Medium-term Oncological Efficacy and Patient-reported Outcomes After Focal High-intensity Focused Ultrasound: The FOXPRO Trial

Outcomes of Focal Therapy for Localized Prostate Cancer: A Systematic Review and Meta-analysis of Prospective Studies

BACKGROUND AND OBJECTIVE

Focal therapies (FTs) for localized prostate cancer (PCa) are recommended only within prospective registries or clinical trials. In this systematic review and meta-analysis, we aimed to synthesize data from prospective trials evaluating the efficacy and safety of FTs in patients with clinically localized PCa.

METHODS

Systematic searches of the PubMed, Scopus, and Web of Science databases identified prospective studies reporting oncological outcomes of FTs in treatment-naïve, clinically localized PCa patients. The primary endpoint was biopsy-proven clinically significant PCa (csPCa; International Society of Urological Pathology grade group ≥2) recurrence-free survival (csPCa RFS). The secondary endpoints included RFS, radical/systemic treatment-free survival, and adverse event (AE) rates.

KEY FINDINGS AND LIMITATIONS

Fifty studies including 4615 patients treated with FTs were analyzed; of these 50 studies, 19 were on predominantly intermediate-risk (n = 2800), 16 on mixed low-/intermediate-risk (n = 990), and 15 on low-risk (n = 825) patients. Estimates of 12- and 24-mo csPCa RFS rates were 86% (95% confidence interval [CI] 82-89%) and 81% (95% CI: 74-86%), respectively. In the intermediate-risk subgroup, the 12-mo csPCa RFS rate was 79% (95% CI: 74-83%). Five-year radical and systemic treatment-free survival was 82% (95% CI: 75-88%). The pooled incidence of grade ≥3 AEs was 3% (95% CI: 2-5%). Pad-requiring urinary incontinence increased by 3% (95% CI: 0-6%), with 11% of patients developing new erectile dysfunction (95% CI: 4-18%). The median follow-up of 21 mo (interquartile range 12-34) and the use of surrogate endpoints constitute the major limitations.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The primarily short-term data from prospective studies of FT in clinically localized PCa demonstrate moderate to high cancer control with a favorable safety profile.

Focal therapy using high-intensity focused ultrasound with intraoperative prostate compression for patients with localized prostate cancer: a multi-center prospective study with 7 year experience

BACKGROUND

To evaluate clinical outcomes of focal therapy using high-intensity focused ultrasound (HIFU) with intraoperative prostate compression for patients with localized prostate cancer (PC).

METHODS

Patients were included if they had prostate specific antigen levels of ≤20 ng/mL and clinically significant PC (CSPC) within the left or right half, or upper or lower half of the prostate. CSPC was detected using magnetic resonance imaging-transrectal ultrasound fusion image-guided target biopsy and a 12-core systematic biopsy. Focal therapy using HIFU with intraoperative prostate compression was administered to lesions visible on the magnetic resonance imaging. Biochemical failure was defined by the Phoenix ASTRO definition. Pathological failure was defined as having CSPC in the biopsy at the time of biochemical failure.

RESULTS

The patients (n = 240; median age, 69 years old; median prostate specific antigen level, 6.42 ng/mL) were divided according to the D'Amico risk classification into: 'low' (n = 51), 'intermediate' (n = 107), and 'high' (n = 82) groups. The biochemical and the pathological disease-free survival rates after a single treatment for the low-, intermediate-, and high-risk groups were 93.7% and 92.2%, 88.5% and 91.6%, and 84.8% and 86.6%, respectively. The radical or systematic treatment-free survival rates were 96.1%, 94.4%, and 95.1%, respectively. Median follow-up period was 48 months (range 24-84). The urinary and sexual function at 1 month post-treatment had deteriorated but returned to preoperative levels at 3 or 6 months after treatment.

CONCLUSIONS

Focal therapy using HIFU with intraoperative prostate compression would improve medium-term oncological outcomes without the risk of functional deterioration.

Proceedings from an international consensus meeting on ablation in urogenital diseases

Percutaneous image-guided ablation techniques are a consolidated therapeutic alternative for patients with high preoperative surgical risk for the management of oncological diseases in multiple body districts. Each technique has both pros and cons according to the type of energy delivered, mechanism of action, and site of application. The present article reviews the most recent literature results on ablation techniques applied in the field of genitourinary diseases (kidney, adrenal glands, prostate, and uterus), describing the advantages of the use of each technique and their technical limitations and summarizing the major recommendations from an international consensus meeting. CRITICAL RELEVANT STATEMENT: The article critically evaluates the efficacy and safety of ablation therapies for various genitourinary tract diseases, demonstrating their potential to improve patient outcomes and advance clinical radiology by offering minimally invasive, effective alternatives to traditional surgical treatments. KEY POINTS: Ablation therapies are effective alternatives to surgery for renal cell carcinoma. Ablation techniques offer effective treatment for intermediate-risk prostate cancer. Ablation is a promising tool for adrenal tumor management. Ablation reduces fibroid symptoms and volume, offering an alternative to surgery.

Established focal therapy-HIFU, IRE, or cryotherapy-where are we now?-a systematic review and meta-analysis

INTRODUCTION

Focal Therapy (FT) is a treatment option for the treatment of limited volume clinically significant prostate cancer (csPCa). We aim to systematically review outcomes of established FT modalities to assess the contemporary baseline and identify gaps in evidence that will aid in further trial and study design.

METHODS

We conducted a systematic review and meta-analysis of all primary studies reporting outcomes of FT using cryotherapy, high-intensity focused ultrasound (HIFU), and irreversible electroporation (IRE). We described patient inclusion criteria, selection tools, treatment parameters, and surveillance protocols, and pooled overall survival (OS), cancer-specific survival (CSS), metastasis-free survival (MFS), biochemical progression (BP), biopsy, secondary treatment, sexual, and urinary function outcomes. Composite failure was defined as salvage whole gland ablation, radical treatment, hormonal therapy or transition to watchful waiting.

SYNTHESIS

We identified 49 unique cohorts of men undergoing FT between 2008 and 2024 (21 cryotherapy, 20 HIFU, and 8 IRE). Median follow-up ranged from 6 to 63 months. Pooled OS was 98.0%, CSS 99.3%, and MFS 98.5%. Pooled BP was 9.4%/year. Biopsy was mandated post-FT within 24 months in 36/49 (73.5%) cohorts, with pooled csPCa (GG ≥ 2) rates of 22.2% overall, 8.9% infield, and 12.3% outfield. The pooled rate of secondary FT was 5.0%, radical treatment 10.5%, and composite failure 14.1%. Of 35 studies reporting sexual function, 45.7% reported a low, 48.6% moderate, and 5.7% severe impact. For 34 cohorts reporting urinary function, 97.1% reported a low impact. No differences were noted between cryotherapy, HIFU, or IRE in any of the outcomes.

CONCLUSION

FT with cryotherapy, HIFU, and IRE is associated with good short-intermediate term oncological and functional outcomes. However, outcome reporting is heterogeneous and often incomplete. Long-term follow-up and standardized reporting are required to better define and report FT outcomes.

Focal therapy with high-intensity focused ultrasound for prostate cancer: 3-year outcomes from a prospective trial

OBJECTIVE

To assess the oncological and functional outcomes of focal high-intensity focused ultrasound (HIFU) in treating localised prostate cancer (PCa), a 3-year prospective study was undertaken using periodic post-ablation saturation biopsies.

PATIENTS AND METHODS

Men with two or fewer lesions of grade group (GG) ≤3 PCa were eligible for participation. Additional criteria included a prostate-specific antigen (PSA) level of ≤15 ng/mL, clinical T1c-T2, and a life expectancy of ≥10 years. The primary endpoint was failure-free survival (FFS), defined as absence of clinically significant PCa (csPCa) in- or out-of-field on protocol-mandated saturation biopsy, no whole-gland or systemic salvage treatment, PCa metastasis, or PCa-related death. Results are reported using two distinct definitions of csPCa: (i) the presence of any GG ≥2 and (ii) any GG ≥3 or core involvement of ≥6 mm. Secondary endpoints were functional patient-reported outcome measures addressing urinary, sexual, and bowel function.

RESULTS

A total of 91 patients were included: six (7%) with GG1 and 85 (93%) with GG ≥2. In all, 83 (91%) underwent at least one follow-up biopsy. Biopsy attendance at 6, 12, and 36 months was 84%, 67%, and 51%, respectively. The FFS at these time points for any GG ≥2 PCa was 79% (95% confidence interval [CI] 80-88%), 57% (95% CI 48-69%) and 44% (95% CI 34-56%), respectively. Using the second definition, FFS were 88% (95% CI 81-95%), 70% (95% CI 61-81%) and 65% (95% CI 55-77%), respectively. The 3-year cancer-specific survival was 100%, and freedom from metastasis was 99%. Magnetic resonance imaging (MRI) (negative predictive value of up to 89%, 95% CI 84-93%) and relative decrease of PSA values (P = 0.4) performed poorly in detecting residual disease. Urinary and bowel assessment returned to baseline questionnaire scores within 3 months. In all, 17 (21%) patients reported meaningful worsening in erectile function. A significant decrease of PCa related anxiety was observed.

CONCLUSIONS

Focal HIFU treatment for localised PCa shows excellent functional outcomes with half of the patients remaining cancer-free after 3 years. Whole-gland treatment was avoided in 81%. Early follow-up biopsies are crucial to change or continue the treatment modality at the right time, while the use of MRI and PSA in detecting PCa recurrence is uncertain.

Follow-up of vascular-targeted photodynamic therapy in a real-world setting

PURPOSE

Vascular-targeted photodynamic therapy (VTP) is an approved treatment option for unilateral low-risk prostate cancer (PCa).

METHODS

Patients with unilateral low- or intermediate-risk PCa undergoing hemiablation by VTP were evaluated in a real-world setting. Oncological outcome after VTP was measured by MRI-based re-biopsy at 12 and 24 months. Functional outcome after 1 year was investigated by IIEF-5 and IPSS questionnaires. Progression was defined as the evidence3 of ISUP ≥ 2 PCa.

RESULTS

At any control biopsy (n = 46) after VTP, only 37% of patients showed no evidence of PCa. Recurrence-free survival was 20 months (95% CI 4.9-45.5) and progression-free survival was 38.5 months (95% CI 33.5-43.6 months). In-field and out-field recurrent PCa occurs in 37% (55% ISUP ≥ 2 PCa) and 35% (56% ISUP ≥ 2 PCa). Seventy-nine percent of patients preserved erectile function, respectively. Ten percent of patients presented long-term bladder outlet obstruction. None of the patients presented incontinence.

CONCLUSION

Due to the high-recurrence in- and out-field recurrence rate in a mainly low-risk prostate cancer cohort, VTP has to be regarded critically as a therapy option in these patients. Pre-interventional diagnostic evaluation is the main issue before focal therapy to reduce the risk of tumor recurrence and progression.

[Oncological and functional results of focal treatment of localized prostate cancer with HIFU]

INTRODUCTION

In recent years, improved diagnosis of prostate cancer has allowed the development of focal therapy, in order to reduce the morbidity of treatments. Our study assesses the medium-term oncological and functional results of FocalOne® HIFU treatment in localized prostate cancer.

METHODS

This is a retrospective, multicentre study including patients with low- or intermediate-risk localized prostate cancer treated with Focal one HIFU between November 2014 and December 2019. The primary endpoint was the retreatment rate and subgroup analyses were performed to identify predictive factors of retreatment.

RESULTS

One hundred and thirty-seven patients were included with a median follow-up of 25.5 months. Seventy percent of patients had clinical stage T2, 64% had an ISUP score of 2 or 3 on initial biopsies and 38% were treated with hemi-ablation. Follow-up biopsies were performed in 76.6% of patients during follow-up with 21.8% having clinically significant cancers. The retreatment rate at 24 months was 37.2%, with positive biopsies being the primary criterion for retreatment. Patients with a PSA>8ng/mL had a significantly higher retreatment rate. Finally, morbidity remained acceptable with 5.8% of patients requiring reoperation for complications and 21% for de novo erectile dysfunction.

CONCLUSION

Our results are in agreement with those of the literature, seeming to indicate a lower morbidity of the focal treatment by HIFU compared to the radical treatments while offering an acceptable oncological control. Prospective randomized trials are ongoing.

LEVEL OF EVIDENCE: 4

A Novel Nomogram to Identify Candidates for Focal Therapy Among Patients with Localized Prostate Cancer Diagnosed via Magnetic Resonance Imaging-Targeted and Systematic Biopsies: A European Multicenter Study

BACKGROUND

Suitable selection criteria for focal therapy (FT) are crucial to achieve success in localized prostate cancer (PCa).

OBJECTIVE

To develop a multivariable model that better delineates eligibility for FT and reduces undertreatment by predicting unfavorable disease at radical prostatectomy (RP).

DESIGN, SETTING, AND PARTICIPANTS

Data were retrospectively collected from a prospective European multicenter cohort of 767 patients who underwent magnetic resonance imaging (MRI)-targeted and systematic biopsies followed by RP in eight referral centers between 2016 and 2021. The Imperial College of London eligibility criteria for FT were applied: (1) unifocal MRI lesion with Prostate Imaging-Reporting and Data System score of 3-5; (2) prostate-specific antigen (PSA) ≤20 ng/ml; (3) cT2-3a stage on MRI; and (4) International Society of Urological Pathology grade group (GG) 1 and ≥6 mm or GG 2-3. A total of 334 patients were included in the final analysis.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was unfavorable disease at RP, defined as GG ≥4, and/or lymph node invasion, and/or seminal vesicle invasion, and/or contralateral clinically significant PCa. Logistic regression was used to assess predictors of unfavorable disease. The performance of the models including clinical, MRI, and biopsy information was evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis. A coefficient-based nomogram was developed and internally validated.

RESULTS AND LIMITATIONS

Overall, 43 patients (13%) had unfavorable disease on RP pathology. The model including PSA, clinical stage on digital rectal examination, and maximum lesion diameter on MRI had an AUC of 73% on internal validation and formed the basis of the nomogram. Addition of other MRI or biopsy information did not significantly improve the model performance. Using a cutoff of 25%, the proportion of patients eligible for FT was 89% at the cost of missing 30 patients (10%) with unfavorable disease. External validation is required before the nomogram can be used in clinical practice.

CONCLUSIONS

We report the first nomogram that improves selection criteria for FT and limits the risk of undertreatment.

PATIENT SUMMARY

We conducted a study to develop a better way of selecting patients for focal therapy for localized prostate cancer. A novel predictive tool was developed using the prostate-specific antigen (PSA) level measured before biopsy, tumor stage assessed via digital rectal examination, and lesion size on magnetic resonance imaging (MRI) scans. This tool improves the prediction of unfavorable disease and may reduce the risk of undertreatment of localized prostate cancer when using focal therapy.

Current status and future outlook of ultrasound treatment for prostate cancer

Radical prostatectomy and radiation therapy are the standard treatment options for localized prostate cancer (PC). However, radical prostatectomy may cause the deterioration of urinary and sexual function, and radiation-induced hemorrhagic cystitis and severe rectal bleeding are risk factors for fatal conditions in patients after radiation therapy. With the recent development of magnetic resonance imaging (MRI) for the localization of clinically significant PC (csPC) and treatment modalities, "focal therapy", which cures csPC while preserving anatomical structures related to urinary and sexual functions, has become a minimally invasive treatment for localized PC. Based on the clinical results of transrectal high-intensity focused ultrasound (HIFU) for localized PC in the whole gland and focal therapy, HIFU is considered an attractive treatment option for focal therapy. Recently, the short-term clinical results of transurethral high-intensity directional ultrasound (HIDU) have been reported. With the resolution of some issues, HIDU may be commonly used for PC treatment similar to HIFU. Because HIFU and HIDU have limitations regarding the treatment of patients with large prostate calcifications and large prostate volumes, the proper use of these modalities will enable the treatment of any target area in the prostate. To establish a standard treatment strategy for localized PC, pair-matched and historically controlled studies are required to verify the oncological and functional outcomes of ultrasound treatment for patients with localized PC.

Role of Perilesional Sampling of Patients Undergoing Fusion Prostate Biopsies

Recently, researchers have proposed perilesional sampling during prostate biopsies to avoid systematic biopsies of patients at risk of prostate cancer. The aim of our study is to evaluate the role of perilesional sampling to avoid systematic biopsies of patients undergoing fusion biopsies. A prospective cohort of patients undergoing transrectal MRI transrectal fusion biopsies were consecutively enrolled. All the patients underwent systematic biopsies (SB), targeted biopsies (TB) and perilesional biopsies within 10 mm from the lesion (PB). The detection rates of different strategies were determined. A total of 262 patients were enrolled. The median age of those enrolled was 70 years. The mean BMI was 27 kg/m2, and the mean and prostate volume was 52 mL. A PIRADS score ≥ 4 was recorded in 163/262 (40%) patients. Overall, the detection rates of cancer were 43.5% (114/262) and 35% (92/262) for csPCa. The use of the target + peri-target strategy resulted in a detection of 32.8% (86/262) of cancer cases and of 29% (76/262) of csPCa cases (Grade Group > 2). Using the target plus peri-target approach resulted in us missing 18/262 (7%) of the csPCa cases, avoiding the diagnosis of 8/262 (3%) of nsPCa cases. A biopsy strategy including lesional and perilesional sampling could avoid unnecessary prostate biopsies. However, the risk of missing significant cancers is present. Future studies should assess the cost-benefit relationship of different strategies.