Focal High-Intensity Focused Ultrasound vs. Active Surveillance for ISUP Grade 1 Prostate Cancer: Medium-Term Results of a Matched-Pair Comparison

INTRODUCTION/BACKGROUND

Only 1 randomized controlled trial has compared focal therapy and active surveillance (AS) for the low-risk prostate cancer (PCa). We investigated whether focal HIFU (fHIFU) yields oncologic advantages over AS for low-risk PCa.

MATERIALS AND METHODS

We included 2 non-randomized prospective series of 132 (fHIFU) and 421 (AS) consecutive patients diagnosed with ISUP 1 PCa between 2008 and 2018. A matched pair analysis was performed to decrease potential bias. Study main outcomes were freedom from radical treatment (RT) or androgen-deprivation therapy (ADT), treatment-free survival (TFS), time to metastasis, and overall survival (OS).

RESULTS

Median fHIFU follow-up was 50 months (interquartile range, 29-84 months). Among matched variables, no major differences were recorded except for AS having more suspicious digital rectal examination findings (P = .0074) and recent enrollment year (P = .0005). Five-year intervention-free survival from RT or ADT was higher for the fHIFU cohort (67.4% vs. 53.8%; P = .0158). Time to treatment was approximately 10 months shorter for AS than for fHIFU (time to RT, P = .0363; time to RT or ADT, P = .0156; time to any treatment, P = .0319). No differences were found in any-TFS (fHIFU, 61.4% vs. AS, 53.8%; P = .2635), OS (fHIFU, 97% vs. AS, 97%; P = .9237), or metastasis (n = 0 in fHIFU and n = 2 in AS; P = .4981). Major complications (≥ Clavien 3) were rare (n = 4), although 36.4% of men experienced complications. No relevant changes were noted in continence (P = .3949).

CONCLUSION

At a 4-year median follow-up, fHIFU for mainly low-risk PCa (ISUP grade 1) is safe, may decrease the need for radical treatment or ADT and may allow longer time to treatment compared to AS. Nonetheless, no advantages are seen in PCa progression and/or death (OS).

Molecular biomarkers in the context of focal therapy for prostate cancer: recommendations of a Delphi Consensus from the Focal Therapy Society

BACKGROUND

Focal therapy (FT) for prostate cancer (PCa) is promising. However, long-term oncological results are awaited and there is no consensus on follow-up strategies. Molecular biomarkers (MB) may be useful in selecting, treating and following up men undergoing FT, though there is limited evidence in this field to guide practice. We aimed to conduct a consensus meeting, endorsed by the Focal Therapy Society, amongst a large group of experts, to understand the potential utility of MB in FT for localized PCa.

METHODS

A 38-item questionnaire was built following a literature search. The authors then performed three rounds of a Delphi Consensus using DelphiManager, using the GRADE grid scoring system, followed by a face-to-face expert meeting. Three areas of interest were identified and covered concerning MB for FT, 1) the current/present role; 2) the potential/future role; 3) the recommended features for future studies. Consensus was defined using a 70% agreement threshold.

RESULTS

Of 95 invited experts, 42 (44.2%) completed the three Delphi rounds. Twenty-four items reached a consensus and they were then approved at the meeting involving (N.=15) experts. Fourteen items reached a consensus on uncertainty, or they did not reach a consensus. They were re-discussed, resulting in a consensus (N.=3), a consensus on a partial agreement (N.=1), and a consensus on uncertainty (N.=10). A final list of statements were derived from the approved and discussed items, with the addition of three generated statements, to provide guidance regarding MB in the context of FT for localized PCa. Research efforts in this field should be considered a priority.

CONCLUSIONS

The present study detailed an initial consensus on the use of MB in FT for PCa. This is until evidence becomes available on the subject.

The real-time intraoperative guidance of the new HIFU Focal-One® platform allows to minimize the perioperative adverse events in salvage setting

PURPOSE

To assess the use of the new Focal-One^® HIFU platform in salvage setting to evaluate the occurrence of postoperative complications.

METHODS

Patients who underwent salvage HIFU (sHIFU) with Focal-One^® platform were enrolled prospectively (Candiolo cancer institute-FPO IRCCS; registry number: 258/2018). Perioperative and postoperative outcomes (in terms of oncological and functional ones) were recorded during the first year of follow-up. In particular postoperative complications were classified according to Clavien-Dindo system.

RESULTS

20 patients were enrolled. No grade 3 complications were recorded. Referring to grade 2 complications, eight patients reported urgency after 3 months of follow-up, and in 4 cases, a low urinary tract infection occurred. Evaluating the impact of sHIFU on patients' sexual potency, micturition and quality of life, no significant deterioration was recorded during the follow-up as proven using the ANOVA analysis for repeated measurements. Only two patient had a biochemical failure after 12 months of follow-up.

CONCLUSIONS

The real-time intraoperative guidance with Focal-One^® platform, allows a continuous monitoring and tailoring of the treatment, with a minimization of the adverse events even in a salvage setting.

Long-term Outcomes of Focal Cryotherapy for Low- to Intermediate-risk Prostate Cancer: Results and Matched Pair Analysis with Active Surveillance

BACKGROUND

To date, only one trial compared focal therapy and active surveillance (AS) for low-risk prostate cancer (PCa). In addition, long-term outcomes of focal cryotherapy (FC) are lacking.

OBJECTIVE

Our aim was to evaluate long-term outcomes of FC and compare them with AS.

DESIGN, SETTING, AND PARTICIPANTS

We included two prospective series of 121 (FC) and 459 (AS) consecutive patients (2008-2018) for low- to intermediate-risk PCa.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Study outcomes were radical therapy-free or androgen deprivation therapy (ADT)-free, any treatment-free, metastasis-free, and overall survival. A matched pair analysis was performed using seven covariates.

RESULTS AND LIMITATIONS

The median FC follow-up was 85 mo (interquartile range 58-104); 92 (76%) men had International Society of Urological Pathology (ISUP) grade 1. Among matched variables, no significant differences were present except for cT stage and year of entry (both p < 0.01). Ten-year radical therapy-free or ADT-free, any treatment-free, metastasis-free, and overall survival were 51%, 40.2%, 93.9%, and 97%, respectively for FC. No differences were noted with AS (all p > 0.05), with the exception of time to radical therapy, time to radical therapy and ADT, and time to any treatment, all being shorter for AS (all p < 0.01). Freedom from radical treatment or ADT was higher for FC (AS 10 yr 39.3%; p = 0.04). Complications were relatively rare (26.5%) and mainly of low grade (Clavien >2, n = 3); three men developed incontinence (p = 0.0814), while both International Index of Erectile Function 5 and International Prostate Symptom Score scores increased (p = 0.0287 and p = 0.0165, respectively). Limitations include absence of randomization.

CONCLUSIONS

At an early long-term follow-up, FC in the context of mainly low-risk PCa is safe and increases time to radical therapy but does not provide meaningful oncological advantages compared with AS.

PATIENT SUMMARY

We compared focal cryotherapy with active surveillance mainly for low-risk prostate cancer. Focal cryotherapy, despite having fewer complications, did not yield meaningful advantages over active surveillance at 10 yr. Active surveillance should be preferred to focal cryotherapy for these patients.

Does mpMRI guidance improve HIFU partial gland ablation compared to conventional ultrasound guidance? Early functional outcomes and complications from a single center

Background

Focal therapy (FT) for localized prostate cancer (PCa) treatment is raising interest. New technological mpMRI-US guided FT devices have never been compared with the previous generation of ultrasound-only guided devices.

Materials and Methods

We retrospectively analyzed prospectively recorded data of men undergoing FT for localized low- or intermediate-risk PCa with US- (Ablatherm®-2009 to 2014) or mpMRI-US (Focal One®-from 2014) guided HIFU. Follow-up visits and data were collected using internationally validated questionnaires at 1, 2, 3, 6 and 12 months.

Results

We included n=88 US-guided FT HIFU and n=52 mpMRI-US guided FT HIFU respectively. No major baseline differences were present except higher rates of Gleason 3+4 for the mpMRI-US group. No major differences were present in hospital stay (p=0.1), catheterization time (p=0.5) and complications (p=0.2) although these tended to be lower in the mpMRI-US group (6.8% versus 13.2% US FT group). At 3 months mpMRI-US guided HIFU had significantly lower urine leak (5.1% vs. 15.9%, p=0.04) and a lower drop in IIEF scores (2 vs. 4.2, p=0.07). Of those undergoing 12-months control biopsy in the mpMRI-US-guided HIFU group, 26% had residual cancer in the treated lobe.

Conclusion

HIFU FT guided by MRI-US fusion may allow improved functional outcomes and fewer complications compared to US- guided HIFU FT alone. Further analysis is needed to confirm benefits of mpMRI implementation at a longer follow-up and on a larger cohort of patients.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Making a case "against" focal therapy for intermediate-risk prostate cancer

INTRODUCTION

Focal therapy (FT) for localized prostate cancer (PCa) is a promising treatment strategy. Although, according to guidelines, it should be regarded as an experimental option, its introduction into clinical practice has occurred at an accelerated speed. It is, thus, crucial for Urologists to understand FT limitations and potential drawbacks that may derive from its use.

METHODS

We performed a literature search of peer-reviewed English language articles using Pubmed and the words "focal therapy" AND "prostate cancer" to identify relevant articles. Web search was complemented by manual search.

RESULTS

From a biological perspective, in contrast with the index lesion theory, which still needs to be better supported, PCa is a multifocal and multiclonal entity. Also, the effects of FT on PCa microenvironment are unclear. From a clinical perspective, patient selection is still not precisely defined. Even when all variables potentially decreasing mpMRI and biopsy accuracy are optimized, up to one out of two men may be incorrectly selected for FT, leaving a significant proportion of clinically significant PCa (csPCa) untreated. Underestimation of PCa volume and variant histologies are other additional mpMRI potential limitations. No RCTs have been performed against the standard of care to support FT. There is absence of long-term results and FT series reaching medium-term follow-up have non-optimal oncological control with significant re-treatment needs. When PCa recurs/persists after FT, little is known about the appropriate management strategies and their outcomes. Finally, the optimal follow-up scheme post-FT remains unclear.

CONCLUSIONS

Several arguments are present against the use of FT for localized PCa. Studies are needed to overcome current limitations and support FT before it can be included as part of the standard management of prostate cancer.

Persistence and adherence to androgen deprivation therapy in men with prostate cancer: an administrative database study

BACKGROUND

The aim of this study was to assess adherence to and persistence with androgen deprivation therapy (ADT) in a large cohort of prostate cancer (PCa) patients selected from an administrative database, with special attention to elderly patients.

METHODS

Patients treated with LHRH analogues, LHRH antagonists, the novel androgen antagonist enzalutamide, and the CYP17 inhibitor abiraterone were included spanning the years 2011-2017. Descriptive statistics were used to analyze persistence and adherence in older patients stratified by age (46-55, 56-65, 66-75, 76-85, and >85 years). The effect of persistence duration on overall survival in super-elderly patients was analyzed by the Kaplan-Meier method, together with the influence of multiple prescriptions on overall survival.

RESULTS

A total of 1160 male patients were treated with ADT. Of these, 1075 were given LHRH analogues, 80 LHRH antagonists, 14 novel androgen antagonists, and 109 the CYP17 inhibitor. Median adherence values were 0.93, 0.97, 0.95, and 0.99 respectively. The highest persistence was recorded for LHRH analogues/antagonists (24 months), followed enzalutamide and abiraterone (8 months). A total of 107 patients (9.2%) were classified as super-elderly (age range 85-97 years). Median persistence and OS in this group were 13 months and 29 months, respectively. The adherence was 0.92. Overall survival was significantly associated with additional prescriptions for other conditions-indications (P=0.0047) but not with differences in adherence rates (P=0.98).

CONCLUSIONS

Our data showed high adherence and persistence rates in men on ADT. The overall survival in the super-elderly is not influenced by persistence and/or adherence but rather by coprescriptions.