Focal high-intensity focused ultrasound therapy for localized prostate cancer: An interim analysis of the multinational FASST study

BACKGROUND

High-intensity focused ultrasound (HIFU) emerged as a novel approach for the treatment of localized prostate cancer (PCa). However, prospective studies on HIFU-related outcomes and predictors of treatment failure (TF) remain scarce.

MATERIALS AND METHODS

We conducted a multinational prospective cohort study among patients undergoing HIFU therapy for localized, low- to intermediate-risk PCa. Follow-up data on serial prostate specific antigen (PSA), multi-parametric magnetic resonance imaging (mpMRI), targeted/systematic biopsies, adverse events and functional outcomes were collected. The primary endpoint was TF, defined as histologically confirmed PCa requiring whole-gland salvage treatment. Uni- and multi-variable adjusted hazard ratios (HRs) were calculated using Cox proportional hazard regression models.

RESULTS

At baseline, mean (standard deviation) age was 64.14 (7.19) years, with the majority of patients showing T-stage 1 (73.9%) and International Society of Urological Pathology grading system Grade 2 (58.8%). PSA nadir (median, 1.70 ng/mL) was reached after 6 months. Of all patients recruited, 16% had clinically significant PCa, as confirmed by biopsy, of which 13.4% had TF. Notably, T-stage and number of positive cores at initial biopsy were independent predictors of TF during follow-up (HR [95% CI] 1.27 [1.02-1.59] and 5.02 [1.80-14.03], respectively). Adverse events were minimal (17% and 8% early and late adverse events, respectively), with stable or improved functional outcomes in the majority of patients.

CONCLUSIONS

This interim analysis of a multinational study on HIFU therapy for the management of low-to-intermediate-risk PCa reveals good functional outcomes, minimal adverse events and low incidence of TF over the short-term. Data on long-term outcomes, specifically as it relates to oncological outcomes, are awaited eagerly.

High-intensity focused ultrasound with visually directed power adjustment for focal treatment of localized prostate cancer: systematic review and meta-analysis

PURPOSE

To characterize patient outcomes following visually directed high-intensity focused ultrasound (HIFU) for focal treatment of localized prostate cancer.

METHODS

We performed a systematic review of cancer-control outcomes and complication rates among men with localized prostate cancer treated with visually directed focal HIFU. Study outcomes were calculated using a random-effects meta-analysis model.

RESULTS

A total of 8 observational studies with 1,819 patients (median age 67 years; prostate-specific antigen 7.1 mg/ml; prostate volume 36 ml) followed over a median of 24 months were included. The mean prostate-specific antigen nadir following visually directed focal HIFU was 2.2 ng/ml (95% CI 0.9-3.5 ng/ml), achieved after a median of 6 months post-treatment. A clinically significant positive biopsy was identified in 19.8% (95% CI 12.4-28.3%) of cases. Salvage treatment rates were 16.2% (95% CI 9.7-23.8%) for focal- or whole-gland treatment, and 8.6% (95% CI 6.1-11.5%) for whole-gland treatment. Complication rates were 16.7% (95% CI 9.9-24.6%) for de novo erectile dysfunction, 6.2% (95% CI 0.0-19.0%) for urinary retention, 3.0% (95% CI 2.1-3.9%) for urinary tract infection, 1.9% (95% CI 0.1-5.3%) for urinary incontinence, and 0.1% (95% CI 0.0-1.4%) for bowel injury.

CONCLUSION

Limited evidence from eight observational studies demonstrated that visually directed HIFU for focal treatment of localized prostate cancer was associated with a relatively low risk of complications and acceptable cancer control over medium-term follow-up. Comparative, long-term safety and effectiveness results with visually directed focal HIFU are lacking.

ASO Author Reflections: High-Intensity Focused Ultrasound will Become the Routine Practice for Treatment of Localized Prostate Cancer

PAST: Most prostate cancers are slow growing and are often diagnosed at an old age, which may result in treatment never being needed. However, definitive treatments such as radical prostatectomy and radiation therapy are often associated with many serious adverse effects, harming the physical and mental health of patients. PRESENT: In recent years, different types of minimally invasive therapy have been developed to achieve cancer control, continence, and even potency preservation, such as high-intensity focused ultrasound (HIFU). HIFU has been proposed for prostate cancer patients to provide an equivalent oncologic result to definitive treatment, with a reduced adverse effect profile, thus increasing the interest in HIFU for the treatment of localized prostate cancer. FUTURE: Sonablate® HIFU performed an outstanding cancer control in treating localized prostate cancer, with low biochemical recurrence and complication rates. As further long-term follow-up data mature, we anticipate the routine application of HIFU for localized prostate cancer within the next few years.

Single-center, prospective phase 2 trial of high-intensity focused ultrasound (HIFU) in patients with unilateral localized prostate cancer: good functional results but oncologically not as safe as expected

PURPOSE

Focal therapy (FT) for localized prostate cancer (PCa) is only recommended within the context of clinical trials by international guidelines. We aimed to investigate oncological follow-up and safety data of focal high-intensity focused ultrasound (HIFU) treatment.

METHODS

We conducted a single-center prospective study of 29 patients with PCa treated with (focal) HIFU between 2016 and 2021. Inclusion criteria were unilateral PCa detected by mpMRI-US-fusion prostate biopsy and maximum prostate specific antigen (PSA) of 15 ng/ml. Follow-up included mpMRI-US fusion-re-biopsies 12 and 24 months after HIFU. No re-treatment of HIFU was allowed. The primary endpoint was failure-free survival (FFS), defined as freedom from intervention due to cancer progression.

RESULTS

Median follow-up of all patients was 23 months, median age was 67 years and median preoperative PSA was 6.8 ng/ml. One year after HIFU treatment PCa was still detected in 13/ 29 patients histologically (44.8%). Two years after HIFU another 7/29 patients (24.1%) were diagnosed with PCa. Until now, PCa recurrence was detected in 11/29 patients (37.93%) which represents an FFS rate of 62%.One patient developed local metastatic disease 2 years after focal HIFU. Adverse events (AE) were low with 70% of patients remaining with sufficient erectile function for intercourse and 97% reporting full maintenance of urinary continence.

CONCLUSION

HIFU treatment in carefully selected patients is feasible. However, HIFU was oncologically not as safe as expected because of progression rates of 37.93% and risk of progression towards metastatic disease. Thus, we stopped usage of HIFU in our department.

Transrectal high-intensity focused ultrasound (HIFU) for management of rectosigmoid deep infiltrating endometriosis: results of Phase-I clinical trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) of the rectosigmoid is associated with painful symptoms. When medical treatment is ineffective, surgical resection remains the standard treatment, despite significant risk of adverse events. High-intensity focused ultrasound (HIFU) is a minimally invasive ablative procedure. Focal One® is a transrectal HIFU (TR-HIFU) device used in prostate cancer treatment. The primary objective of this study was to confirm the feasibility of treatment with TR-HIFU in patients presenting with posterior DIE with rectosigmoid involvement. We also assessed its safety and clinical efficacy in this context.

METHODS

This was a non-controlled, prospective, Phase-I clinical trial in a French University Hospital which is a multidisciplinary center for management of endometriosis. Included were patients older than 25 years, without plans to conceive within 6 months, who presented with a single lesion of posterior DIE, with rectosigmoid invasion, after failure of hormonal therapy. All lesions were assessed preoperatively using transvaginal sonography and magnetic resonance imaging. Patients completed questionnaires on gynecological and intestinal symptoms (similar to a visual analog scale (VAS)), and on quality of life (Medical Outcomes Study 36-item short-form survey (SF-36) and, for the second half of patients recruited, symptom scoring system for constipation (KESS), female sexual function index (FSFI) and endometriosis health profile short-version score (EHP-5)), before, and at 1, 3 and 6 months after, TR-HIFU treatment with a Focal One real-time ultrasound-guided HIFU device.

RESULTS

Twenty-three consecutive patients were included in the study between September 2015 and October 2019. All 23 lesions were visualized, giving a detection rate of 100%. Twenty lesions were treated ('feasibility rate', 87.0%): in 13 the whole lesion was treated and in seven the lesion was treated partially. The mean duration of the TR-HIFU procedure was 55.6 min. We observed a significant improvement in VAS score at 6 months, with differences relative to preoperative scores as follows, for: dysmenorrhea (-3.6, P = 0.004), dyspareunia (-2.4, P = 0.006), diarrhea (-3.0, P = 0.006), constipation (-3.0, P = 0.002), dyschezia (-3.2, P = 0.003), false urge to defecate (-3.3, P = 0.007), posterior pelvic pain (-3.8, P = 0.002) and asthenia (-3.8, P = 0.002). There was also a significant improvement in the SF-36 score, with an increase at 6 months relative to the preoperative score in both the physical component summary (+ 9.3%, P = 0.002) and mental component summary (+ 10.9%, P = 0.017). No major complications occurred during or after any procedure.

CONCLUSIONS

TR-HIFU therapy for posterior DIE is feasible. If its efficacy and safety are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

[The correlation of PSA-nadir PS recurrence after total HIFU-ablation in patients with localized prostate cancer]

OBJECTIVE

To study the survival rate of patients without biochemical recurrence according to the Stuttgart and Phoenix criteria in terms of their correlation with four different PSA nadir values as predictors of clinical recurrence in patients with localized prostate cancer who underwent total HIFU prostate ablation.

MATERIAL AND METHODS

The object of the study was patients with morphologically proven localized RP by biopsy results, who were treated with prostate cancer by HIFU ablation on the Ablatherm Integrated Imaging apparatus (EDAP TMS, France). The study included 658 patients in whom HIFU ablation was used as primary treatment of localized prostate cancer (stages T1 - T2) without previous use of other methods (hormonal, radiation therapy) For the analysis, a continuous sample of patients was selected, which were divided into four groups depending on the PSA nadir level: less or equal 0.2 ng / ml (1 group), 0.21-0.5 ng / ml (group 2), 0.51-1 ng / ml (group 3) and> 1 ng / ml (group 4). sensitivity, specificity, predictive value, and 5-year biochemical relapse-free survival according to the Stuttgart definition and the Phoenix definition in the PSA nadir groups.

RESULTS

The median (range) of the observation period for the patients was 5.3 (3-7) years, the mean time to reaching PSA nadir was 14.5+/-2.6 weeks. PSA nadirs less or equal 0.2, 0.21-0.5, 0.51-1.0 and > 1 ng/ml were achieved in 231 (35.1%), 132 (20.0%), 105 (15, 9%) and 190 (28.8%) patients, respectively. Survival without biochemical relapse in accordance with the Stuttgart definition in the four groups allocated for the PSA nadir was 82, 65, 43 and 32%, respectively (p<0.001), according to the Phoenix definition - 94, 74, 66 and 47% (p<0.001) respectively. According to the results of the control biopsy, 601 (91.3%) patients in the 1st and 2nd groups had a negative oncological status (approximately 85%).

CONCLUSION

This study confirms that PSA nadir after HIFU ablation predicts biochemical recurrence-free survival and is a reliable marker that is easy to integrate into routine clinical practice.

[Clinical, morphological and microcirculatory criteria of local recurrence of the prostate cancer after HIFU therapy]

AIM

to study the clinical, morphological and microcirculatory criteria for treatment efficiency and prognosis of local recurrence after HIFU.

MATERIALS AND METHODS

On the basis of the urological department of Clinical Hospital "Russian Railways - Medicine" in Barnaul (the clinical base of the Department of Urology and Andrology with a course of Specialized Surgery of FGBOU VO "Altai State Medical University") for the period 2011-2018, a comprehensive examination and treatment of 240 patients with prostate cancer (PCa) by means of HIFU using "Ablatherm" was performed following transurethral resection of the prostate (TURP). The indication for HIFU was morphologically-proven PCa (stage T2a-cN0M0) in patients with contraindications due to comorbidities or those who refused from radical prostatectomy.

RESULTS

A decrease in PSA to 0.5 ng/ml or less was observed in 74% of patients. A stable PSA level for 3 years was observed in 76% of patients. PSA levels differed depending on the PCa risk group. In the low-risk PCa, negative biopsy was seen in 89.6% of cases, in comparison with 72.2% and 69.4% in intermediate and high-risk PCa, respectively. There was a significant decrease in the volume of the prostate in all patients with low-risk PCa. The largest decrease in prostate volume was observed 12 months after HIFU. Regarding recurrence-free survival after HIFU therapy, during follow-up of 3 years or more, 77% of patients didnt have any signs of recurrence. A 3-year overall survival after HIFU was 83%. In addition, an increase in postoperative PSA levels, change in parameters of Doppler study and laser Doppler flowmetry at the area of the prostate during the period of 6-36 months after HIFU was associated with a significant increase in the risk of recurrence of PCa at biopsy.

CONCLUSION

HIFU therapy is an effective treatment method for inducing prostate necrosis with minimal collateral damage to the surrounding tissue. The best results were achieved in patients with low-risk PCa. There were minimal adverse events after HIFU. In addition, in case of relapse after HIFU therapy, there is an opportunity for an early assessment of the efficiency and prognosis.

An Exploratory Study of Dose Escalation vs Standard Focal High-Intensity Focused Ultrasound for Treating Nonmetastatic Prostate Cancer

Objective: Analysis of treatment success regarding oncological recurrence rate between standard and dose escalation focal high-intensity focused ultrasound (HIFU) of prostate cancer. Materials and Methods: In this analysis of our prospectively maintained HIFU (Sonablate^® 500) database, 598 patients were identified who underwent a focal HIFU (Sonablate 500) between March 2007 and November 2016. Follow-up occurred with 3-monthly clinic visits and prostate specific antigen (PSA) testing in the first year. Thereafter, PSA was measured 6-monthly or annually at least. Routine and for-cause multiparametric MRI (mpMRI) was conducted with biopsy for MRI suspicion of recurrence. Treatments were delivered in a quadrant or hemiablation fashion depending on the gland volume as well as tumor volume and location. Before mid-2015, standard focal HIFU was used (two HIFU blocks); after this date, some urologists conducted dose escalation focal HIFU (three overlapping HIFU blocks). Propensity matching was used to ensure two matched groups, leading to 162 cases for this analysis. Treatment failure was defined by any secondary treatment (systemic therapy, cryotherapy, radiotherapy, prostatectomy, or further HIFU), metastasis from prostate cancer without further treatment, tumor recurrence with Gleason score ≥7 (≥3 + 4) on prostate biopsy without further treatment, or prostate cancer-related mortality. Complications and side-effects were also compared. Results: Median age was 64.5 years (interquartile range [IQR] 60-73.5) in the standard focal-HIFU group and 64.5 years (IQR 60-69) in the dose-escalation group. Median prostate volume was 37 mL (IQR 17-103) in the standard group and 47.5 mL (IQR 19-121) in the dose-escalation group. As tumor volume on mpMRI and Gleason score were major matching criteria, these were identical with 0.43 mL (IQR 0.05-2.5) and Gleason 3 + 3 = 6 in 1 out of 32 (3%), 3 + 4 = 7 in 27 out of 32 (84%), and 4 + 3 = 7 in 4 out of 32 (13%). Recurrence in treated areas was found in 10 out of 32 (31%) when standard treatment zones were applied, and in 6 out of 32 (19%) of dose-escalation focal HIFU (p = 0.007). Conclusion: This exploratory study shows that dose escalation focal HIFU may achieve higher rates of disease control compared with standard focal HIFU. Further prospective comparative studies are needed.

[Prognostic significance of prostate-specific antigen in defining indications for initial prostate biopsy]

Currently, prostate biopsy remains the main method used to diagnose prostate cancer (PCa). The indication for the procedure is an elevated level of the serum level of the total prostate-specific antigen (PSA). However, the PSA test is organ- but not cancer-specific, and patients may undergo an unnecessary biopsy, which is an invasive procedure associated with a risk of complications. Additional tests have been developed aimed to improve the diagnostic performance of PSA for detecting PCa. They include PSA derivatives such as free PSA fraction, -2proPSA, PSA density, PHI and the free /total PSA fraction.

AIM

To investigate the diagnostic accuracy of PSA and its derivatives in detecting benign and malignant diseases of the prostate after an initial prostate biopsy.

MATERIALS AND METHODS

The current study analyzed 65 initial biopsies performed due to an elevated serum PSA level and compared them with the results of extended PSA testing with the use of PSA derivatives.

RESULTS

The histological findings consistent with PCa were found in about 30% of initial biopsies performed due to elevated serum levels of total PSA. The incidence of histologically confirmed PCa increased with age, and 70-79 year old men were more likely to have it than 60-69 years old patients. PSA density in 85% of PCa cases exceeded that for benign prostatic hyperplasia (BPH). In all PCa patients, PHI and free /total PSA fraction were greater than 25 and less than 0.15, respectively. In most patients with BPH, the PHI and free /total PSA fraction did not exceed 25 and were greater than 0.15.

CONCLUSIONS

1. Initial biopsy triggered by elevated serum level of total PSA allows detection of PCa in about 30% of cases. 2. The age of 60 years and older should be regarded as a risk factor for PCa. The probability of malignant transformation of prostate epithelial cells in men over 70 years of age is greater than in 60-69-year-olds. 3. The density of PSA in men with morphologically verified PCa is statistically significantly greater than that in men with BPH and the threshold value in 85% of cases. 4. Determination of PHI and free/total PSA fraction can improve the accuracy of predicting malignant lesions of the prostate and adjust the indications for histological examination, reduce the number of unnecessary biopsies. 5. When defining indications for initial prostate biopsy in cases with serum PSA varying from 2 to 10 ng/ml, PSA derivatives should be used, including PSA density, prostate health index, and the free /total PSA fraction.

[Morphological evidence of the ischemic nature of the prostatic fibrosis in the classical chronic pelvic pain syndrome / IIIB chronic prostatitis]

AIM

To examine the structure of the prostate tissue in patients with III B chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS).

MATERIALS AND METHODS

The study analyzed transrectal fine-needle biopsy specimens of 10 patients with the verified diagnosis of chronic pelvic pain syndrome/category III B chronic prostatitis (CPPS/IIIB CP) according to the National Institutes of Health classification. Tissues were examined using light and electron microscopy, and immunohistochemical study of the expression of CD31, CD34, NSE and S-100 markers.

RESULTS

All biopsy specimens of all patients showed fibroplastic changes of the prostate tissue most markedly pronounced in the stroma and muscle fibers in the form of total fibrosis, myofibril atrophy, and extracellular lipofuscin deposition. The examination revealed a significant reduction in the density of microcirculatory bed vessels and arteriolar luminal stenosis, a reduction in the number of nerve fibers, and compression of their fibrous tissue. No inflammatory changes were found in the prostate.

DISCUSSION

In patients with CPPS/IIIB CP, the changes in the prostate at the microscopic and ultrastructural levels are characteristic of severe chronic tissue hypoxia, which leads to the development of fibrosis resulting in stenosis of microcirculatory bed vessels and degenerative changes in nerve fibers and cells. No signs of an inflammatory reaction in the examined tissue were established.

CONCLUSION

Changes in the prostate tissue in CPPS/IIIB CP suggest the presence of chronic pelvic ischemia and exclude its association with inflammation as the main pathological process.

Online Robust Projective Dictionary Learning: Shape Modeling for MR-TRUS Registration

Robust and effective shape prior modeling from a set of training data remains a challenging task, since the shape variation is complicated, and shape models should preserve local details as well as handle shape noises. To address these challenges, a novel robust projective dictionary learning (RPDL) scheme is proposed in this paper. Specifically, the RPDL method integrates the dimension reduction and dictionary learning into a unified framework for shape prior modeling, which can not only learn a robust and representative dictionary with the energy preservation of the training data, but also reduce the dimensionality and computational cost via the subspace learning. In addition, the proposed RPDL algorithm is regularized by using the norm to handle the outliers and noises, and is embedded in an online framework so that of memory and time efficiency. The proposed method is employed to model prostate shape prior for the application of magnetic resonance transrectal ultrasound registration. The experimental results demonstrate that our method provides more accurate and robust shape modeling than the state-of-the-art methods do. The proposed RPDL method is applicable for modeling other organs, and hence, a general solution for the problem of shape prior modeling.

High intensity focused ultrasound for Focal Therapy of prostate cancer

High Intensity Focused Ultrasound (HIFU) is a heat based energy source used for tissue ablation. HIFU has several clinical applications and prostate cancer ablation is one of the uses that have been explored for more than a decade. Focal therapy is an alternative treatment option for selected patients with low/intermediate PCa, that is based on complete ablation of tumor within the prostate with preservation of normal parenchyma and better preservation of Genitourinary functions. In spite of PCa being predominantly a multi-centric disease, it is postulated that a specific dominant (large volume) 'index lesion' dictates the biological behavior of the cancer and subsequent lethality of the disease. The use of HIFU for focal ablation of PCa, have demonstrated satisfactory cancer control with fewer morbidity and better preservation of continence and erection. The aim of this article is to present the readers with a brief review of the principles, devices available for clinical uses, published clinical experience and future directions and research opportunities in focal HIFU ablation of prostate cancer.

[QUALITY OF LIFE IN PATIENTS UNDERGOING PROSTATE CRYOABLATION]

Not long ago, survival rates were the primary outcome measures of surgical management of prostate cancer. Currently, more attention is paid to the quality of life, because even minor changes in the quality of life can lead to serious alterations in the psycho-emotional status and significantly reduce patients' self-esteem. Most experts believe that the quality of life of patients treated for prostate cancer, is mostly affected by urinary incontinence, erectile dysfunction, urethral stricture, and bowel dysfunction. Thanks to advances in the treatment of prostate cancer, the incidence of complications was reduced to a minimum. To some extent, this was due to the use of novel minimally invasive treatment for prostate cancer, such as cryoablation, interstitial brachytherapy and HIFU-therapy. The quality of life in 65 patients undergoing cryoablation of the prostate was evaluated using EORTC QLQ-C30 questionnaire. Analyzing the findings of the survey enabled us to estimate the patients' quality of life, as well as to identify the various components of the postoperative health problems.

[Treatment of prostate cancer using cryoablation: a prospective study]

Currently, the choice of tactics of treatment of the patient with prostate cancer (PCa) requires to take into account the degree of differentiation and stage of tumor, age of the patient and his somatic diseases, the risk of complications, as well as the patient's desire and physician's experience. Due to the progressive development of medical technology, interest in minimally invasive treatments for prostate cancer, such as cryoablation, interstitial brachytherapy and HIFU-therapy, has grown. Cryoablation of the prostate gland is a tissue ablation by local effects of very low temperatures and is minimally invasive, highly effective treatment for prostate cancer that can be used as the primary treatment, and in the case of tumor recurrence after radiotherapy. Focal cryoablation of the prostate allows to selectively destroy the known tumor with preservation of organ function and without reducing the quality of life of the patient. Focal therapy for prostate cancer is an alternative to radical treatment and active surveillance, occupying an intermediate position between them. Due to the lack of long-term results, focal cryoablation is an experimental type of treatment. First cryoablation of the prostate using modern equipment was carried out in Russia in March 2010, at the Department of Urology MSMSU. Since that time, we performed this procedure in 122 patients with prostate cancer; cryoablation was primary treatment in 110 patients and was used as salvage treatment in 12 patients. In most cases, the operation was performed under epidural or spinal anesthesia. According to the protocol, all the patients underwent 2 cycles of freezing and thawing under transrectal ultrasound guidance. A significant improvement of equipment for cryosurgery, the use of cryoneedles with smaller diameter, and the use of temperature sensors and catheters to warm the urethral mucosa have allowed to minimize the number of complications in comparison with other methods of treatment of prostate cancer and achieve a high disease-free survival. Our prospective study was aimed to analyze our own results cryoablation of the prostate gland.

The value of TRUS in the staging of rectal carcinoma before and after radiotherapy and comparison with the staging postoperative pathology

AIM

To compare the effectiveness of transrectal ultrasonography (TRUS) with that of postoperative pathological examination in staging rectal carcinoma before surgery and before and after radiotherapy.

MATERIALS AND METHODS

A prospective study was undertaken comprising 62 patients with stage T3 or T4 rectal carcinoma confirmed by endoscopic biopsy.

RESULTS

TRUS showed significant differences (p < 0.01) in tumour echogenicity and volume, border delineation, local invasion, and draining lymph node involvement before and after radiotherapy, and significant reduction in blood flow resistance index after radiotherapy but no difference (p > 0.05) in the classification of tumour blood flow. In ultrasonographic assessments, 53 of the 62 cases (85.5%) showed lower T stages after radiotherapy. TRUS showed an accuracy of 94.1% for T2 cases, 77.3% for T3 cases, and 83.3% for T4 cases, and an overall accuracy of 87.1% in comparison with the results of postoperative pathological examination.

CONCLUSION

TRUS is expected to play a vital role in the accurate preoperative staging of rectal carcinoma with the increasing utilization of adjuvant radiotherapy in rectal carcinoma and to contribute to the assessment of treatment.

Sonochemiluminescence observation and acoustic detection of cavitation induced by pulsed HIFU at a tissue-fluid interface

The aim of this study is to investigate the mechanism of the erosion process induced by 1.2 MHz pulsed high-intensity focused ultrasound (pulsed HIFU). By using Sonochemiluminescence (SCL) photograph, the initiation and maintenance of active cavitation were observed. In order to understand the role of both inertial cavitation and stable cavitation, a passive cavitation detection (PCD) transducer was used. Since the exposure variables of HIFU are important in the controlled ultrasound tissue erosion, the influence of pulse length (PL) and duty cycle (DC, Ton:Toff) has been examined. The results of tissue hole, SCL observation and acoustic detection revealed that the erosion was highly efficient for shorter PL. For higher DCs, the area of SCL increased with increasing PL. For lower DCs, the area of SCL increased with increasing PL from 10 to 20 μs and then kept constant. For all PLs, the intensity of SCL decreased with lower DC. For all DCs, the intensity of SCL per unit area (the ratio of SCL intensity to SCL area) also decreased with increasing PL from 10 to 80 μs, which suggested that the higher the intensity of SCL is, the higher the efficiency of tissue erosion is. At DC of 1:10, the position of the maximum pixel in SCL pictures was distant from the tissue-fluid interface with the increasing PL because of shielding effect. By the comparison of inertial cavitation dose (ICD) and the stable cavitation dose (SCD), the mechanisms associated with inertial cavitation are very likely to be the key factor of the erosion process.

Experience with high-intensity focused ultrasound therapy for management of organ-confined prostate cancer: critical evaluation of oncologic outcomes

OBJECTIVES

To assess the oncologic results of high-intensity focused ultrasound therapy (HIFU) as treatment for clinically localized prostate cancer.

METHODS

A total of 180 patients with clinically localized prostate cancer underwent HIFU and were retrospectively reviewed. Of those 171 patients primarily treated with HIFU were included in the analysis. They were stratified by prostatic volume, neoadjuvant hormonal ablation (NHA), and post-treatment PSA nadir. PSA level was monitored every month during the first 6 months after the treatment and every 3 months thereafter. According to the latest Phoenix criteria, biochemical failure was defined by a PSA rise of2 ng/ml or more above the PSA nadir. Seventy-six (44.4%) patients were offered preoperative NHA in median duration of 3 months (IQR: 3-5.75). Preoperative transurethral resection of the prostate (TURP) was performed in 56 (32.7%) patients having the calcification within the prostatic gland.

RESULTS

Mean patient age was 68.3 +/- 7.0. The median follow-up time was 43 months (IQR: 30-55). According to D'amico risk groups 52 (30.4%) patients were identified with low risk, 47 (27.5%) patients with intermediate risk, and 72 (42.1%) with high risk. The overall and cancer-specific survival rates at 5 years were 98.8% and 100%. The metastasis-free survival rate at 5 years was 99.4%. No significant differences were seen in biochemical failure-free survival when stratified according to preoperative prostatic volume and administration of preoperative NHA (p = 0.931 and p = 0.712, respectively). Regardless NHA administration, patients with smaller PSA nadir (0.2 ng/ml) achieved better biochemical failure-free survival ratio.

CONCLUSION

High-intensity focused ultrasound therapy provides sufficient oncologic control only in patients with low-risk prostate cancer. However, our data could be used to improve the selection of patients who are potential candidates for HIFU therapy.

[Diagnostic imaging of the prostate cancer]

Diagnosis of the prostate cancer is based on clinical, biochemical and histological examinations, as well as various imaging techniques. From the last listed group, magnetic resonance imaging (MRI) provides precise identification of focal areas and local staging of the cancer. It improves evaluation of the local extracapsular extension and involvement of regional lymph nodes, which has significant implications for a patient management. MRI, supplemented by dynamic contrast enhanced and diffusion-weighted imaging (DWI), is especially useful in detection of small focal lesions. MRI also plays an important role in the evaluation of a local recurrence and monitoring of the early and late response to treatment. Whole-body MRI should be performed in patients with a disseminated disease. In patients with an increased level of prostate specific antigen (PSA), small lesions, local recurrence and distant metastases, not detected by other imaging techniques, a positron emission tomography (PET) should be also performed. Computed tomography (CT) does not play a significant role in the diagnosis of the primary prostate cancer, however new CT scanners improve the accuracy of prostate cancer staging. Diagnostic imaging is also widely used in the screening process. Transrectal ultrasound (TRUS) examination of the organ is applied to obtain systematic core biopsies for a histological examination.

Higher second fourth digit ratio predicts higher incidence of prostate cancer in prostate biopsy

OBJECTIVES

To analyze the validity of the ratio between the second and fourth finger (digit ratio; 2D/4D) of the left hand as a predictor for prostate cancer (PCa) in a group of men undergoing prostate biopsy.

METHODS

We prospectively recruited 204 consecutive patients referred for transrectal prostate biopsy due to PSA elevation or abnormal digital rectal examination between January 2008 and June 2009. The same physician performed all clinical examinations, digit ratio measurements and transrectal biopsy in all cases. Digit ratio determination was done with a Vernier caliper in the left hand. Patients underwent determination of hormone profile (testosterone and sexual hormone binding globulin (SHBG)) between 7:00AM and 11:00AM. Age, digital rectal examination, PSA, free PSA, PSA density, testosterone and SHBG, pathological report and D2 and D4 measurements were recorded prospectively.

RESULTS

Variables age and SHBG were directly related to PCa. Prostate volume was inversely related to neoplasia. 2D/4D ratio >0,95 (OR (CI 95%) 4,4 (1,491-13,107) was related to neoplasia. No differences in PCa were seen regarding PSA, free PSA, PSA density, digital rectal examination and testosterone.

CONCLUSION

High digit ratio predicts PCa in men undergoing prostate biopsy. Digit ratio >0,95 has 4-fold risk of PCa compared to men with digit ratio ≤0.95.

[Contemporary methods of treatment in local advanced prostate cancer]

The prostate cancer is one of the most often cancers amongst males. Its frequency is increasing with age. Thanks to widespread of screening denomination of specific prostate specific antigen (PSA), ultrasonography including the one in transrectal (TRUS), computed tomography, magnetic resonance and especially the awareness of society, the number of patients with low local advance of illness is increasing. The basic method of treatment in such cases is still the surgical removal of prostate with seminal bladder or radiotherapy. To this purpose tele-(IMRT, VMAT) or brachytherapy (J125, Ir192, Pa103) is used. In patients with higher risk of progression the radiotherapy may be associated with hormonotherapy (total androgen blockage-LH-RH analog and androgen). Despite numerous clinical researches conducted there is still no selection of optimal sequence of particular methods. Moreover, no explicit effectiveness was determined. The general rule of treatment in patients suffering from prostate cancer still remains individual selection of therapeutic treatment depending on the age of a patient, general condition and especially patient's general preferences. In case of elderly patients and patients with low risk of progression, recommendation of direct observation including systematical PSA denomination, clinical transrectal examination, TRUS, MR of smaller pelvis or scintigraphy of the whole skeleton may be considered.

[Clinical observation on high intensity focused ultrasound combined with transcatheter arterial chemoembolization in the treatment of hepatocellular carcinoma]

OBJECTIVE

To study on the efficacy, prognosis and security of high-intensity focused ultrasound (HIFU) combined with transcatheter arterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC).

METHODS

Totally 72 HCC patients treated by HIFU from December 2009 to January 2011 were divided into two groups according to treatment methods: 40 cases in HIFU group, 32 cases in TACE + HIFU treatment group (combined group). Then set up a control group include 40 cases treated by only TACE in the same period (TACE group). The improvement of clinical symptoms, AFP, reduce rate of tumor volume, survival rate of 1 year after operation and postoperative complications in front and behind the treatment were analyzed.

RESULTS

There was no significant statistical difference on the improvement of clinical symptoms in all these three groups (P > 0.05) after treatment for HCC. There is no significant statistical difference also on reduce rate of tumor volume and decrease rate of AFP in both HIFU group (35.0%, 41.4%) and TACE group (37.5%, 41.9%) (χ² = 0.054, P = 0.816; χ² = 0.002, P = 0.965). Both reduce rate of tumor volume (62.5%) and decrease rate of AFP (72.0%) in combined group were better than HIFU group (χ² = 5.394, P = 0.020; χ² = 5.098, P = 0.024) and TACE group (37.5%, 41.9%) (χ² = 4.448, P = 0.035; χ² = 5.062, P = 0.024). Kaplan-Meier survival curve showed that there was no significant statistical difference on short-term survival rate in the 3 groups. But the long-term survival rate of combined group was better than TACE group and HIFU group.

CONCLUSION

TACE combined with HIFU is a effective, safe and noninvasive treatment method to HCC.

Active surveillance failure for prostate cancer: does the delay in treatment increase the risk of urinary incontinence?

INTRODUCTION

Active surveillance for low risk prostate cancer has become an acceptable management strategy. However, a percentage of these patients in active surveillance move on to active treatment. Our aim was to examine urinary incontinence (UI) rates in men who move on to treatment from active surveillance and compare it to quoted rates in the literature. We examined the question that a potential delay in the treatment of prostate cancer in those on active surveillance may result in an increase in incontinence rates.

MATERIALS AND METHODS

From July 1992 to June 2009, 443 men at our institution entered into active surveillance for newly diagnosed prostate cancer. We reviewed their medical records and data was abstracted from physician-reported medical records. The mean age of the entire group was 64.1 years old (range 40-80). Their mean prostate-specific antigen (PSA) was 7.65 (range 0.21-36) and their mean Gleason score was 6.2 (range 4-8). Of these patients on active surveillance, 150/443 (33.3%) went on to active treatment. Median time to active treatment was 31.5 months (range 3-180 months). Only 5 patients went onto active treatment less than 1 year after starting active surveillance. Of these patients who went onto active treatment, 85 had radiation alone, 48 had a radical prostatectomy (RP), 7 had a RP and radiation, 7 had HIFU alone, 2 had focal ablation and 1 had HIFU followed by salvage RP. Of those undergoing radiation (92 patients), 66 had external beam and 26 had brachytherapy.

RESULTS

Prior to active treatment 25/443 (5.6%) patients had UI documented in their history. Of those 25 patients only 3 went on to a RP and all had persistent UI after surgery. Two of the 25 patients went on to radiation therapy and their UI resolved. In the active treatment groups, after RP alone, 14/48 (29.2%) patients had new onset UI that persisted at a mean of 47.2 months (range 11-149 months) postoperatively. Of these 14 patients, 7 patients (14.6%) had significant leakage (> 1 pad/day). After radiation therapy alone 2/85(2.4%) had new onset persistent UI at 34 and 49 months post radiation. Only 1/7 (14.3%) patients that had high intensity focused ultrasound (HIFU) alone had persistent UI at 38 months after HIFU. Of the 7 patients that had both a RP and radiation, 2 had persistent significant UI at 49 and 153 months after surgery. One patient that had HIFU and a RP had persistent UI at 23 months post surgery. The 2 patients that had focal ablation were dry.

CONCLUSIONS

The UI rates in our cohort of active surveillance patients who move on to active treatment are similar to patients who undergo treatment immediately after prostate cancer is diagnosed as quoted in the literature. This suggests that active surveillance, as an initial mode of therapy, does not increase the risk of UI if active treatment occurs at a later date.

Focal therapy for clinically localized prostate cancer

The stage migration for newly diagnosed prostate cancer, improvements in prostate imaging, and devices capable of inducing subtotal prostate ablation have allowed for the formal study and evaluation of focal therapy for low-risk prostate cancer. Significant limitations remain: 1) the need for more accurate pre-treatment determination of cancer location, extent, and size, 2) determining appropriate methods of post-treatment surveillance and definitions of clinical progression, 3) the uncertainty whether repeat treatment, by focal or whole-gland therapy, is effective and safe. Clinical trials are ongoing to provide data on the feasibility and reliability of these new therapies, the capability of eradicating cancers, rates of secondary treatment, and impact on urinary and sexual function.

Infectious complications after transrectal ultrasound-guided prostatic biopsy. Analysis of our experience

OBJECTIVES

To establish the rate of infectious complications derived from the use of transrectal ultrasound-guided prostate biopsy (TRUS), identify its microbiological profile and related risk factors.

METHODS

We designed a prospective non-randomized study in which we enrolled 220 patients undergoing TRUS biopsy at our centre between April and September 2008. The inclusion criteria were: suspicious digital rectal examination, PSA >10 ng/ml, and free/total ratio of PSA is assessed in patients with PSA 4-10 ng/ml. The exclusion criteria were: having an indwelling urinary catheter, the administration of antibiotic treatment in the week before the needle biopsy, manipulation of the urinary tract in the month prior to the needle biopsy, allergy to quinolones and risk of endocarditis, failure to comply with the antibiotic prophylaxis regimen and loss to follow-up. We analyzed the relationship between diabetes, immunodepression, previous UTI or prostatitis and positive prebiopsy urine culture with the appearance of fever, dysuria or bacteriuria following needle biopsy.

RESULTS

Mean age was 69.5 years (+/-7.9), mean total PSA 12.7 ng/ml (+/-28.7), mean prostate volume 50.6 cc (+/-29.6) and mean number of cores obtained by needle biopsy 13.5 (+/-1.7). 25% of the patients had dysuria following needle biopsy, 3.2% fever and 4.5% bacteriuria. E.coli was the pathogen most frequently found in pre- and post-biopsy urine cultures. No statistically significant relationship was found between the appearance of dysuria and fever and being diabetic, having immunosuppression, previous UTI or prostatitis, prostate volume and number of cores obtained in the biopsy. Only the existence of a positive pre-biopsy urine culture and biopsy with more than 14 cores proved to have a statistically significant association with the existence of bacteriuria following biopsy, p=0.007 and p= 0.018, respectively.

CONCLUSIONS

Our rate of infectious complications was similar to that described in other series. The existence of a positive prebiopsy urine culture and obtaining more than 14 cores per biopsy was related, with statistical significance, to the existence of bacteriuria following the biopsy. E.coli was the most frequently isolated pathogen.

The value and limitations of contrast-enhanced ultrasound in detection of prostate cancer

The aim of our study was to evaluate the diagnostic value of contrast-enhanced ultrasonography (CEUS) in comparision to morphological examinations of radical prostatectomy specimens and to study factors limiting the visibility of malignant lesions.

PATIENTS AND METHODS

Fifty patients with proven prostate cancer (PV) were examined transrectally using, grey-scale, power Doppler (PD) and CEUS (pulse-inversion mode, low mechanical index) shortly before prostatectomy. The results were compared with morphological findings. The influence of tumour size, localization and grade on tumour visibility was studied.

RESULTS

A total of 72 prostate cancer foci were found at pathologic evaluation. Grey-scale imaging demonstrated 34 (47.2%), power Doppler 37 (51.4%) and CEUS 44 (61.1%) of these foci. No lesion less than 1 cm in size was detected. Statistically significant correlation was established between the visibility of of tumour in CEUS and the size of a focus (r=0.610, p=0.001). Sensitivity of CEUS in detection of peripheral gland tumours was 63.3%, of lesions invading both peripheral and central gland 83.3%, and of centrally located tumours 27.8%. In comparision, sensitivity of grey-scale imaging was 53.3%, 70.8% and 5.6%, respectively. CEUS detected 35.5% of low-grade and 80% of intermediate-grade tumours; the corresponding results of grey-scale imaging were 16.1% and 70%, respectively. Statistically significant correlation was detected (r=0.459: p=0.001) between visualization capabilities of CEUS and the malignant grade of prostate cancer.

CONCLUSION

CEUS improves prostate cancer detection. Sensitivity of CEUS is lower in cases of small low-grade tumours, centrally located lesions and large infiltrating prostate tumours.

PCA3 urinary test versus 1H-MRSI and DCEMR in the detection of prostate cancer foci in patients with biochemical alterations

AIM

To compare the prostate antigen 3 (PCA3) test with (1)H-magnetic resonance spectroscopic imaging ((1)H-MRSI) and dynamic contrast-enhanced magnetic resonance imaging (DCEMR) combined examination in the detection of prostate tumor foci in patients with persistently elevated prostate-specific antigen (PSA) levels and prior negative random transrectal ultrasound (TRUS)-guided biopsy.

PATIENTS AND METHODS

Forty-three patients with a first random biopsy negative for prostate adenocarcinoma, persistent elevated PSA and negative digital rectal examination were recruited. All the patients were submitted to MRSI examination (MRSI-DCEMR) and were submitted to an attentive prostate massage in order to perform PCA3 assay. Afterwards, 10-core laterally-directed random TRUS-guided prostate biopsy was performed.

RESULTS

The overall sensitivity and specificity of a PCA3 score ≥35 for positive biopsy were 76.9% and 66.6%, respectively, with a positive predictive value (PPV) of 80% and a negative predictive value (NPV) of 62.5%; as for MRSI sensitivity and specificity were, respectively, 92.8% and 86.6% with a PPV of 92.8% and a NPV of 86.6%. Receiver operating characteristic (ROC) analysis rates were 0.755 for PCA3 and 0.864 for MRSI.

CONCLUSION

Combined MRSI/DCEMR can better improve the cancer detection rate in patients with prior negative TRUS-guided biopsy and altered PSA serum levels than PCA3. Optimization of MRSI will allow more precise diagnosis of local invasion and improved bioptical procedures.

PSA testing and DRE, TRUS scanning with sector biopsy, improved histology, curative treatments, and active surveillance for prostate cancer: a success story for men's health

PSA, DRE, and TRUS sector biopsy have been used clinically internationally for almost two decades and have been available in New Zealand since 1993. The incidence of prostate cancer has approximately doubled. Many countries especially in Western Europe, North America and including Australia report decreases in prostate cancer mortality due to this change ranging from 10 to 39%. This has not so far occurred in New Zealand, however, and likely reasons for this are discussed. They include a negative approach encouraged by the New Zealand Guidelines Group and others, and more difficult access to investigations and treatments for New Zealand men than other countries. Technological advances in TRUS sector biopsy, histological diagnosis, and management are discussed. Changes in international prostate cancer mortality data and results from several clinical trials are also discussed. It is concluded that the weight of evidence in favour of PSA/DRE testing is now overwhelming and that potentially between 200 and 300 of the 600 men who currently die of prostate cancer in New Zealand could be saved by the application of current technology.

[Ejaculatory duct obstruction]

BACKGROUND

Prostatic cysts are rare lesions with a reported incidence from 1 to 7.9%. They have been associated with primary infertility. The main characteristic is the benign course and positive prognosis after correct surgical management.

CLINICAL CASES

We present three clinical cases, two with primary infertility and another with a history of primary infertility who presented with recurrent hemospermia and refractory medical treatment. All patients had hypospermia and alteration of the seminal parameters represented by moderate oligospermia (MOS), asteno- and teratozoospermia, in addition to hemospermia in two patients. Diagnosis was confirmed by transrectal ultrasound. Transurethral resection (TUR) of the cyst was performed in two cases and resection of the veru montanum in one, obtaining improvement in the seminal parameters after 1 month of follow-up and acceptable parameters for spontaneous conception at 6 months.

CONCLUSIONS

Infertility associated with partially obstructed ejaculatory ducts may be suspected clinically by hypospermia. Transrectal ultrasound is essential to confirm the diagnosis. TUR of this lesion reestablishes the free passage of semen in almost all patients, with potential recovery of fertility 6 months after treatment.

[Treatment of localized prostate cancer]

Treatments for localized prostate cancer include radical prostatectomy, brachytherapy, conformal external beam irradiation, and focused ultrasound. This paper describes the oncologic and functional results of each approach. The treatment choice depends on the patient's general status and on the results of biopsy and imaging studies. Watchful waiting and hormone therapy are other options for elderly patients.

[Transurethral resection of prostate just following high intensity focused ultrasound in localized prostate cancer--trial for early removal of the urethral catheter]

We studied the impact of combined transurethral resection of the prostate (TURP) and high intensity focused ultrasound (HIFU) for localized prostate cancer (CaP) to decrease side effects such as prolonged urinary voiding disturbance observed after HIFU treatment. Included in this study were 18 patients with clinically localized CaP indicated for HIFU just followed by TURP (TUR combination group). Complete response was defined in accordance with ASTRO consensus statement and negative sample in biopsies performed 6 months after the HIFU treatment. Prostate specific antigen (PSA) nadir, International Prostate Symptom Score (IPSS) and morbidity during follow-up of TUR combination group were compared with those of a control of 18 patients who took HIFU treatment alone (HIFU monotherapy group). No statistical significances on the values of preoperative parameters (PSA, prostate volume, Gleason score, and IPSS) between these two groups. The median follow-up duration was 10 (5-15) months in both groups. A statistically significant impact was observed between TUR combination group and HIFU monotherapy group on median catheter time (5 versus 13 days, P<0.0001), PSA nadir (0.096 ng/ml versus 0.430 ng/ml in median, P<0.05) and the evolution of the post-treatment IPSS (8 versus 13.5 in median, P<0.0003) at 3 months after treatment. Urethral stricture necessary for urethral dilation was noted in 1 patient (5.6%) in the TUR combination group while in 2 (11.1%) in the HIFU monotherapy group. CR was obtained in 88.9% in the TUR combination group and 83.3% in the HIFU monotherapy group. Our study suggests that the combination of TURP with HIFU treatment improves posttreatment urinary status without additional morbidity.

Significance of lateral biopsy specimens during transrectal ultrasound-guided prostate biopsies in Japanese men

OBJECTIVES

Lateral biopsies are thought to have a better cancer detection rate compared with standard sextant biopsies. This study aimed to determine whether lateral peripheral zone biopsies in Japanese men who underwent transrectal ultrasound-guided prostate biopsies provided a significantly higher cancer detection rate than sextant biopsies.

METHODS

Between 1999 and 2004, data were collected from 461 men who underwent prostate biopsy and had enough data regarding the performance of lateral biopsies for statistical analysis. There were two categories in this study: (i) patients who underwent sextant prostate biopsies; and (ii) patients who underwent sextant biopsies plus lateral biopsies.

RESULTS

Prostate cancer was detected in 141 (30.6%) of 461 patients. It was detected in 24 (22.2%) of 108 patients who underwent sextant biopsies and 117 (33.1%) of 353 patients who underwent sextant plus lateral biopsies. Lateral biopsies were not associated with a statistically higher rate of positive biopsy findings; however, we found a significantly higher ratio of patients with positive findings in those with prostate specific antigen (PSA) levels <or=10 ng/mL (10 of 40, 25%) than in those with PSA levels >10 ng/mL (one of 71, 1.4%) among those who had positive cores only in lateral biopsy samples (P < 0.0001).

CONCLUSIONS

Lateral biopsies did not show a significantly higher detection ratio of prostate cancer compared to sextant biopsies. However, lateral biopsies were more effective than sextant biopsies in patients with lower PSA levels. Our findings might be useful for the establishment of biopsy strategies to detect prostate cancer, especially in patients with lower PSA levels.

[Could the transrectal prostate biopsy predict the rate of positive lymph nodes in prostate cancer patients?]

Since 1989, when Hodge and al. demonstrated transrectal ultrasound guided prostate biopsy, it has become a "gold standard" for the diagnosis of prostate cancer. According to the experience gained in the period 1999-2003 in the Department of Urology-Medical University, Sofia, in a prospective follow-up of 20 prostate cancer patients, we found relationship between the positive tru-cut biopsy cores and the rate of positive lymph nodes.

[Transrectal high-intensity focused ultrasound with the Sonablate 500 for the treatment of prostate cancer]

OBJECTIVE

To evaluate the clinical effect of transrectal high-intensity focused ultrasound (HIFU) in the treatment of prostate cancer (PCa).

METHODS

A total of 57 PCa patients, 27 localized and 30 advanced, underwent transrectal HIFU with the Sonab- late 500, the localized group treated by transrectal HIFU only, while the advanced group by transrectal HIFU combined with androgen ablation.

RESULTS

For the HIFU treatment, the mean operating time, hospital stay and follow-up were 111 mm (ranging from 86 to 153 mm), 3.2 days (ranging from 2 to 18 days) and 18 months (ranging from 6 to 30 months), respectively. The biochemical disease-free rates at 1, 2 and 3 years in the localized group were 86%, 81% and 79%, respectively. While in the advanced group, the serum prostate specific antigen (PSA) was < 4.0 microg/L in 26 cases ( < 0.51 microg/L in 20) and the prostate volume decreased more than 50% in 21 cases after treated for an average of 8 months (ranging from 3 to 24 months). After transrectal HIFU prostate ablation, the prostate volume reduced, serum PSA lowered, Qmax raised and IPSS improved significantly (P < 0.05). No serious complications occurred including severe urethrorectal fistula and incontinence.

CONCLUSION

Transrectal HIFU is a safe, effective and minimally invasive therapy for patients with prostate cancer.

Clinical and radiological evaluation of ejaculatory duct obstruction

Ejaculatory duct obstruction (EDO) is a rare but surgically correctable cause of male infertility. With the advent and increased use of transrectal ultrasonography and magnetic resonance imaging, abnormalities of the ejaculatory duct (ED) related to infertility have been diagnosed more frequently. Recently, with the increased awareness of functional obstruction of ED, reports have been focusing on the diagnosis of partial or functional EDO. We present 2 review of the ED pathologies, imaging modalities and treatment options.

Influence of perfusion on high-intensity focused ultrasound prostate ablation: a first-pass MRI study

Our aim was to evaluate the influence of regional prostate blood flow (rPBF) on high-intensity focused ultrasound (HIFU) treatment outcome. A total of 48 patients with clinically localized prostate cancer were examined by dynamic contrast-enhanced (DCE)-MRI prior to HIFU therapy. A prostate-specific antigen (PSA) nadir threshold of 0.2 ng/ml was used to define the populations of responders and nonresponders. A dedicated tracer kinetic model, namely "monoexponential plus constant" (MPC) deconvolution, was implemented to provide quantitative estimates of rPBF. The results were compared with those obtained by semiquantitative (steepest slope, mean gradient) and quantitative (Fermi deconvolution) approaches. Of the four methods studied, quantitative rPBF obtained by MPC deconvolution proved the most sensitive to the perfusion changes encountered in this study. Furthermore, blood-flow values obtained with MPC deconvolution in the prostate and muscle (12 +/- 8 and 5 +/- 3 ml/min/100 g, respectively) were in good agreement with literature data. The mean pretreatment rPBF obtained with MPC deconvolution was significantly higher in nonresponders compared to responders (16 +/- 9 vs. 10 +/- 6 ml/min/100 g), suggesting a correlation between baseline perfusion and treatment outcome. The present work describes and validates the use of dynamic MRI to estimate rPBF in patients, which in the future may help to refine the conduct of HIFU therapy.

Transrectal high-intensity focused ultrasound ablation of prostate cancer: Effective treatment requiring accurate imaging

Transrectal HIFU ablation has become a reasonable option for the treatment of localized prostate cancer in non-surgical patients, with 5-year disease-free survival similar to that of radiation therapy. It is also a promising salvage therapy of local recurrence after radiation therapy. These favourable results are partly due to recent improvements in prostate cancer imaging. However, further improvements are needed in patient selection, pre-operative localization of the tumor foci, assessment of the volume treated and early detection of recurrence. A better knowledge of the factors influencing the HIFU-induced tissue destruction and a better pre-operative assessment of them by imaging techniques should improve treatment outcome. Whereas prostate HIFU ablation is currently performed under transrectal ultrasound guidance, MR guidance with real-time operative monitoring of temperature will be available in the near future. If this technique will give better targeting and more uniform tissue destruction, its cost-effectiveness will have to be carefully evaluated. Finally, a recently reported synergistic effect between HIFU ablation and chemotherapy opens possibilities for treatment in high-risk or clinically advanced tumors.

Influence of the docetaxel administration period (neoadjuvant or concomitant) in relation to HIFU treatment on the growth of Dunning tumors: results of a preliminary study

The objective of this study was to evaluate mechanisms of the synergy between high intensity-focused ultrasound (HIFU) and docetaxel and to determine the best sequence of chemotherapy administration in relation to HIFU treatment for obtaining optimum control of tumoral growth. A total of 15 days after s.c. implantation of the tumor, 52 Copenhagen rats studied were randomized in 4 groups of 13: controls, docetaxel alone (group 1), HIFU and docetaxel concomitant (group 2) and HIFU and docetaxel administered 24 h before treatment (group 3). The number of HIFU shots was calculated in order to cover 75% of the tumor volume. The effects of docetaxel, HIFU and their interaction on tumor volumes were analyzed using a linear regression. The distributions of the tumor volumes were significantly greater in the control group than in the group 1 (P=0.002) and than in both groups 2 and 3 (P < 0.0001 and P = 0.0001). These volumes were also significantly greater in group 1 than in both groups 2 and 3 and there was no difference between the groups 2 and 3. The tumor doubling times were 7.8 days for the group 1, 43.8 days for the group 2, 16.1 days for the group 3 and 5.9 days for the controls. The mechanism of the synergy between HIFU and docetaxel on the growth of Dunning tumors is apparently multifaceted. The results are encouraging because in the two groups of rats treated with the combination of HIFU and docetaxel, the percentage of complete remission was approximately 30%.

Comparison of two different artificial neural networks for prostate biopsy indication in two different patient populations

OBJECTIVES

Different artificial neural networks (ANNs) using total prostate-specific antigen (PSA) and percentage of free PSA (%fPSA) have been introduced to enhance the specificity of prostate cancer detection. The applicability of independently trained ANN and logistic regression (LR) models to different populations regarding the composition (screening versus referred) and different PSA assays has not yet been tested.

METHODS

Two ANN and LR models using PSA (range 4 to 10 ng/mL), %fPSA, prostate volume, digital rectal examination findings, and patient age were tested. A multilayer perceptron network (MLP) was trained on 656 screening participants (Prostatus PSA assay) and another ANN (Immulite-based ANN [iANN]) was constructed on 606 multicentric urologically referred men. These and other assay-adapted ANN models, including one new iANN-based ANN, were used.

RESULTS

The areas under the curve for the iANN (0.736) and MLP (0.745) were equal but showed no differences to %fPSA (0.725) in the Finnish group. Only the new iANN-based ANN reached a significant larger area under the curve (0.77). At 95% sensitivity, the specificities of MLP (33%) and the new iANN-based ANN (34%) were significantly better than the iANN (23%) and %fPSA (19%). Reverse methodology using the MLP model on the referred patients revealed, in contrast, a significant improvement in the areas under the curve for iANN and MLP (each 0.83) compared with %fPSA (0.70). At 90% and 95% sensitivity, the specificities of all LR and ANN models were significantly greater than those for %fPSA.

CONCLUSIONS

The ANNs based on different PSA assays and populations were mostly comparable, but the clearly different patient composition also allowed with assay adaptation no unbiased ANN application to the other cohort. Thus, the use of ANNs in other populations than originally built is possible, but has limitations.