2019) with continuation to the 24-month follow-up projected to December 2021. Real-time ablation monitoring was performed with MR thermography. Nonperfused volume was measured at treatment completion. Periprocedural complications were recorded. Follow-up included International Prostate Symptom Score (IPSS) and International Index of Erectile Function-15 (IIEF-15) score at 6 weeks and 5 months, and multiparametric MRI and targeted biopsy of the treated area at 5 months. The generalized estimating equation model was used for statistical analysis, and the Holm method was used to adjust P value. Results Treatment was successfully completed in all 44 men, 36 with grade group (GG) 2 and eight with GG 3 disease (median age, 67 years; interquartile range [IQR], 62-70 years). No major treatment-related adverse events occurred. Forty-one of 44 participants (93%; 95% CI: 82, 98) were free of clinically significant prostate cancer (≥6 mm GG 1 disease or any volume ≥GG 2 disease) at the treatment site at 5-month biopsy (median, seven cores). Median IIEF-15 and IPSS scores were similar at baseline and at 5 months (IIEF-15 score at baseline, 61 [IQR, 34-67] and at 5 months, 53 [IQR, 24-65.5], P = .18; IPSS score at baseline, 3.5 [IQR, 1.8-7] and at 5 months, 6 [IQR, 2-7.3], P = .43). Larger ablations (≥15 cm3) compared with smaller ones were associated with a decline in IIEF-15 scores at 6 weeks (adjusted P < .01) and at 5 months (adjusted P = .07). Conclusion Targeted focal therapy of intermediate-risk prostate cancer performed with MRI-guided focused ultrasound ablation was safe and had encouraging early oncologic and functional outcomes. © RSNA, 2021 Online supplemental material is available for this article See also the editorial by Tempany-Afdhal in this issue.
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Affiliation(s)
- Sangeet Ghai
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Antonio Finelli
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Kateri Corr
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Rosanna Chan
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Sarah Jokhu
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Xuan Li
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Stuart McCluskey
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Anna Konukhova
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Eugen Hlasny
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Theodorus H van der Kwast
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Peter F Incze
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Alexandre R Zlotta
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Robert J Hamilton
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Masoom A Haider
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Walter Kucharczyk
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
| | - Nathan Perlis
- From the Joint Department of Medical Imaging (S.G., R.C., E.H., M.A.H., W.K.), Division of Urology, Department of Surgical Oncology (A.F., K.C., S.J., A.K., A.R.Z., R.J.H., N.P.), Biostatistics Department, Princess Margaret Cancer Centre (X.L.), Department of Anaesthesia (S.M.), and Department of Pathology, Laboratory Medicine Program (T.H.v.d.K.), University Health Network-Mount Sinai Hospital-Women's, College Hospital, University of Toronto, 585 University Ave, Toronto, ON, Canada M5G 2N2; and Department of Urology, Oakville Trafalgar Memorial Hospital, Toronto, Canada (P.F.I.)
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8
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Connor MJ, Gorin MA, Ahmed HU, Nigam R. Focal therapy for localized prostate cancer in the era of routine multi-parametric MRI. Prostate Cancer Prostatic Dis 2020; 23:232-243. [PMID: 32051551 DOI: 10.1038/s41391-020-0206-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prostate cancer focal therapy aims to minimize the side-effects of whole gland treatments, such as radical prostatectomy and radiotherapy without compromising oncological efficacy. However, concerns exist regarding the multifocal nature of prostate cancer and the lack of long-term oncological data for this form of treatment. In recent years, the routine adoption of multi-parametric magnetic resonance imaging (mpMRI) of the prostate has improved our ability to select candidates for focal therapy and to accurately deliver this form of prostate cancer treatment. METHODS We performed a review of the literature to provide a summary of the oncological and functional outcomes of men receiving primary prostate focal therapy. Furthermore, we discuss the impact of the routine implementation of mpMRI as part of the initial prostate cancer diagnostic pathway on the selection of candidates and delivery of focal therapy. Finally, we summarize knowledge gaps in the field and highlight active clinical trials in this arena. RESULTS Primary focal therapy involves the application of one of a number of energies that ablate tissue, such as cryotherapy and high intensity focused ultrasound (HIFU). Success is principally dependent on highly accurate patient selection and disease localization underpinned in large part by the routine integration of pre-biopsy mpMRI. Prospective medium-term follow-up data for primary HIFU and cryotherapy for men with intermediate-risk disease have shown acceptable cancer control with low risk of side effects and complications. Additional research is needed to clearly define an appropriate follow-up approach and to guide the management of in- and out-of-field recurrences. Multiple comparative trials with randomization against standard care are currently underway in men with intermediate- and high-risk prostate cancer. CONCLUSION The widespread adoption of prostate mpMRI has led to improved disease localization, enabling the performance of focal therapy as a viable treatment strategy for men with low volume intermediate-risk prostate cancer.
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Affiliation(s)
- M J Connor
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Charing Cross Hospital, London, W6 8RF, UK. .,Imperial Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, W6 8RF, UK.
| | - M A Gorin
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - H U Ahmed
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Charing Cross Hospital, London, W6 8RF, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, W6 8RF, UK
| | - R Nigam
- Royal Surrey NHS Foundation Trust, Guildford, Surrey, GU2 7XX, UK.,University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
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9
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Abstract
Prostate cancer is the fifth leading cause of death worldwide. A variety of treatment options is available for localized prostate cancer and may range from active surveillance to focal therapy or whole gland treatment, that is, surgery or radiotherapy. Serum prostate-specific antigen levels are an important tool to monitor treatment success after whole gland treatment, unfortunately prostate-specific antigen is unreliable after focal therapy. Multiparametric magnetic resonance imaging of the prostate is rapidly gaining field in the management of prostate cancer and may play a crucial role in the evaluation of recurrent prostate cancer. This article will focus on postprocedural magnetic resonance imaging after different forms of local therapy in patients with prostate cancer.
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10
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Herrera-Caceres JO, Nason GJ, Salgado-Sanmamed N, Goldberg H, Woon DTS, Chandrasekar T, Ajib K, Tan GH, Alhunaidi O, van der Kwast T, Finelli A, Zlotta AR, Hamilton RJ, Berlin A, Perlis N, Fleshner NE. Salvage radical prostatectomy following focal therapy: functional and oncological outcomes. BJU Int 2020; 125:525-530. [PMID: 31863617 DOI: 10.1111/bju.14976] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To report the oncological and functional outcomes of salvage radical prostatectomy (sRP) after focal therapy (FT). PATIENTS AND METHODS A retrospective review of all patients who underwent sRP after FT was performed. Clinical and pathological outcomes focussed on surgical complications, oncological, and functional outcomes. RESULTS In all, 34 patients were identified. The median (interquartile range [IQR]) age was 61 (8.25) years. FT modalities included high-intensity focussed ultrasound (19 patients), laser ablation (13), focal brachytherapy (one) and cryotherapy (one). The median (IQR) time from FT to recurrence was 10.9 (17.6) months. There were no rectal or ureteric injuries. Two (5.9%) patients had iatrogenic cystotomies and four (11.8%) developed bladder neck contractures. The mean (sd) hospital stay was 2.5 (2.1) days. The T-stage was pT2 in 14 (41.2%) patients, pT3a in 16 (47.1%), and pT3b in four (11.8%). In all, 13 (38%) patients had positive surgical margins (PSMs). Six (17.6%) patients received adjuvant radiotherapy (RT). At a mean follow-up of 4.3 years, seven (20.6%) patients developed biochemical recurrence (BCR), and of these, six (17.6%) patients required salvage RT. PSMs were associated with worse BCR-free survival (hazard ratio 6.624, 95% confidence interval 2.243-19.563; P < 0.001). The median (IQR) preoperative International Prostate Symptom Score and International Index of Erectile Function score was 7 (4.5-9.5) and 23.5 (15.75-25) respectively, while in the final follow-up the median (IQR) values were 7 (3.5-11) and 6 (5-12.25), respectively (P = 0.088 and P < 0.001). At last follow-up, 31 (91.2%) patients were continent, two (5.9%) had moderate (>1 pad/day) incontinence, and one (2.9%) required an artificial urinary sphincter. CONCLUSIONS sRP should be considered as an option for patients who have persistent clinically significant prostate cancer or recurrence after FT. PSMs should be recognised as a risk for recurrent disease after sRP.
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Affiliation(s)
- Jaime O Herrera-Caceres
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gregory J Nason
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Noelia Salgado-Sanmamed
- Department of Radiation Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Hanan Goldberg
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Dixon T S Woon
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Thenappen Chandrasekar
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Khaled Ajib
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Guan Hee Tan
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Omar Alhunaidi
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Theodorus van der Kwast
- Department of Pathology and Laboratory Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Antonio Finelli
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Alexandre R Zlotta
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nathan Perlis
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Neil E Fleshner
- Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
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11
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Stabile A, Giganti F, Rosenkrantz AB, Taneja SS, Villeirs G, Gill IS, Allen C, Emberton M, Moore CM, Kasivisvanathan V. Multiparametric MRI for prostate cancer diagnosis: current status and future directions. Nat Rev Urol 2020; 17:41-61. [PMID: 31316185 DOI: 10.1038/s41585-019-0212-4] [Citation(s) in RCA: 188] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2019] [Indexed: 12/31/2022]
Abstract
The current diagnostic pathway for prostate cancer has resulted in overdiagnosis and consequent overtreatment as well as underdiagnosis and missed diagnoses in many men. Multiparametric MRI (mpMRI) of the prostate has been identified as a test that could mitigate these diagnostic errors. The performance of mpMRI can vary depending on the population being studied, the execution of the MRI itself, the experience of the radiologist, whether additional biomarkers are considered and whether mpMRI-targeted biopsy is carried out alone or in addition to systematic biopsy. A number of challenges to implementation remain, such as ensuring high-quality execution and reporting of mpMRI and ensuring that this diagnostic pathway is cost-effective. Nevertheless, emerging clinical trial data support the adoption of this technology as part of the standard of care for the diagnosis of prostate cancer.
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Affiliation(s)
- Armando Stabile
- Division of Surgery and Interventional Science, University College London, London, UK.
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.
- Department of Urology and Division of Experimental Oncology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Francesco Giganti
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Samir S Taneja
- Department of Radiology, NYU Langone Health, New York, NY, USA
- Department of Urology, NYU Langone Health, New York, NY, USA
| | - Geert Villeirs
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Inderbir S Gill
- USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Clare Allen
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Veeru Kasivisvanathan
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
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12
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Medium-term Follow-up of Vascular-targeted Photodynamic Therapy of Localized Prostate Cancer Using TOOKAD Soluble WST-11 (Phase II Trials). Eur Urol Focus 2018; 5:1022-1028. [PMID: 29661587 DOI: 10.1016/j.euf.2018.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/04/2018] [Accepted: 04/01/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE To assess the medium-term tumor control in patients with localized prostate cancer (PCa) treated with vascular-targeted photodynamic (VTP) therapy with TOOKAD Soluble WST11 (VTP) and to assess the medium-term tolerability of the treatment. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION During the clinical phase II studies, 68 patients were treated with VTP under optimal treatment conditions (WST11 at 4mg/kg, light energy at 200J/cm, and a light density index ≥1) and have been included in a 3.5-yr follow-up. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Post-interventional visits were scheduled every 6 mo and conducted as per local standard practice in each study center. Cancer-free status was assessed by means of prostate-specific antigen kinetics, multiparametric magnetic resonance imaging and/or prostate biopsies. RESULTS AND LIMITATIONS At the end of the 3.5-yr follow-up, overall successful focal ablation was achieved for 51 patients (75%). Cancer was identified in the untreated lobe in 17 patients (25%). In total, 34 patients (50%) were cancer-free in both the prostate lobes. In case of recurrent/persistent malignancy, the Gleason score remained consistent or changed at the maximum by one point (upgrading by 1 Gleason point to 3+4 for eight patients and 4+3 for two patients). There were 64 related adverse events (AEs): 48% were Clavien grade I, 47% were grade II, and 5% were grade III. There were no Clavien grade IV and V AEs. Limitations included small sample size and heterogeneity in the follow-up for some centers. CONCLUSIONS VTP is a safe and efficient treatment and represents an alternative option for localized low-risk PCa management over the medium term. Precise diagnostic methods and imaging tools are thereby essential requirements to ensure safe and complete targeted therapy. PATIENT SUMMARY In this report, we looked at the medium-term outcomes of focal photodynamic therapy for early-stage prostate cancer. We found that this form of treatment is efficient and might have the potential to become a therapeutic option for low-risk cancer. Effectiveness depends on precise diagnostic methods, such as magnetic resonance imaging and accurate biopsy.
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13
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Lotte R, Lafourcade A, Mozer P, Conort P, Barret E, Comperat E, Ezziane M, de Guibert PHJ, Tavolaro S, Belin L, Boudghene F, Lucidarme O, Renard-Penna R. Multiparametric MRI for Suspected Recurrent Prostate Cancer after HIFU:Is DCE still needed? Eur Radiol 2018; 28:3760-3769. [DOI: 10.1007/s00330-018-5352-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 01/23/2018] [Indexed: 01/28/2023]
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14
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Kumar V, Bora GS, Kumar R, Jagannathan NR. Multiparametric (mp) MRI of prostate cancer. PROGRESS IN NUCLEAR MAGNETIC RESONANCE SPECTROSCOPY 2018; 105:23-40. [PMID: 29548365 DOI: 10.1016/j.pnmrs.2018.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 01/17/2018] [Accepted: 01/28/2018] [Indexed: 06/08/2023]
Abstract
Prostate cancer (PCa) is one of the most prevalent cancers in men. A large number of men are detected with PCa; however, the clinical behavior ranges from low-grade indolent tumors that never develop into a clinically significant disease to aggressive, invasive tumors that may rapidly progress to metastatic disease. The challenges in clinical management of PCa are at levels of screening, diagnosis, treatment, and follow-up after treatment. Magnetic resonance imaging (MRI) methods have shown a potential role in detection, localization, staging, assessment of aggressiveness, targeting biopsies, etc. in PCa patients. Multiparametric MRI (mpMRI) is emerging as a better option compared to the individual imaging methods used in the evaluation of PCa. There are attempts to improve the reproducibility and reliability of mpMRI by using an objective scoring system proposed in the prostate imaging reporting and data system (PIRADS) for standardized reporting. Prebiopsy mpMRI may be used to detect PCa in men with elevated prostate-specific antigen or abnormal digital rectal examination and to enable targeted biopsies. mpMRI can also be used to decide on clinical management of patients, for example active surveillance, and may help in detecting only the pathology that requires detection. It can potentially not only guide patient selection for initial and repeat biopsy but also reduce false-negative biopsies. This review presents a description of the MR methods most commonly applied for investigations of prostate. The anatomical, functional and metabolic parameters obtained from these MR methods are discussed with regard to their physical basis and their contribution to mpMRI investigations of PCa.
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Affiliation(s)
- Virendra Kumar
- Department of NMR & MRI Facility, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | - Girdhar S Bora
- Department of Urology, Post-Graduate Institute of Medical Sciences, Chandigarh 160012, India
| | - Rajeev Kumar
- Department of Urology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Naranamangalam R Jagannathan
- Department of NMR & MRI Facility, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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15
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Focal Ablation of Early-Stage Prostate Cancer: Candidate Selection, Treatment Guidance, and Assessment of Outcome. Urol Clin North Am 2017; 44:575-585. [PMID: 29107274 DOI: 10.1016/j.ucl.2017.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Prostate cancer lesions smaller than 0.5 m3, or Gleason pattern 3, are likely clinically insignificant. Clinically significant disease is often limited to a single index lesion. Focal ablation targets this index lesion, maintains oncological control, and minimizes complications by preserving healthy prostate tissue. Template mapping biopsy or multiparametric MRI-targeted biopsies are used to identify appropriate index lesions. Multiple energy modalities have been tested, including high-intensity frequency ultrasound, cryoablation, laser ablation, photodynamic therapy, focal brachytherapy, radiofrequency ablation, irreversible electroporation. Outcome is assessed by biopsy of the target area, triggered by prostate-specific antigen measurements or MRI imaging, or performed per protocol at 12 months.
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16
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Prostate-specific antigen vs. magnetic resonance imaging parameters for assessing oncological outcomes after high intensity-focused ultrasound focal therapy for localized prostate cancer. Urol Oncol 2016; 35:30.e9-30.e15. [PMID: 27663393 DOI: 10.1016/j.urolonc.2016.07.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/11/2016] [Accepted: 07/21/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Focal therapy for localized prostate cancer has the potential for oncological control without the side effects of radical therapies. However, there is currently no validated method for monitoring treatment success. We assessed the diagnostic performance of prostate-specific antigen (PSA) parameters and MRI compared to histological outcomes following focal therapy. PATIENTS AND METHODS Patients from 3 Ethics Review Board approved prospective studies of focal high intensity-focused ultrasound (HIFU) (Sonablate 500) for localized prostate cancer (T1c-T3a, Gleason grade≤4+3, and PSA≤20). Post-HIFU PSA nadir, 6-month PSA, PSA density, and early (<3wk) and late (6mo) MRI (T2-weighted, dynamic contrast-enhanced±diffusion-weighted) was assessed for predictive accuracy of cancer on postoperative biopsy, using receiver operating characteristic (ROC) analysis and sensitivity, specificity, and positive and negative predictive estimates. ROC areas for MRI and PSA were compared. Calculations for statistical significance (P≤0.05) were obtained in a subset of patients comparing area under ROC for 6-month MRI and PSA criteria, across 4 different histological definitions of disease significance. RESULTS Of 118 men, 111 underwent at least 1 postoperative biopsy (median 6 cores), with an overall positive biopsy rate of 37% (41/118), over a mean follow-up period of 716 days post-HIFU. Areas under ROC for early and late MRI were (depending on definition of significant disease) 0.65 to 0.76 and 0.77 to 0.85, respectively, with sensitivity, specificity, and negative predictive values of 68% to 91%, 52% to 55%, and 85% to 98% (early MRI), and 63% to 80%, 67% to 73%, and 86% to 97% (late MRI). The area under the ROC curve was statistically significantly higher for late MRI than 6 months and nadir PSA for residual disease >3mm or any Gleason 4 tumor. CONCLUSIONS Early and late MRI performed better than PSA measurements in the detection of residual tumor after focal therapy.
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17
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Hoquetis L, Malavaud B, Game X, Beauval JB, Portalez D, Soulie M, Rischmann P. MRI evaluation following partial HIFU therapy for localized prostate cancer: A single-center study. Prog Urol 2016; 26:517-23. [PMID: 27567745 DOI: 10.1016/j.purol.2016.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/11/2016] [Accepted: 07/22/2016] [Indexed: 02/07/2023]
Affiliation(s)
- L Hoquetis
- Urology department, Rangueil university hospital, 1, avenue du Pr-Jean-Poulhes, 31059 Toulouse cedex, France.
| | - B Malavaud
- Urology department, Rangueil university hospital, 1, avenue du Pr-Jean-Poulhes, 31059 Toulouse cedex, France
| | - X Game
- Urology department, Rangueil university hospital, 1, avenue du Pr-Jean-Poulhes, 31059 Toulouse cedex, France
| | - J B Beauval
- Urology department, Rangueil university hospital, 1, avenue du Pr-Jean-Poulhes, 31059 Toulouse cedex, France
| | - D Portalez
- Urology department, Rangueil university hospital, 1, avenue du Pr-Jean-Poulhes, 31059 Toulouse cedex, France
| | - M Soulie
- Urology department, Rangueil university hospital, 1, avenue du Pr-Jean-Poulhes, 31059 Toulouse cedex, France
| | - P Rischmann
- Urology department, Rangueil university hospital, 1, avenue du Pr-Jean-Poulhes, 31059 Toulouse cedex, France
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Dickinson L, Arya M, Afzal N, Cathcart P, Charman SC, Cornaby A, Hindley RG, Lewi H, McCartan N, Moore CM, Nathan S, Ogden C, Persad R, van der Meulen J, Weir S, Emberton M, Ahmed HU. Medium-term Outcomes after Whole-gland High-intensity Focused Ultrasound for the Treatment of Nonmetastatic Prostate Cancer from a Multicentre Registry Cohort. Eur Urol 2016; 70:668-674. [PMID: 26951947 DOI: 10.1016/j.eururo.2016.02.054] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 02/18/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND High-intensity focused ultrasound (HIFU) is a minimally-invasive treatment for nonmetastatic prostate cancer. OBJECTIVE To report medium-term outcomes in men receiving primary whole-gland HIFU from a national multi-centre registry cohort. DESIGN, SETTING, AND PARTICIPANTS Five-hundred and sixty-nine patients at eight hospitals were entered into an academic registry. INTERVENTION Whole-gland HIFU (Sonablate 500) for primary nonmetastatic prostate cancer. Redo-HIFU was permitted as part of the intervention. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Our primary failure-free survival outcome incorporated no transition to any of the following: (1) local salvage therapy (surgery or radiotherapy), (2) systemic therapy, (3) metastases, or (4) prostate cancer-specific mortality. Secondary outcomes included adverse events and genitourinary function. RESULTS AND LIMITATIONS Mean age was 65 yr (47-87 yr). Median prostate-specific antigen was 7.0 ng/ml (interquartile range 4.4-10.2). National Comprehensive Cancer Network low-, intermediate-, and high-risk disease was 161 (28%), 321 (56%), and 81 (14%), respectively. One hundred and sixty three of 569 (29%) required a total of 185 redo-HIFU procedures. Median follow-up was 46 (interquartile range 23-61) mo. Failure-free survival at 5 yr after first HIFU was 70% (95% confidence interval [CI]: 64-74). This was 87% (95% CI: 78-93), 63% (95% CI: 56-70), and 58% (95% CI: 32-77) for National Comprehensive Cancer Network low-, intermediate-, and high-risk groups, respectively. Fifty eight of 754 (7.7%) had one urinary tract infection, 22/574 (2.9%) a recurrent urinary tract infection, 22/754 (3%) epididymo-orchitis, 227/754 (30%) endoscopic interventions, 1/754 (0.13%) recto-urethral fistula, and 1/754 (0.13%) osteitis pubis. Of 206 known to be pad-free pre-HIFU, 183/206 (88%) remained pad free, and of 236 with good baseline erectile function, 91/236 (39%) maintained good function. The main limitation is lack of long-term data. CONCLUSIONS Whole-gland HIFU is a repeatable day-case treatment that confers low rates of urinary incontinence. Disease control at a median of just under 5 yr of follow-up demonstrates its potential as a treatment for nonmetastatic prostate cancer. Endoscopic interventions and erectile dysfunction rates are similar to other whole-gland treatments. PATIENT SUMMARY In this report we looked at the 5-yr outcomes following whole-gland high-intensity focused ultrasound treatment for prostate cancer and found that cancer control was acceptable with a low risk of urine leakage. However, risk of erectile dysfunction and further operations was similar to other whole-gland treatments like surgery and radiotherapy.
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Affiliation(s)
- Louise Dickinson
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Manit Arya
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK; Department of Urology, Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Naveed Afzal
- Department of Urology, Dorset County Hospital, Dorchester, UK
| | - Paul Cathcart
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Andrew Cornaby
- Department of Urology, Dorset County Hospital, Dorchester, UK
| | - Richard G Hindley
- Department of Urology, Basingstoke Hospital, Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
| | - Henry Lewi
- Department of Urology, Broomfield Hospital, Mid Essex NHS Trust, Chelmsford, UK
| | - Neil McCartan
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Senthil Nathan
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Chris Ogden
- Department of Academic Urology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Raj Persad
- Department of Urology, North Bristol NHS Trust, Bristol, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Shraddha Weir
- Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Division of Surgery and Interventional Sciences, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK.
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Emerging Modalities in Radiation Therapy for Prostate Cancer. Prostate Cancer 2016. [DOI: 10.1016/b978-0-12-800077-9.00048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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The role of multi-parametric MRI in loco-regional staging of men diagnosed with early prostate cancer. Curr Opin Urol 2015; 25:510-7. [DOI: 10.1097/mou.0000000000000215] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shah TT, Kasivisvanathan V, Jameson C, Freeman A, Emberton M, Ahmed HU. Histological outcomes after focal high-intensity focused ultrasound and cryotherapy. World J Urol 2015; 33:955-64. [PMID: 25944676 PMCID: PMC4480821 DOI: 10.1007/s00345-015-1561-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 04/13/2015] [Indexed: 01/28/2023] Open
Abstract
Introduction Focal therapy has increasingly become an accepted treatment option for patients with localised prostate cancer. Most follow-up protocols use a mixture of protocol biopsies or “for cause” biopsies triggered by a rising PSA. In this paper, we discuss the histological outcomes from these biopsies and their use in guiding subsequent management and trial development. Methods We conducted a literature search and reviewed the post-treatment biopsy results from studies on focal HIFU and focal cryotherapy. We subsequently reviewed the results of three recently published consensus statements released discussing many of the issues concerning focal therapy. Results Research suggests that 1 in 5 of all post-treatment biopsies after focal therapy are positive. However, the majority of these seemed to be from the untreated portion of the gland or met criteria for clinically insignificant disease. The histological outcomes from focal therapy are promising and confirm its effectiveness in the short to medium term. Furthermore re-treatment is possible whilst maintaining a low-side-effect profile. Conclusion Debate is ongoing about the clinical significance of various levels of residual disease after focal therapy and the exact threshold at which to call failure within a patient who has had focal therapy.
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Affiliation(s)
- Taimur T Shah
- Division of Surgery and Interventional Science, Urology Research Group, UCL, Room 4.23, 4th Floor, 132 Hampstead Road, London, NW1 2PS, UK,
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Muller BG, van den Bos W, Pinto PA, de la Rosette JJ. Imaging modalities in focal therapy: patient selection, treatment guidance, and follow-up. Curr Opin Urol 2014; 24:218-24. [PMID: 24637316 DOI: 10.1097/mou.0000000000000041] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Focal therapy for prostate cancer is emerging as a management option between active surveillance and radical treatments. In this article, we present two of the most important imaging modalities in focal therapy, multiparametric MRI (mpMRI) and ultrasonography. We review the recent advances within these two platforms. RECENT FINDINGS State-of-the-art imaging in all phases of focal therapy is essential for treatment safety. In patient selection, treatment guidance, and follow-up, different aspects of imaging are important. mpMRI is an imaging technology with high imaging resolution and contrast. This makes it an excellent technology for patient selection and treatment planning and follow-up. Ultrasound has the unique property of real-time image acquisition. This makes it an excellent technology for real-time treatment guidance. There are multiple novelties in these two platforms that have increased the accuracy considerably. Examples in ultrasound are contrast-enhanced ultrasonography, elastography, shear-wave elastography, and histoscanning. In mpMRI, these advantages consist of multiple sequences combined to one image and magnetic resonance thermometry. SUMMARY Standardization of multiparametric transrectal ultrasound and mpMRI is of paramount importance. For targeted treatment and follow-up, a good negative predictive value of the test is important. There is much to gain from both of these developing fields and imaging accuracy of the two platforms is comparable. Standardization in conduct and interpretation, three-dimensional reconstruction, and fusion of the two platforms can make focal therapy the standard of care for prostate cancer.
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Affiliation(s)
- Berrend G Muller
- aDepartment of Urology, AMC University Hospital, Amsterdam, The Netherlands bDepartment of Urology, National Cancer Institute, Bethesda, Maryland, USA
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Valerio M, Stricker PD, Ahmed HU, Dickinson L, Ponsky L, Shnier R, Allen C, Emberton M. Initial assessment of safety and clinical feasibility of irreversible electroporation in the focal treatment of prostate cancer. Prostate Cancer Prostatic Dis 2014; 17:343-7. [PMID: 25179590 PMCID: PMC4227889 DOI: 10.1038/pcan.2014.33] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 05/29/2014] [Accepted: 07/25/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND To evaluate the safety and clinical feasibility of focal irreversible electroporation (IRE) of the prostate. METHODS We assessed the toxicity profile and functional outcomes of consecutive patients undergoing focal IRE for localised prostate cancer in two centres. Eligibility was assessed by multi-parametric magnetic resonance imaging (mpMRI) and targeted and/or template biopsy. IRE was delivered under transrectal ultrasound guidance with two to six electrodes positioned transperineally within the cancer lesion. Complications were recorded and scored accordingly to the NCI Common Terminology Criteria for Adverse Events; the functional outcome was physician reported in all patients with at least 6 months follow-up. A contrast-enhanced MRI 1 week after the procedure was carried out to assess treatment effect with a further mpMRI at 6 months to rule out evidence of residual visible cancer. RESULTS Overall, 34 patients with a mean age of 65 years (s.d. = ± 6) and a median PSA of 6.1 ng ml(-1) (interquartile range (IQR) = 4.3-7.7) were included. Nine (26%), 24 (71%) and 1 (3%) men had low, intermediate and high risk disease, respectively (D'Amico criteria). After a median follow-up of 6 months (range 1-24), 12 grade 1 and 10 grade 2 complications occurred. No patient had grade >/= 3 complication. From a functional point of view, 100% (24/24) patients were continent and potency was preserved in 95% (19/20) men potent before treatment. The volume of ablation was a median 12 ml (IQR = 5.6-14.5 ml) with the median PSA after 6 months of 3.4 ng ml(-1) (IQR = 1.9-4.8 ng ml(-1)). MpMRI showed suspicious residual disease in six patients, of whom four (17%) underwent another form of local treatment. CONCLUSIONS Focal IRE has a low toxicity profile with encouraging genito-urinary functional outcomes. Further prospective development studies are needed to confirm the functional outcomes and to explore the oncological potential.
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Affiliation(s)
- Massimo Valerio
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Phillip D. Stricker
- Department of Urology, St. Vincent’s Prostate Cancer Centre, Sydney, New South Wales, Australia
| | - Hashim U. Ahmed
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Louise Dickinson
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lee Ponsky
- Department of Urology, St. Vincent’s Prostate Cancer Centre, Sydney, New South Wales, Australia
- Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ron Shnier
- Department of Radiology, St. Vincent’s Prostate Cancer Centre, Sydney, New South Wales, Australia
| | - Clare Allen
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
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Lee DJ, Ahmed HU, Moore CM, Emberton M, Ehdaie B. Multiparametric magnetic resonance imaging in the management and diagnosis of prostate cancer: current applications and strategies. Curr Urol Rep 2014; 15:390. [PMID: 24430171 DOI: 10.1007/s11934-013-0390-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Magnetic resonance imaging (MRI) has become increasingly used worldwide in the diagnosis and management of prostate cancer. With advances in multiparametric MRI (mpMRI) technology, such as the use of dynamic contrast-enhanced and diffusion-weighted imaging sequences, observational studies have evaluated the utility for mpMRI in the continuum of prostate cancer management, from improving the detection of clinically significant prostate cancer, to planning radical prostatectomy and radiation therapy and the early detection of local recurrence. Furthermore, the potential for advanced imaging to reduce the burden of routine serial prostate needle biopsies for men on active surveillance is a promising area of research. MRI technology continues to evolve, and the potential applications in the management of prostate cancer care will require well-designed multi-institutional prospective clinical trials and rigorous efforts to standardize reporting and improve dissemination of expertise across institutions.
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Affiliation(s)
- Daniel J Lee
- Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
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Valerio M, Dickinson L, Ali A, Ramachandran N, Donaldson I, Freeman A, Ahmed HU, Emberton M. A prospective development study investigating focal irreversible electroporation in men with localised prostate cancer: Nanoknife Electroporation Ablation Trial (NEAT). Contemp Clin Trials 2014; 39:57-65. [PMID: 25072507 PMCID: PMC4189798 DOI: 10.1016/j.cct.2014.07.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 07/20/2014] [Accepted: 07/21/2014] [Indexed: 11/27/2022]
Abstract
Introduction Focal therapy may reduce the toxicity of current radical treatments while maintaining the oncological benefit. Irreversible electroporation (IRE) has been proposed to be tissue selective and so might have favourable characteristics compared to the currently used prostate ablative technologies. The aim of this trial is to determine the adverse events, genito-urinary side effects and early histological outcomes of focal IRE in men with localised prostate cancer. Methods This is a single centre prospective development (stage 2a) study following the IDEAL recommendations for evaluating new surgical procedures. Twenty men who have MRI-visible disease localised in the anterior part of the prostate will be recruited. The sample size permits a precision estimate around key functional outcomes. Inclusion criteria include PSA ≤ 15 ng/ml, Gleason score ≤ 4 + 3, stage T2N0M0 and absence of clinically significant disease outside the treatment area. Treatment delivery will be changed in an adaptive iterative manner so as to allow optimisation of the IRE protocol. After focal IRE, men will be followed during 12 months using validated patient reported outcome measures (IPSS, IIEF-15, UCLA-EPIC, EQ-5D, FACT-P, MAX-PC). Early disease control will be evaluated by mpMRI and targeted transperineal biopsy of the treated area at 6 months. Discussion The NEAT trial will assess the early functional and disease control outcome of focal IRE using an adaptive design. Our protocol can provide guidance for designing an adaptive trial to assess new surgical technologies in the challenging landscape of health technology assessment in prostate cancer treatment.
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Affiliation(s)
- Massimo Valerio
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Louise Dickinson
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Afia Ali
- Department of Mental Health Sciences, University College London, London, UK
| | - Navin Ramachandran
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ian Donaldson
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
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Rosenkrantz AB, Geppert C, Grimm R, Block TK, Glielmi C, Feng L, Otazo R, Ream JM, Romolo MM, Taneja SS, Sodickson DK, Chandarana H. Dynamic contrast-enhanced MRI of the prostate with high spatiotemporal resolution using compressed sensing, parallel imaging, and continuous golden-angle radial sampling: preliminary experience. J Magn Reson Imaging 2014; 41:1365-73. [PMID: 24833417 DOI: 10.1002/jmri.24661] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 04/24/2014] [Accepted: 04/28/2014] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To demonstrate dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) of the prostate with both high spatial and temporal resolution via a combination of golden-angle radial k-space sampling, compressed sensing, and parallel-imaging reconstruction (GRASP), and to compare image quality and lesion depiction between GRASP and conventional DCE in prostate cancer patients. MATERIALS AND METHODS Twenty prostate cancer patients underwent two 3T prostate MRI examinations on separate dates, one using standard DCE (spatial resolution 3.0 × 1.9 × 1.9 mm, temporal resolution 5.5 sec) and the other using GRASP (spatial resolution 3.0 × 1.1 × 1.1 mm, temporal resolution 2.3 sec). Two radiologists assessed measures of image quality and dominant lesion size. The experienced reader recorded differences in contrast arrival times between the dominant lesion and benign prostate. RESULTS Compared with standard DCE, GRASP demonstrated significantly better clarity of the capsule, peripheral/transition zone boundary, urethra, and periprostatic vessels; image sharpness; and lesion conspicuity for both readers (P < 0.001-0.020). GRASP showed improved interreader correlation for lesion size (GRASP: r = 0.691-0.824, standard: r = 0.495-0.542). In 8/20 cases, only GRASP showed earlier contrast arrival in tumor than benign; in no case did only standard DCE show earlier contrast arrival in tumor. CONCLUSION High spatiotemporal resolution prostate DCE is possible with GRASP, which has the potential to improve image quality and lesion depiction as compared with standard DCE.
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Muller BG, Fütterer JJ, Gupta RT, Katz A, Kirkham A, Kurhanewicz J, Moul JW, Pinto PA, Rastinehad AR, Robertson C, de la Rosette J, Sanchez-Salas R, Jones JS, Ukimura O, Verma S, Wijkstra H, Marberger M. The role of magnetic resonance imaging (MRI) in focal therapy for prostate cancer: recommendations from a consensus panel. BJU Int 2013; 113:218-27. [PMID: 24215670 DOI: 10.1111/bju.12243] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To establish a consensus on the utility of multiparametric magnetic resonance imaging (mpMRI) to identify patients for focal therapy. METHODS Urological surgeons, radiologists, and basic researchers, from Europe and North America participated in a consensus meeting about the use of mpMRI in focal therapy of prostate cancer. The consensus process was face-to-face and specific clinical issues were raised and discussed with agreement sought when possible. All participants are listed among the authors. Topics specifically did not include staging of prostate cancer, but rather identifying the optimal requirements for performing MRI, and the current status of optimally performed mpMRI to (i) determine focality of prostate cancer (e.g. localising small target lesions of ≥0.5 mL), (ii) to monitor and assess the outcome of focal ablation therapies, and (iii) to identify the diagnostic advantages of new MRI methods. In addition, the need for transperineal template saturation biopsies in selecting patients for focal therapy was discussed, if a high quality mpMRI is available. In other words, can mpMRI replace the role of transperineal saturation biopsies in patient selection for focal therapy? RESULTS Consensus was reached on most key aspects of the meeting; however, on definition of the optimal requirements for mpMRI, there was one dissenting voice. mpMRI is the optimum approach to achieve the objectives needed for focal therapy, if made on a high quality machine (3T with/without endorectal coil or 1.5T with endorectal coil) and judged by an experienced radiologist. Structured and standardised reporting of prostate MRI is paramount. State of the art mpMRI is capable of localising small tumours for focal therapy. State of the art mpMRI is the technique of choice for follow-up of focal ablation. CONCLUSIONS The present evidence for MRI in focal therapy is limited. mpMRI is not accurate enough to consistently grade tumour aggressiveness. Template-guided saturation biopsies are no longer necessary when a high quality state of the art mpMRI is available; however, suspicious lesions should always be confirmed by (targeted) biopsy.
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Affiliation(s)
- Berrend G Muller
- Department of Urology, AMC University Hospital, Amsterdam, the Netherlands
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Lai CY, Fite BZ, Ferrara KW. Ultrasonic enhancement of drug penetration in solid tumors. Front Oncol 2013; 3:204. [PMID: 23967400 PMCID: PMC3746679 DOI: 10.3389/fonc.2013.00204] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 07/25/2013] [Indexed: 12/22/2022] Open
Abstract
Increasing the penetration of drugs within solid tumors can be accomplished through multiple ultrasound-mediated mechanisms. The application of ultrasound can directly change the structure or physiology of tissues or can induce changes in a drug or vehicle in order to enhance delivery and efficacy. With each ultrasonic pulse, a fraction of the energy in the propagating wave is absorbed by tissue and results in local heating. When ultrasound is applied to achieve mild hyperthermia, the thermal effects are associated with an increase in perfusion or the release of a drug from a temperature-sensitive vehicle. Higher ultrasound intensities locally ablate tissue and result in increased drug accumulation surrounding the ablated region of interest. Further, the mechanical displacement induced by the ultrasound pulse can result in the nucleation, growth and collapse of gas bubbles. As a result of such cavitation, the permeability of a vessel wall or cell membrane can be increased. Finally, the radiation pressure of the propagating pulse can translate particles or tissues. In this perspective, we will review recent progress in ultrasound-mediated tumor delivery and the opportunities for clinical translation.
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Affiliation(s)
- Chun-Yen Lai
- Department of Biomedical Engineering, University of California Davis , Davis, CA , USA
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Reply by Author. J Urol 2013; 189:1602. [DOI: 10.1016/j.juro.2012.11.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Firjani A, Elnakib A, Khalifa F, Gimel’farb G, El-Ghar MA, Elmaghraby A, El-Baz A. A diffusion-weighted imaging based diagnostic system for early detection of prostate cancer. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/jbise.2013.63a044] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ahmed HU, Hindley RG, Dickinson L, Freeman A, Kirkham AP, Sahu M, Scott R, Allen C, Van der Meulen J, Emberton M. Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study. Lancet Oncol 2012; 13:622-32. [PMID: 22512844 PMCID: PMC3366323 DOI: 10.1016/s1470-2045(12)70121-3] [Citation(s) in RCA: 284] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background Radical whole-gland therapy can lead to significant genitourinary and rectal side-effects for men with localised prostate cancer. We report on whether selective focal ablation of unifocal and multifocal cancer lesions can reduce this treatment burden. Methods Men aged 45–80 years were eligible for this prospective development study if they had low-risk to high-risk localised prostate cancer (prostate specific antigen [PSA] ≤15 ng/mL, Gleason score ≤4 + 3, stage ≤T2), with no previous androgen deprivation or treatment for prostate cancer, and who could safely undergo multiparametric MRI and have a general anaesthetic. Patients received focal therapy using high-intensity focused ultrasound, delivered to all known cancer lesions, with a margin of normal tissue, identified on multiparametric MRI, template prostate-mapping biopsies, or both. Primary endpoints were adverse events (serious and otherwise) and urinary symptoms and erectile function assessed using patient questionnaires. Analyses were done on a per-protocol basis. This study is registered with ClinicalTrials.gov, number NCT00561314. Findings 42 men were recruited between June 27, 2007, and June 30, 2010; one man died from an unrelated cause (pneumonia) 3 months after treatment and was excluded from analyses. After treatment, one man was admitted to hospital for acute urinary retention, and another had stricture interventions requiring hospital admission. Nine men (22%, 95% CI 11–38) had self-resolving, mild to moderate, intermittent dysuria (median duration 5·0 days [IQR 2·5–18·5]). Urinary debris occurred in 14 men (34%, 95% CI 20–51), with a median duration of 14·5 days (IQR 6·0–16·5). Urinary tract infection was noted in seven men (17%, 95% CI 7–32). Median overall International Index of Erectile Function-15 (IIEF-15) scores were similar at baseline and at 12 months (p=0·060), as were median IIEF-15 scores for intercourse satisfaction (p=0·454), sexual desire (p=0·644), and overall satisfaction (p=0·257). Significant deteriorations between baseline and 12 months were noted for IIEF-15 erectile (p=0·042) and orgasmic function (p=0·003). Of 35 men with good baseline function, 31 (89%, 95% CI 73–97) had erections sufficient for penetration 12 months after focal therapy. Median UCLA Expanded Prostate Cancer Index Composite (EPIC) urinary incontinence scores were similar at baseline as and 12 months (p=0·045). There was an improvement in lower urinary tract symptoms, assessed by International Prostate Symptom Score (IPSS), between baseline and 12 months (p=0·026), but the IPSS-quality of life score showed no difference between baseline and 12 months (p=0·655). All 38 men with no baseline urinary incontinence were leak-free and pad-free by 9 months. All 40 men pad-free at baseline were pad-free by 3 months and maintained pad-free continence at 12 months. No significant difference was reported in median Trial Outcomes Index scores between baseline and 12 months (p=0·113) but significant improvement was shown in median Functional Assessment of Cancer Therapy (FACT)-Prostate (p=0·045) and median FACT-General scores (p=0·041). No histological evidence of cancer was identified in 30 of 39 men biopsied at 6 months (77%, 95% CI 61–89); 36 (92%, 79–98) were free of clinically significant cancer. After retreatment in four men, 39 of 41 (95%, 95% CI 83–99) had no evidence of disease on multiparametric MRI at 12 months. Interpretation Focal therapy of individual prostate cancer lesions, whether multifocal or unifocal, leads to a low rate of genitourinary side-effects and an encouraging rate of early absence of clinically significant prostate cancer. Funding Medical Research Council (UK), Pelican Cancer Foundation, and St Peters Trust.
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Affiliation(s)
- Hashim U Ahmed
- Division of Surgery and Interventional Science, University College London, London, UK.
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Emberton M. Tissue preservation may offer a harm-reduction strategy for men with early prostate cancer. Eur Urol 2012; 62:64-6; discussion 66-7. [PMID: 22480458 DOI: 10.1016/j.eururo.2012.03.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 03/22/2012] [Indexed: 12/01/2022]
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