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

Oncological and functional outcome after partial prostate HIFU ablation with Focal-One®: a prospective single-center study

BACKGROUND

We aimed to evaluate oncological and functional outcomes of index lesion HIFU ablation with Focal-One^®.

MATERIALS AND METHODS

We prospectively assessed treatment-naïve men with localized prostate cancer between 2017 and 2019. Inclusion criteria were stage cT ≤ 2, ≥5 years of life expectancy, grade group ≤3. Multiparametric magnetic resonance was performed before ablation. Patients with a prostate volume of ≥80 ml underwent debulking. Treatment failure was defined as a histologically confirmed tumor that required salvage treatment or androgen deprivation therapy.

RESULTS

One hundred and eighty nine patients were enrolled. Data are presented as median and Interquartile Range (IQR). Median age was 70(11) years. Median baseline PSA was 5.8(3) ng/ml. Fourteen (7.4%) patients had prostate debulking before ablation. 104 (55%) patients underwent targeted ablation, 45 (23.8%) extended targeted ablation, 31 (16.4%) hemiablation, and 9 (4.8%) extended hemiablation. Median targeted ablated volume was 14(9) ml. Ninety-three complications occurred in 63/189 (33.3%) patients within 90 days. There were 77/93 (82.8%) minor (Clavien grade 1-2) and 16/93 (17.2%) major complications (Clavien grade 3a). Thirty-nine patients suffered from genito-urinary infections (Clavien grade 2). Fifteen patients required transurethral resection of the prostate/urethrotomy for recurrent urinary retention (Clavien grade 3a). One patient developed a recto-urethral fistula (Clavien grade 3a) and two long-lasting urinary incontinence. Median PSA nadir was 2.2(2.9) ng/ml. At a median follow-up of 29(15) months, 21/177 (11.9%) patients were treatment failures, 26 on monitoring, and 26 had a further ablation. Multivariable logistic regression found that failure patients had higher PSA (7.8 vs 5.7 ng/ml,p0.001) and double PSA nadir (4.8 vs 2.0 ng/ml, p < 0.001). Higher PSA nadir correlated with a 74% higher probability of failure (OR 1.74 95% CI 1.40-2.16). Cancer in the anterior stroma increased the odds of failure of three folds (OR 3.36 95% CI 1.18-9.53). Two mixed effect models (one for IPSS and one for IEEF-15) were estimated and they showed that time reaches the statistical significance coefficient only for the IEEF-15, meaning that subsequent evaluations of the indicators were significantly lower at each time point.

CONCLUSIONS

Index lesion HIFU ablation demonstrated satisfactory early oncological outcome but anteriorly located tumors had inadequate ablation. Urinary function was well preserved. Sexual function slightly decreased during follow-up.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Review article: MRI-targeted biopsies for prostate cancer diagnosis and management

PURPOSE

Transrectal ultrasound (TRUS)-guided biopsy has been the traditional biopsy route in the detection of prostate cancer. However, due to concern regarding overdetection of low-risk cancer and missed clinically significant cancers as well as risk of sepsis, alternative approaches have been explored. Transperineal template biopsy-sampling the gland every 5 m to 10 mm-reduces error by sampling the whole prostate but increases risk of detecting clinically insignificant cancers as well as conferring risks of side effects such as urinary retention and bleeding.

METHODS

There are various targeted biopsy techniques, each with different cancer detection rates, costs and learning curves. Current research focuses on refining biopsy methodology to maximize detection of significant cancers, whilst minimising invasiveness and complications. In this article, the up-to-date research data about MRI-targeted prostate biopsy were reviewed to show its utilization in prostate cancer management and diagnosis.

RESULTS AND CONCLUSION

Prostate multiparametric MRI has become an effective tool in the detection of significant cancers and an essential component of the prostate cancer diagnostic pathway incorporating MRI-guided biopsy decisions.

Expanding indication of padeliporfin (WST11) vascular-targeted photodynamic therapy: results of prostate cancer Latin-American multicenter study

OBJECTIVES

To explore the proportion of patients with higher risk localized prostate cancer (PCa) that would become safely biopsy negative 12 months after non-thermal focal therapy with padeliporfin vascular-targeted photodynamic therapy (VTP).

METHODS

Multicenter study in a scenario of prostate-specific antigen (PSA) ≤20ng/ml and variable PCa target volumes Gleason pattern 3 or low-volume secondary Gleason pattern 4, all patients received VTP, consisting of intravenous 4mg/kg padeliporfin activated by light-diffusing fibers in the prostate. The prostate was biopsied at baseline, months 6 and 12, PSA, patient-reported functional outcomes and quality of life (QoL) questionnaires were recorded at baseline, months 3, 6, and 12 and adverse events (AE) throughout the study.

RESULTS

In the intention-to-treat population (n=81), the proportion of patients with negative biopsies at month 12 was 74% (60/81 patients; 95% CI: 63.1%,83.2%). In the per-protocol population, the proportion was 79% (58/73 patients; 95% CI: 68.4%,88.0%). Questionnaire results indicated a slight improvement in urinary function and limited deterioration in sexual function. No difference in QoL was observed over time. A total of 42/81 (52%) patients reported mild or moderate and 4 of 81 (4.9%) experienced serious AE, all resolved without sequelae. No phototoxicity, cardiovascular event, fistula or prolonged urinary incontinence, secondary cancer or death was reported.

CONCLUSIONS

Results support the efficacy, safety, and QoL associated with padeliporfin focal treatment for low/intermediate risk localized PCa.

Focal Treatment for Unilateral Prostate Cancer Using High-Intensity Focal Ultrasound: A Comprehensive Study of Pooled Data

BACKGROUND

Focal therapy for prostate cancer (PCa) remains experimental. Aim of the current study is to review available evidence and perform a pooled analysis exploring oncologic and functional results of high intensity focus ultrasound (HIFU) focal therapy for the treatment of unilateral PCa.

METHODS

The National Library of Medicine Database was searched for relevant articles. A wide search was performed, including the combination of following words: "HIFU," "prostate," "cancer," and "focal." Overall, 167 articles were reviewed. Of these, seven articles were identified and eligible for the pooled analysis. Data on HIFU hemiablation or focal prostate ablation, oncologic and functional results were pooled from these seven studies that included 366 men with unilateral PCa.

RESULTS

In the 366 analyzed cases, mean age was 67 years (95% confidence interval 66-69), and mean preoperative prostate-specific antigen was 6.4 ng/cc (5.5-7.4). Three studies included PCa up to Gleason 7 (3 + 4), three studies did include also Gleason 7 (4 + 3), whereas one study had no limitation in terms of Gleason score. Regarding early complications, low-grade Clavien-Dindo I-II were reported in 26% (16-37), whereas high-grade Clavien-Dindo ≥III were found in 3.8% (0-8.6). Analyzing oncologic outcomes mean follow-up was 26 months (23-31): at one year after HIFU, negative biopsy rate for clinically significant PCa was 87% (79-96), whereas salvage treatment-free survival rate was 92% (85-98). Regarding functional outcomes, reported potency rates were 74% (64-84), and continence 96% (91-100), although definitions of potency and continence were not homogenous across studies.

CONCLUSIONS

This pooled analysis of the results of focal HIFU treatment of PCa shows promising oncologic and functional outcomes. Well-selected patients may be candidates for such a conservative partial treatment of the gland. Well-designed trials are awaited to compare HIFU focal treatment with current standard of care.

High-intensity focused ultrasound therapy for the treatment of prostate cancer: Medium-term experience

INTRODUCTION

The treatment of localised prostate cancer seeks to minimise the impact on sexual function and urinary continence. In this respect, therapy with high-intensity focused ultrasound offers important results. We present our experience with this technique in 2 Spanish centres.

MATERIAL AND METHODS

We conducted a retrospective review of 75 patients with localised prostate cancer treated with high-intensity focused ultrasound between March 2007 and July 2016. The oncological results and perioperative complications were assessed, as well as the impact on sexual function and continence.

RESULTS

A total of 67 patients were analysed. The mean follow-up was 7.2 years. The PSA nadir was 0.2ng/mL (0-3), 24 patients (35.5%) presented biochemical recurrence, and 18 underwent a further biopsy, with 10 cases (55.5%) presenting disease recurrence. The overall biochemical relapse-free survival at 5 and 8 years was 93.2 and 80.5%, respectively. The cancer-specific survival at 5 and 8 years was 96% in both cases. In the postoperative period, 50 patients (74.6%) were continent, 16 (23.9%) reported mild incontinence, and one (1.5%) reported moderate incontinence. The median International Index of Erectile Function-5 before and after the surgery was 17 (5-25) and 16 (2-23) points, respectively. Nine patients reported de novo erectile dysfunction (13.5%).

CONCLUSION

High-intensity focused ultrasound appears to be a safe alternative for the treatment of localised prostate cancer, especially for low-risk localised prostate cancer. In our experience, this technique offers advantages in preserving urinary continence, and the medium-term oncological results are encouraging. Given the natural progression of prostate cancer, long-term studies with a larger number of cases are needed to corroborate these results.

Prostate cancer treatment by the latest focal HIFU device with MRI/TRUS-fusion control biopsies: A prospective evaluation

OBJECTIVES

Magnetic resonance imaging/transrectal ultrasound (MRI/TRUS) fusion-guided focal high intensity focused ultrasound (HIFU) therapy of the prostate has recently been developed as a selective HIFU-therapy technique to enable targeted ablation of prostate cancer. Here we report a series of patients treated with focal HIFU therapy, discuss its potential pitfalls, and address controversies concerning the indications.

MATERIALS AND METHODS

This single-center prospective study reports outcomes of patients treated from September 2014 to March 2016. Follow-up was a minimum of 12 months. MRI/TRUS-fusion-guided HIFU was performed under general anesthesia using the Focal One® device (EDAP, France). A control biopsy at 12 months was taken using the MRI/TRUS-fusion biopsy platform Artemis™ (Eigen, California) combining targeted and systematic cores. Prostate-specific antigen (PSA) changes from baseline, patient-reported outcome measures, and complications using the Clavien-Dindo classification system are also reported.

RESULTS

Twenty-four patients (PSA < 10 ng/ml, n = 17 Gleason 3+3, n = 7 Gleason 3+4) with either unifocal or bifocal prostate imaging reporting and data system (PI-RADS) 3-5 lesions (n = 19) or without a PI-RADS lesion (n = 5) were treated. Nineteen patients underwent focal HIFU, five patients zonal HIFU. Of the 20 patients that had biopsies at 12 months, 8 patients had a positive biopsy within the ablation zone (overall cancer free rate: 60%). Using different definitions of clinically significant cancer, the cancer-free rate for the ablation zone varies between 75% and 95%. Four of the eight patients (all persistent Gleason 3+4 or upgrading to 4+3) underwent a radical whole gland salvage therapy. Patient-reported outcome measures showed no significant decrease in urinary continence (expanded prostate cancer index composite -26 urinary incontinence: P = 0.080), but there was a reduction in potency (International index of erectile function in preoperatively potent patients: median decrease of 2 points to a median of 19 points at 12 months; 95% confidence interval: 15.79-22.21; P = 0.044). Only one complication > grade II occurred.

CONCLUSIONS

Targeted MRI/TRUS fusion-guided focal HIFU allows local tumor ablation, but is not free from limitations. The procedure has good functional outcomes and a quick recovery. Multicenter trials with more patients are required to determine the procedure´s role in the prostate cancer therapy algorithm.

Focal Therapy for Prostate Cancer: Pending Questions

Focal therapy (FT) represents a potential shift in clinical practice by featuring a tissue-sparing approach for prostate cancer (PCa) treatment. It stands midway between active surveillance (AS) and more aggressive options like radical prostatectomy (RP) or radiotherapy. The field has enormously evolved in the last few years but there are still pending questions to answer in the future. The manuscript overlooks FT in terms of indications, available energies, situation of tumor microenvironment, follow-up, re-interventions, and the future of this approach for PCa.