HIFU focal therapy for prostate cancer using intraoperatory contrast enhanced ultrasound

OBJECTIVE

High-intensity focused ultrasound (HIFU) Focal therapy appears to have encouraging oncologic outcomes and urinary and erectile function. The control of the treated area can be done using contrast enhanced ultrasound with sulfur hexafluoride (Sonovue®) at the end of the procedure. We report oncological and functional outcomes in HIFU focal therapy (FT) for prostate cancer (PCa) management using sonovue.

METHODS

A total of 274 HIFU procedures were found in our registry in the period between June 2014 and July 2018. Prospective data of 59 consecutive patients after focal high-intensity focused ultrasound (HIFU) using Sonovue were collected. FT failure was defined as positive biopsy Gleason score (GS) ≥ 7 in- or out-field, local or systemic salvage treatment, PCa-metastasis or PCa-specific death.

RESULTS

A total of 59 patients submitted to HIFU with median follow-up of 18 months were included in the analysis. Median age was 66.7 yr (IQR 59.1-74.3). Median preoperative prostate-specific antigen (PSA) was 7.6 ng/ml (IQR 5-10.2) and preoperative biopsies GS 6, 7(3+4), 7(4+3) were found in 26 (44%), 30 (50.8%) and 3 (5%), respectively. Failure was found in 16 (27.1%) patients. Failure-free survival (FFS) in 2 and 4yr was 83% and 74% respectively (Figure 1). No PCa-specific death was registered in the period of study. Median nadir PSA after FT was 2.67 ng/ml. Sexual potency was achieved in 75% of previous potent patients and urinary continence in 93.4% of patients at 3 months. Fourteen (23%) patients presented with complications. Four (6.7%) patients have presented complications grade 1 and 10 (16.9%) patients have presented complications grade 2. Six (10.1%) patients have presented acute urinary retention.

CONCLUSIONS

Our study shows that the use of Sonovue after HIFU FT was safe. Patients present a significant proportion of failure after HIFU FT but with good functional outcomes and without incidence of severe complications.

Oncological outcomes and pathological characteristics of cT1 upstaging to pT3a renal cell carcinoma compared with de novo pT3a tumors

INTRODUCTION

The significance of upstaging of cT1 renal tumors to pT3a is not clear. We evaluate the incidence of upstaging, identify predictors and analyze oncological outcomes of these patients versus those who did not upstage. We also compared the oncological outcomes of cT1 upstaging to pT3a with de novo pT3a renal tumors.

METHODS

From a database of 1021 renal tumors with complete available follow-up data, 517 patients had cT1. Patients upstaging to pT3a were compared to those who did not. Baseline clinical, perioperative, histopathologic features and oncological outcomes were analysed.

RESULTS

Out of 517 cT1 patients, 105 (20.3%) upstaged to pT3a and 412 (79.7%) did not. Proportion of patients in each group undergoing partial and radical nephrectomy, postoperative tumor size, histology, margin status and lymph node involvement were similar. Among upstaged, 9 patients (8.6%) developed first recurrence as compared to only 3 (0.7%) in those not upstaging (P <0.001). The median time to recurrence (57 vs. 107 months; P <0.001) was lesser in de novo pT3a renal tumors.

CONCLUSIONS

Pathological upstaging from cT1 to pT3a and necrosis on histopathology were associated with recurrence. Advanced age, smoking, necrosis on histopathology, clear cell histology and higher Fuhrman grades contributed to pathological upstaging of cT1 tumors. De novo pT3a RCC had worse survival when compared to cT1 patients upstaging to pT3a RCC.

Comprehensive Evaluation of Focal Therapy Complications in Prostate Cancer: A Standardized Methodology

Purpose: Today, up to one-third of newly diagnosed prostate cancer (PCa) cases may be suitable for focal treatment. The lack of data about the toxicity profiles of lesion-targeting therapies, however, has made it difficult to compare treatment modalities. The aim of the present study was to evaluate comprehensively the incidence, severity, and timing of onset of complications for PCa patients undergoing focal high-intensity focused ultrasound (HIFU) and focal cryosurgical ablation of the prostate (CSAP). Materials and Methods: A total of 336 patients were included who underwent focal HIFU or focal CSAP as a primary treatment for PCa between January 2009 and December 2017. Mean follow-up was 11 months (standard deviation: 3.0). All complications were captured and graded according to severity, and classified by timing of onset. Univariate and multivariate analysis was performed to identify predictors of the most common side effects. Results: There were 98 complications in 79/210 patients (38%) undergoing focal HIFU and 34 complications in 27/126 patients (21%) undergoing focal CSAP. In terms of severity, 95% of the complications of focal HIFU and 91% of the complications of focal CSAP were minor. Most complications presented in the early postoperative period. On multivariate analysis, subtotal HIFU was associated with acute urinary retention (AUR), while a smaller prostate size and longer catheterization time with dysuria. In CSAP patients, longer catheterization time was associated with AUR and urethral sloughing. The main limitation is the nonrandomized and retrospective nature. Conclusions: Focal HIFU and focal CSAP provide a tolerable toxicity, with primarily minor complications presenting in the early postoperative period.

Switch from abiraterone plus prednisone to abiraterone plus dexamethasone at asymptomatic PSA progression in patients with metastatic castration-resistant prostate cancer

OBJECTIVE

To evaluate the effects of switching from prednisone (P) to dexamethasone (D) at asymptomatic prostate-specific antigen (PSA) progression in patients with metastatic castration-resistant prostate cancer (mCRPC) treated with abiraterone acetate (AA).

MATERIALS AND METHODS

Among 93 patients treated with AA between January 2013 and April 2016 in our institution, 48 consecutive asymptomatic patients with mCRPC, who experienced biochemical progression on treatment with AA+P 10 mg/day, were included. A corticosteroid switch to AA+D 0.5 mg/day at PSA increase was administered until radiological and/or clinical progression. The primary endpoint was progression-free-survival (PFS). A prognostic score based on independent prognostic factors was defined.

RESULTS

The median time to PSA progression on AA+P was 8.94 months. The median PFS on AA+D and AA+corticosteroids (P then D) was 10.35 and 20.07 months, respectively. A total of 56.25% of patients showed a decrease or stabilization in PSA levels after the switch. In univariate analysis, three markers of switch efficiency were significantly associated with a longer PFS: long hormone-sensitivity duration (≥5 years; median PFS 16.62 vs 4.17 months, hazard ratio [HR] 0.30, 90% confidence interval [CI] 0.16-0.56); low PSA level at the time of switch (<50 ng/mL; median PFS 15.21 vs 3.86 months, HR 0.33, 90% CI 0.18-0.60); and short time to PSA progression on AA+P (<6 months; median PFS 28.02 vs 6.65 months, HR 0.41 (90% CI 0.21-0.81). In multivariate analysis, hormone sensitivity duration and PSA level were independent prognostic factors.

CONCLUSION

A steroid switch from P to D appears to be a safe and non-expensive way of obtaining long-term responses to AA in selected patients with mCRPC. A longer PFS has been observed in patients with previous long hormone sensitivity duration, and/or low PSA level and/or short time to PSA progression on AA+P.

[Management of ablative therapies in prostate cancer]

OBJECTIVES

To describe the specific modalities of ablative therapies management in prostate cancer.

MATERIALS AND METHODS

A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of keywords. Publications obtained were selected based on methodology, language and relevance. After selection, 61 articles were analysed.

RESULTS

Development of innovations such as ablative therapies in prostate cancer induces specific modalities in their management, during pre-, per- and post-procedure. More than for classical and well-known treatments, the decision to propose an ablative therapy requires analysis and consensus of medical staff and patient's agreement. Patient's specificities and economical aspects must also be considered. Procedures and follow-up must be realized by referents actors.

CONCLUSION

Indication, procedure and follow-up of ablative therapies in prostate cancer require specific modalities. They must be respected in order to optimize the results and to obtain a precise and objective evaluation for defining future indications.

Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.

Grade Group Underestimation in Prostate Biopsy: Predictive Factors and Outcomes in Candidates for Active Surveillance

OBJECTIVE

We intended to analyze the outcomes and predictive factors for underestimating the prostate cancer (PCa) grade group (GG) from prostate biopsies in a large monocentric cohort of patients treated by minimally invasive radical prostatectomy (RP).

MATERIALS AND METHODS

Using a monocentric prospectively maintained database, we included 3062 patients who underwent minimally invasive RP between 2006 and 2013. We explored clinicopathologic features and outcomes associated with a GG upgrade from biopsy to RP. Multivariate logistic regression was used to develop and validate a nomogram to predict upgrading for GG1.

RESULTS

Biopsy GG was upgraded after RP in 51.5% of cases. Patients upgraded from GG1 to GG2 or GG3 after RP had a longer time to biochemical recurrence than those with GG2 or GG3 respectively, on both biopsy and RP, but a shorter time to biochemical recurrence than those who remained GG1 after RP (P < .0001). In multivariate analyses, variables predicting upgrading for GG1 PCa were age (P = .0014), abnormal digital rectal examination (P < .0001), prostate-specific antigen density (P < .0001), percentage of positive cores (P < .0001), and body mass index (P = .037). A nomogram was generated and validated internally.

CONCLUSIONS

Biopsy grading system is misleading in approximately 50% of cases. Upgrading GG from biopsy to RP may have consequences on clinical outcomes. A nomogram using clinicopathologic features could aid the probability of needing to upgrade GG1 patients at their initial evaluation.

High intensity focused ultrasound with Focal-One® device: Prostate-specific antigen impact and morbidity evaluation during the initial experience

OBJECTIVE

We report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-One^® device.

MATERIAL AND METHODS

Retrospective review of the prospectively populated database. Between June 2014 to October 2015, 85 patients underwent HIFU (focal/whole-gland) treatment for localized PCa. Preoperative cancer localization was done with multiparametric magnetic resonance imaging (mpMRI) and transperineal mapping biopsies. Treatment was carried out using the Focal-One^® device under general anesthesia. Oncological follow-up: PSA measurement and control biopsy with mpMRI according to protocol. Questionnaire-based functional outcome assessment was done. Complications were reported using Clavien classification.

RESULTS

The median PSA was 7.79ng/ml (IQR 6.32-9.16), with a median prostate volume of 38cc (IQR: 33-49.75). Focal and whole-gland therapy was performed in 64 and 21 patients respectively. Ten patients received salvage HIFU. Complications were encountered in 15% of cases, all Clavien 2 graded. Mean hospital stay was 1.8 days (0-7) and bladder catheter was removed on day 2 (1-6). Mean percentage reduction of PSA was 54%. Median follow-up was 3 months (IQR: 2-8). Functional outcomes: All patients were continents at 3 months and potency was maintained in 83% of the preoperatively potent.

CONCLUSIONS

Focal-One^® HIFU treatment appears to be a safe procedure with few complications. Functional outcomes proved no urinary incontinence and sexual function were maintained in 83%.

Evolution of prostate biopsy techniques. Looking back on a meaningful journey

BACKGROUND

The technique of prostate biopsy has evolved a long way since its inception to being a safe diagnostic procedure. The principles of the biopsy technique continue to improvise with the knowledge about prostate cancer and availability of newer treatment options like active surveillance and focal therapy. Currently, we depend on accurate cancer information from the biopsy more than ever for deciding the ideal treatment option.

AIM

The aim of this review is to present the major milestones in prostate biopsy technique evolutions and its impact on the prostate cancer management.

ACQUISITION OF EVIDENCE

We performed a detailed non-systematic literature review to present the historical facts on the transformations in prostate biopsy techniques and also the direction of present research to improve accurate cancer detection.

SUMMARY OF EVIDENCE

There is a clear change in trend in biopsy technique before and after the introduction of transrectal ultrasound and prostate specific antigen. In the earlier era, the biopsies were aimed at palpable nodules and obtaining adequate prostatic tissue for diagnosis while the later era has moved towards detection of non-palpable and early prostate cancer. Recently, there is an increasing trend towards image guided targeted biopsies to extract maximum cancer information from minimum biopsy cores.

CONCLUSION

Prostate biopsy techniques have seen major changes since its inception and have a major impact on prostate cancer management. There is a great potential for research which can further support the newer treatment options like focal therapy.

Long-term oncological and functional outcomes of prostate sparing cystectomy: Single tertiary care institution experience

413

Background: To analyze the oncological and functional outcome of Prostate Sparing Cystectomy (PSC) in the treatment of Bladder Cancer (BC) in a single tertiary care referral institution. Methods: At our institution, we treated 147 patients (1992 – 2014) with PSC for muscle invasive BC and recurrent high grade non-muscle invasive BC. Out of these, 64 patients received a standardized PSC technique featuring a Millin adenomectomy between 2001 – 2014 and composed the population of the study. Inclusion criteria were: Normal prostate examination and prostate specific antigen (PSA) +/- negative transrectal ultrasound guided biopsies; Frozen section negative for cancer in prostatic urethra prostate base, distal ureters and trigone. Oncological outcome was evaluated with Overall survival (OS); Cancer-specific survival (CSS); Recurrence-free survival (RFS). Functional outcomes: Continence - being pad-free or leak-free requiring ≤ 1 pad per day/night. Sexual function was assessed by self- reported erectile function sufficient for intercourse with or without medical treatment. Results: Median age was 62 years (IQR 55-67,5) with a median follow-up of 70 months (IQR 46-103). Thirty one (48,4%) patients ≤ pT1, 19 (29,7%) pT2, 14 (21,9%) ≥ pT3 at pathological diagnosis. Lymphadenectomy was performed in 95,3% of the cases. Positive lymph nodes were found in 4.9% patients and 3.1% patients showed positive surgical margins. Ten patients (15,7%) had Clavien grade 3–5 complications.The 5 and 10-y survival rates were OS: 84,7% and 68,3%; CSS: 84,7% and 77,5%; RFS: 76% and 65,5% respectively. No case of recurrence at the remnant prostatic urothelium was observed. Pad-free and leak-free continence, were achieved in 85.9% and 93.8% for daytime continence respectively, with 50% and 85,9% for night continence, respectively. Erectile function was maintained in 56,3%. Prostate cancer was diagnosed in 3 (4,7%) patients, 2 at the pathology report of the adenomectomy followed with active surveillance, and 1 was diagnosed during the follow up being treated with brachytherapy. Conclusions: PSC appears to be an oncologically safe procedure with adequate functional outcomes in treating selected patients with BC.

First off-time treatment prostate-specific antigen kinetics predicts survival in intermittent androgen deprivation for prostate cancer

BACKGROUND

Prostate-specific antigen (PSA) doubling time is relying on an exponential kinetic pattern. This pattern has never been validated in the setting of intermittent androgen deprivation (IAD). Objective is to analyze the prognostic significance for PCa of recurrent patterns in PSA kinetics in patients undergoing IAD.

METHODS

A retrospective study was conducted on 377 patients treated with IAD. On-treatment period (ONTP) consisted of gonadotropin-releasing hormone agonist injections combined with oral androgen receptor antagonist. Off-treatment period (OFTP) began when PSA was lower than 4 ng/ml. ONTP resumed when PSA was higher than 20 ng/ml. PSA values of each OFTP were fitted with three basic patterns: exponential (PSA(t) = λ.e(αt)), linear (PSA(t) = a.t), and power law (PSA(t) = a.t(c)). Univariate and multivariate Cox regression model analyzed predictive factors for oncologic outcomes.

RESULTS

Only 45% of the analyzed OFTPs were exponential. Linear and power law PSA kinetics represented 7.5% and 7.7%, respectively. Remaining fraction of analyzed OFTPs (40%) exhibited complex kinetics. Exponential PSA kinetics during the first OFTP was significantly associated with worse oncologic outcome. The estimated 10-year cancer-specific survival (CSS) was 46% for exponential versus 80% for nonexponential PSA kinetics patterns. The corresponding 10-year probability of castration-resistant prostate cancer (CRPC) was 69% and 31% for the two patterns, respectively. Limitations include retrospective design and mixed indications for IAD.

CONCLUSION

PSA kinetic fitted with exponential pattern in approximately half of the OFTPs. First OFTP exponential PSA kinetic was associated with a shorter time to CRPC and worse CSS.

Robotics in urological surgery: evolution, current status and future perspectives

CONTEXT

Robotic surgery is rapidly evolving and has become an essential part of surgical practice in several parts of the world. Robotic technology will expand globally and most of the surgeons around the world will have access to surgical robots in the future. It is essential that we are updated about the outcomes of robot assisted surgeries which will allow everyone to develop an unbiased opinion on the clinical utility of this innovation.

OBJECTIVE

In this review we aim to present the evolution, objective evaluation of clinical outcomes and future perspectives of robot assisted urologic surgeries.

ACQUISITION OF EVIDENCE

A systematic literature review of clinical outcomes of robotic urological surgeries was made in the PUBMED. Randomized control trials, cohort studies and review articles were included. Moreover, a detailed search in the web based search engine was made to acquire information on evolution and evolving technologies in robotics.

SYNTHESIS OF EVIDENCE

The present evidence suggests that the clinical outcomes of the robot assisted urologic surgeries are comparable to the conventional open surgical and laparoscopic results and are associated with fewer complications. However, long term results are not available for all the common robotic urologic surgeries. There are plenty of novel developments in robotics to be available for clinical use in the future.

CONCLUSION

Robotic urologic surgery will continue to evolve in the future. We should continue to critically analyze whether the advances in technology and the higher cost eventually translates to improved overall surgical performance and outcomes.

Clinical utility of transperineal template-guided mapping biopsy of the prostate after negative magnetic resonance imaging-guided transrectal biopsy

PURPOSE

We evaluated the prostate cancer detection with transperineal template-guided mapping biopsy in patients with elevated prostate-specific antigen and negative magnetic resonance imaging (MRI)-guided biopsy.

MATERIALS AND METHODS

Totally 75 patients underwent transperineal template-guided mapping biopsy for prior negative MRI-guided (cognitive registration) biopsy during April 2013 to August 2014. Primary objective was to report clinically significant cancer detection in this cohort of patients. Significant cancer was defined using varying thresholds of MCL or Gleason grade 3+4 or greater or both. Cancers with more than 80% of positive core length anterior to the level of urethra were termed anterior zone cancer. Secondary objective was to evaluate the potential clinical and radiological predictors for significant cancer detection.

RESULTS

The mean age was 61.6 ± 6.5 years and median prostate-specific antigen was 10.4 ng/dl (7.9-18) with a mean MRI target size of 7.2mm (4-11). Transperineal template-guided mapping biopsy identified cancer in 36% (27/75) patients and 66.6% (18/27) of them were anterior zone cancers. The rates of detection of clinically significant and insignificant cancer according to the several definitions used range from 22.7% to 30.7% and 5.3% to 13.3%, respectively. Multivariate analysis did not identify any predictors for finding clinically significant and anterior cancers in this group of patients.

CONCLUSION

Transperineal template-guided mapping biopsy appears to be an excellent biopsy protocol for downstream management following negative MRI-guided biopsy. Most of the cancers detected were predominantly anterior tumors.

T-helper 1 immunoreaction influences survival in muscle-invasive bladder cancer: proof of concept

Objective

To define immunoscore in bladder cancer studying T helper 1 (Th1) immunoreaction. To define a cancer-specific survival model based on Th1 cells infiltration.

Methods

A total of 252 patients underwent primary transurethral resection of bladder tumour at our Institution. A retrospective review of a selected cohort with pT1 and muscle-invasive bladder cancer (MIBC) lesions was performed. Pathology blocks were marked with CD3 and CD8 antibodies. Immune cells density in stromal reaction (SR) was measured on five distinct high-power field (HPF) by two dedicated uro-pathologist blinded for patients’ evolution.

Statistics

Student test or non-parametric Wilcoxon test as appropriate to compare means between two groups. Receiver operating characteristics (ROC) curve to define markers threshold. Cox model to assess survival’s predictors.

Results

Ten pT1 and 20 MIBC consecutive cases were analysed. Median follow-up was 33.4 months. Immunohistological analysis for pT1 lesions featured limited SR. For MIBC, the mean density of lymphocytes in the SR was of 105/HPF (CD3) and 86/HPF (CD8). Survivors harboured higher lymphocytes densities versus non survivors (CD3: p = 0.0319; CD8: p = 0.0279). CD3 (p = 0.034) and CD8 (p = 0.034) lymphocytes densities were independently associated with cancer-specific survival on Cox model analyses. The retrospective design and small size of cohorts are the study limitations.

Conclusions

High CD3 and CD8 lymphocytes SR densities are associated with better cancer-specific survival for MIBC. Th1 reaction against the tumour seems to be protective for bladder cancer. Further evaluation is warranted.

Transperineal template-guided mapping biopsy of the prostate

Accurate diagnosis of prostate cancer has eluded clinicians for decades. With our current understanding of prostate cancer, urologists should devise and confidently present the available treatment options – active surveillance/radical treatment/focal therapy to these patients. The diagnostic modalities used for prostate cancer have the dual problem of false negativity and overdiagnosis. Various modifications in the prostate biopsy techniques have increased the accuracy of cancer detection, but we are still far from an ideal diagnostic technique. Transperineal template-guided mapping biopsy of the prostate is an exhaustive biopsy technique that has been improvised over the past decade, and has shown superior results to other available modalities. We have carried out a PubMed search on the available experiences on this diagnostic modality, and along with our own experiences, we present a brief review on transperineal template-guided mapping biopsy of the prostate.

Predictive factors associated with Gleason score underestimation on prostate biopsy in a monocentric cohort of 3,062 patients treated by mini-invasive radical prostatectomy

113

Background: Gleason score (GS) on prostate biopsy is a critical factor in the initial evaluation of patients with prostate cancer (PC), and can lead to different therapeutic options. However, it may differ from the final pathologic result on radical prostatectomy (RP) specimen in up to 30 to 50% of cases. The aim of this study was to explore the clinicopathological features and outcomes associated with Gleason upgrading from biopsy to RP in a contemporary cohort and to develop an upgrading risk tool available preoperatively. Methods: Using a monocentric prospectively maintained database, we included 3,062 patients who underwent minimally invasive RP between 2005 and 2012. All biopsies and surgical specimens were analyzed by dedicated pathologists. We explored clinicopathological features and outcomes associated with Gleason upgrading from biopsy to RP. A multivariate logistic regression was used to develop a nomogram predicting upgrading for Gleason 6 PC. Results: The median number of biopsy cores was 12 (10 to 13). The GS on biopsy was respectively 6, 7, and more than 7 in 58.5%, 37.4%, and 4.1%. The GS on biopsy was consistent with the specimen in 42.7%. The GS was upgraded in 37.8% and the primary pattern was upgraded in 14.1%. Patients upgraded from biopsy Gleason 6 to Gleason 7 on RP had a longer time to biochemical recurrence than those with Gleason 7 on both biopsy and RP, but a shorter time to BCR than those who remained Gleason 6 on RP (p<0,0001). On multivariate analysis, variables predicting upgrading for Gleason 6 PC were: age (p=0.0014), abnormal digital rectal examination (p<0.0001), prostate-specific antigen density (p<0.0001), percentage of positive cores (p<0.0001) and body-mass index (p=0.037). A nomogram was generated and validated internally. Conclusions: Biopsy GS is misleading in one third of cases. Gleason upgrading from biopsy to PR seems to have consequences on the clinical outcomes. A nomogram using clinicopathological features can be useful to recognize the probability of upgrading in patients with Gleason 6 PC at initial evaluation. This could help to better choose therapeutic options in low-risk PC.

PSA patterns during off-time treatment period in patients undergoing intermittent androgen deprivation: Is PSA doubling time reliable in every case?

150

Background: Indicators such as prostate-specific antigen (PSA) nadir after the first on-treatment period (ONTP), off-phase interval duration and PSA doubling time (PSADT) were interpreted as potentially predictive, regarding outcomes of intermittent androgen deprivation (IAD). From actual PSA measurement data recorded on patients undergoing IAD during their off-treatment period (OFTP), we conducted a systematic analysis aimed at screening indicators and finely assessing their relevance as predictive candidates. Methods: Between 1992 and 2012, 727 patients with PC were selected for IAD at our institution. Three hundred ten patients had biochemical recurrence (BCR) after local treatment, 172 showed metastatic disease. ONTP consisted of three-month dose injections of gonadatropin-releasing hormone (GnRH) agonist combined with daily oral androgen receptor antagonist. OFTP was indicated when PSA was less than 4 ng/ml. Criteria for resumption of hormonal therapy were PSA more than 20 ng/ml or clinical symptoms. We tested two basic patterns of PSA behavior-exponential and power law (a<1) and combinations of them, on 597 patients with at least one completed OFTP based on four visits or more (population of the study). Results: We identified 597 patients with a total of 1,573 OFTPs. Median follow-up was 12,2 months (3,0-132,6). Median age at initiation was 76,7 (56,7 to 88,5); 811 OFTPs (51,6%) fitted with a pure exponential (r=0,01), whereas the other part (48,4%) followed more complex patterns (power law or two-steps or linear pattern). Mean cancer specific survival duration was 77,4 months (13,5 to 179,8). 5- and 10-year PC survival rate were respectively of 89,3% and 65,2% (CI 95%). Conclusions: Some OFTPs do not present an exponential pattern behavior: logarithmic calculation of PSADT is not suitable. PSADT determination should be adapted to the nature of the OFTP pattern. Through identification and analysis of the different types of OFTP, it is expected to improve the forecast of clinical outcomes.

Positive surgical margins after minimally invasive radical prostatectomy in patients with pT2 and pT3a disease could be considered pathological upstaging

OBJECTIVE

To assess the prognostic significance of positive surgical margins (PSMs) after minimally invasive radical prostatectomy (MIRP) in interaction with other established prognosis factors.

PATIENTS AND METHODS

We retrospectively analysed data prospectively collected between 1998 and 2010 for 4628 consecutive patients who underwent MIRP for clinically localized prostate cancer. The impact of PSM on biochemical recurrence (BCR), defined as prostate-specific antigen (PSA) >0.2 ng/mL, was evaluated using multivariable Cox proportional hazards regression. Estimates of BCR-free survival were generated using the Kaplan-Meier method and compared among groups using the log-rank test.

RESULTS

The median follow-up was 55 months. On multivariable analysis, PSM was an independent prognostic factor for BCR (adjusted hazard ratio: 2.14 for PSMs vs negative surgical margins (NSMs); 95% confidence interval [CI]: 1.86-2.45; P < 0.001). Other independent predictors for BCR were preoperative PSA, date of surgery, pT stage, Gleason score and lymph node involvement (all P < 0.001). The 5-year BCR-free probability was 80.6% (95% CI: 79-82.2) for NSMs vs 51% (95% CI: 47-55) for PSMs (log-rank P < 0.001). Patients with pT2 and pT3a PSMs had a similar prognosis to those with pT3a and pT3b NSMs, respectively (log-rank P ≥ 0.05).

CONCLUSION

A PSM after MIRP is associated with 2.14-fold increased risk of BCR. In patients with pT2 and pT3a disease, a PSM could be considered a pathological upstaging.

Focal brachytherapy for selected low-risk prostate cancers: a pilot study

PURPOSE

To evaluate the feasibility and the early toxicity of focal brachytherapy in highly selected localized prostate cancer patients.

METHODS AND MATERIALS

Twenty-one patients underwent a focal brachytherapy between February 2010 and March 2012, representing 3.7% of the cases treated by our group during this period. Patient selection was based on (at least) two series of prostate biopsies and a high-resolution MRI. Only patients with very limited and localized tumors, according to strict criteria, were selected for the procedure. The technique used a real-time procedure with the implantation of free (125)I seeds and dynamic dose calculation. The prescribed dose for the focal volume was 145Gy.

RESULTS

The treated volume corresponded to a mean value of 34% of the total prostatic volume (range, 20-48%). For the focal volume, the mean D90 and V100 was 183.2Gy (range, 176-188Gy) and 99.3% (range, 98.8-100%), respectively. The technique was performed in an hour and a half. When compared with a previous cohort treated by whole-prostate brachytherapy, urinary toxicity (International Prostate Symptom Score) was borderline reduced (p = 0.04) at 6 months only, whereas the recovery of the International Index of Erectile Function 5 was better (p = 0.014). The International Continence Score was nil in almost all cases as well as rectal toxicity.

CONCLUSION

Focal treatment by brachytherapy is easily feasible with little acute toxicity. Further investigation is needed to assess the results in terms of tumor control and long-term toxicity.

Morbidity of focal therapy in the treatment of localized prostate cancer

BACKGROUND

Focal therapy (FT) for prostate cancer (PCa) seems to be part of a natural evolution in the quest to improve the management of early organ-confined disease.

OBJECTIVE

To assess the morbidity of the initial experience of FT in a tertiary referral center for PCa management.

DESIGN, SETTING, AND PARTICIPANTS

From 2009 to 2011, a total of 1213 patients with clinically localized PCa were treated at our institution. Of these patients, 547 were considered to have indolent disease according to the D'Amico criteria for low-risk disease plus unilateral disease with a maximum of three positive biopsies. A total of 106 patients underwent FT using high-intensity focused ultrasonography (HIFU), brachytherapy, cryotherapy, or vascular-targeted photodynamic therapy (VTP).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Complications were prospectively recorded and graded according to the Clavien-Dindo scale. Data were prospectively collected and retrospectively analyzed.

RESULTS AND LIMITATIONS

This study included 106 patients, median age 66.5 yr (interquartile range [IQR]): 61-73), who had a prostate hemiablation; 50 patients (47%) had cryotherapy, 23 patients (22%) had VTP, 21 patients (20%) received HIFU, and 12 patients (11%) had brachytherapy. The median prostate-specific antigen (PSA) level was 6.1 ng/ml (IQR: 5-8.1), all the patients had a biopsy Gleason score of 6, and the median prostate weight was 43 g (IQR: 33-55). The median International Prostate Symptom Score was 6 (IQR: 3-10), and the median International Index of Erectile Function score was 20 (IQR: 15-23). After treatment, the median PSA at 3, 6, and 12 mo was 3.1 2.9, and 2.7 ng/ml (IQR: 2-5.1, 1.1-4.7, and 1-4.4), respectively. Thirteen percent of the patients experienced treatment-related complications. There were 11 minor medical complications (10 grade 1 complications and 1 grade 2 complication), 2 grade 3 complications, and no grade 4 or higher complications.

CONCLUSIONS

FT for a highly selected population with PCa is feasible and had an acceptable morbidity with <2% major complications.

Evaluation of erectile function after laparoscopic radical prostatectomy in a single center

INTRODUCTION

To evaluate erectile function among men who had undergone laparoscopic radical prostatectomy and received postoperative medical therapy for erectile dysfunction.

MATERIALS AND METHODS

We performed a prospective study in men who underwent laparoscopic radical prostatectomy between September 2003 and November 2005 at our center and who received penile rehabilitation after surgery. All patients had antegrade interfascial dissection. They received 10 mg tadalafil on the fifth postoperative day and continued to receive it every other day, regardless of erectile function. Intracavernous injection of alprostadil was initiated at 3 or 6 months depending on response to treatment with tadalafil. Follow up evaluations were done at 3, 6, 12, 18 and 24 months. Oncologic and functional outcomes and compliance were assessed. Patients filled in International Index of Erectile Function-5 (IIEF-5) questionnaires.

RESULTS

Of 1078 men who underwent laparoscopic radical prostatectomy during this time, 586 patients met inclusion criteria, complied with the study medication, and had complete data for 24 months. The patients had a median preoperative baseline IIEF-5 score of 22. A total of 150 patients (26%) underwent unilateral nerve-sparing surgery, while 436 patients (74%) had bilateral nerve-sparing surgery. At 24 months, 35% of patients who underwent unilateral nerve-sparing surgery and 68% of patients who underwent bilateral nerve-sparing surgery reported having sufficient erectile function for intercourse without using intracavernous injection of alprostadil. At 24 months after surgery, the median IIEF-5 score was 13 (1-25) for the whole cohort, 5 (1-25) for patients who had undergone unilateral nerve-sparing surgery, and 15 (1-25) for patients who had undergone bilateral nerve-sparing surgery.

CONCLUSIONS

The findings suggest that adequate patient selection and postoperative medical intervention allows the preservation or recovery of erectile function after laparoscopic radical prostatectomy. Inaccurate selection of patients and postoperative assessment might explain inferior erectile function results following this surgery.

Focal therapy with high-intensity focused ultrasound for prostate cancer in the elderly. A feasibility study with 10 years follow-up

PURPOSE

To evaluate the long-term efficacy of prostate cancer control and complication rates, in the elderly, after focal therapy with high-intensity focused ultrasound (HIFU).

MATERIALS AND METHODS

Between June 1997 and March 2000, patients with localized prostate cancer were included into a focal therapy protocol. Inclusion criteria were: PSA ≤ 10 ng/mL, ≤ 3 positive biopsies with only 1 lobe involved, clinical stage ≤ T2a, Gleason score ≤ 7 (3+4), negative CT scan and bone scan. Hemi-ablation of the prostate was performed with the Ablatherm® device. Survival, complication rates and urinary continence were evaluated. Control biopsies were performed at 1 year. Treatment failure was defined as a positive biopsy or need for salvage therapy.

RESULTS

Twelve patients with a mean age 70 years were included. Median follow-up was 10 years. Control prostate biopsies were negative in 11/12 (91%) patients. Overall survival was 83% (10/12) and cancer specific survival was 100% at 10 years. Two patients died from other causes. Recurrence free survival was 90% (95% CI; 0.71-1) at 5 years, and 38% (95% CI; 0.04-0.73) at 10 years. Five patients had salvage therapy with repeat HIFU (n = 1) or hormonal therapy (n = 4) and all salvage patients were alive at 10 years. No patients developed lymph node or bone metastasis. No patients suffered from urinary incontinence. International Prostate Symptom Score was stable at 1 year. Complications included two urinary tract infections and one episode of acute urinary retention.

CONCLUSIONS

Hemi-prostate ablation with HIFU can be safely performed in selected elderly patients with adequate long-term cancer control and low complication rates. Results from larger prospective studies using improved imaging techniques and extensive biopsy protocols are awaited.