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Vickers AJ, Assel M, Cooperberg MR, Fine SW, Eggener S. Amount of Gleason Pattern 3 Is Not Predictive of Risk in Grade Group 2-4 Prostate Cancer. Eur Urol 2024:S0302-2838(24)00007-1. [PMID: 38278665 DOI: 10.1016/j.eururo.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/05/2023] [Accepted: 01/06/2024] [Indexed: 01/28/2024]
Abstract
We investigated whether total Gleason pattern 3 or the proportion of Gleason pattern 4 on biopsy is a significant predictor of adverse pathology. Our findings suggest that quantifying the amount rather than the proportion of Gleason pattern 4 would improve grade group assignment for decision-making in localized prostate cancer.
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Affiliation(s)
- Andrew J Vickers
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Melissa Assel
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew R Cooperberg
- Departments of Urology and Epidemiology & Biostatistics, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA, USA
| | - Samson W Fine
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Scott Eggener
- Section of Urology, Department of Surgery, The University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
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Yilmaz EC, Lin Y, Belue MJ, Harmon SA, Phelps TE, Merriman KM, Hazen LA, Garcia C, Johnson L, Lay NS, Toubaji A, Merino MJ, Patel KR, Parnes HL, Law YM, Wood BJ, Gurram S, Choyke PL, Pinto PA, Turkbey B. PI-RADS Version 2.0 Versus Version 2.1: Comparison of Prostate Cancer Gleason Grade Upgrade and Downgrade Rates From MRI-Targeted Biopsy to Radical Prostatectomy. AJR Am J Roentgenol 2024; 222:e2329964. [PMID: 37729551 DOI: 10.2214/ajr.23.29964] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND. Precise risk stratification through MRI/ultrasound (US) fusion-guided targeted biopsy (TBx) can guide optimal prostate cancer (PCa) management. OBJECTIVE. The purpose of this study was to compare PI-RADS version 2.0 (v2.0) and PI-RADS version 2.1 (v2.1) in terms of the rates of International Society of Urological Pathology (ISUP) grade group (GG) upgrade and downgrade from TBx to radical prostatectomy (RP). METHODS. This study entailed a retrospective post hoc analysis of patients who underwent 3-T prostate MRI at a single institution from May 2015 to March 2023 as part of three prospective clinical trials. Trial participants who underwent MRI followed by MRI/US fusion-guided TBx and RP within a 1-year interval were identified. A single genitourinary radiologist performed clinical interpretations of the MRI examinations using PI-RADS v2.0 from May 2015 to March 2019 and PI-RADS v2.1 from April 2019 to March 2023. Upgrade and downgrade rates from TBx to RP were compared using chi-square tests. Clinically significant cancer was defined as ISUP GG2 or greater. RESULTS. The final analysis included 308 patients (median age, 65 years; median PSA density, 0.16 ng/mL2). The v2.0 group (n = 177) and v2.1 group (n = 131) showed no significant difference in terms of upgrade rate (29% vs 22%, respectively; p = .15), downgrade rate (19% vs 21%, p = .76), clinically significant upgrade rate (14% vs 10%, p = .27), or clinically significant downgrade rate (1% vs 1%, p > .99). The upgrade rate and downgrade rate were also not significantly different between the v2.0 and v2.1 groups when stratifying by index lesion PI-RADS category or index lesion zone, as well as when assessed only in patients without a prior PCa diagnosis (all p > .01). Among patients with GG2 or GG3 at RP (n = 121 for v2.0; n = 103 for v2.1), the concordance rate between TBx and RP was not significantly different between the v2.0 and v2.1 groups (53% vs 57%, p = .51). CONCLUSION. Upgrade and downgrade rates from TBx to RP were not significantly different between patients whose MRI examinations were clinically interpreted using v2.0 or v2.1. CLINICAL IMPACT. Implementation of the most recent PI-RADS update did not improve the incongruence in PCa grade assessment between TBx and surgery.
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Affiliation(s)
- Enis C Yilmaz
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Yue Lin
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Mason J Belue
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Stephanie A Harmon
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Tim E Phelps
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Katie M Merriman
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Lindsey A Hazen
- Center for Interventional Oncology, National Cancer Institute, NIH, Bethesda, MD
- Department of Radiology, Clinical Center, NIH, Bethesda, MD
| | - Charisse Garcia
- Center for Interventional Oncology, National Cancer Institute, NIH, Bethesda, MD
- Department of Radiology, Clinical Center, NIH, Bethesda, MD
| | - Latrice Johnson
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Nathan S Lay
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Antoun Toubaji
- Laboratory of Pathology, National Cancer Institute, NIH, Bethesda, MD
| | - Maria J Merino
- Laboratory of Pathology, National Cancer Institute, NIH, Bethesda, MD
| | - Krishnan R Patel
- Radiation Oncology Branch, National Cancer Institute, NIH, Bethesda, MD
| | - Howard L Parnes
- Division of Cancer Prevention, National Cancer Institute, NIH, Bethesda, MD
| | - Yan Mee Law
- Department of Radiology, Singapore General Hospital, Singapore
| | - Bradford J Wood
- Center for Interventional Oncology, National Cancer Institute, NIH, Bethesda, MD
- Department of Radiology, Clinical Center, NIH, Bethesda, MD
| | - Sandeep Gurram
- Urologic Oncology Branch, National Cancer Institute, NIH, Bethesda, MD
| | - Peter L Choyke
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
| | - Peter A Pinto
- Urologic Oncology Branch, National Cancer Institute, NIH, Bethesda, MD
| | - Baris Turkbey
- Molecular Imaging Branch, National Cancer Institute, NIH, 10 Center Dr, MSC 1182, Bldg 10, Rm B3B85, Bethesda, MD 20892
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Gaffney CD, Tin AL, Fainberg J, Fine S, Jibara G, Touijer K, Eastham J, Scardino P, Laudone V, Vickers AJ, Ehdaie B. The oncologic risk of magnetic resonance imaging-targeted and systematic cores in patients treated with radical prostatectomy. Cancer 2023; 129:3790-3796. [PMID: 37584213 DOI: 10.1002/cncr.34981] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI)-targeted prostate biopsy (MRI-biopsy) detects high-Grade Group (GG) prostate cancers not identified by systematic biopsy (S-biopsy). However, questions have been raised whether cancers detected by MRI-biopsy and S-biopsy, grade-for-grade, are of equivalent oncologic risk. The authors evaluated the relative oncologic risk of GG diagnosed by S-biopsy and MRI-biopsy. METHODS This was a retrospective analysis of all patients who had both MRI-biopsy and S-biopsy and underwent with prostatectomy (2014-2022) at Memorial Sloan Kettering Cancer Center. Three logistic regression models were used with adverse pathology as the primary outcome (primary pattern 4, any pattern 5, seminal vesicle invasion, or lymph node involvement). The first model included the presurgery prostate-specific antigen level, the number of positive and negative S-biopsy cores, S-biopsy GG, and MRI-biopsy GG. The second model excluded MRI-biopsy GG to obtain the average risk based on S-biopsy GG. The third model excluded S-biopsy GG to obtain the risk based on MRI-biopsy GG. A secondary analysis using Cox regression evaluated the 12-month risk of biochemical recurrence. RESULTS In total, 991 patients were identified, including 359 (36%) who had adverse pathology. MRI-biopsy GG influenced oncologic risk compared with S-biopsy GG alone (p < .001). However, if grade was discordant between biopsies, then the risk was intermediate between grades. For example, the average risk of advanced pathology for patients who had GG2 and GG3 on S-biopsy was 19% and 66%, respectively, but the average risk was 47% for patients who had GG2 on S-biopsy and patients who had GG3 on MRI-biopsy. The equivalent estimates for 12-month biochemical recurrence were 5.8%, 15%, and 10%, respectively. CONCLUSIONS The current findings cast doubt on the practice of defining risk group based on the highest GG. Because treatment algorithms depend fundamentally on GG, further research is urgently required to assess the oncologic risk of prostate tumors depending on detection technique. PLAIN LANGUAGE SUMMARY Using magnetic resonance imaging (MRI) to help diagnose prostate cancer can help identify more high-grade cancers than using a systematic template biopsy alone. However, we do not know if high-grade cancers diagnosed with the help of an MRI are as dangerous to the patient as high-grade cancers diagnosed with a systematic biopsy. We examined all of our patients who had an MRI biopsy and a systematic biopsy and then had their prostates removed to find out if these patients had risk factors and signs of aggressive cancer (cancer that spread outside the prostate or was very high grade). We found that, if there was a difference in grade between the systematic biopsy and the MRI-targeted biopsy, the risk of aggressive cancer was between the two grades.
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Affiliation(s)
- Christopher D Gaffney
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonathan Fainberg
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Samson Fine
- Department of Genitourinary Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ghalib Jibara
- Southern California Permanente Medical Group, Fontana, California, USA
| | - Karim Touijer
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - James Eastham
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Peter Scardino
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vincent Laudone
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Behfar Ehdaie
- Division of Urology, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Kamecki H, Mielczarek Ł, Szempliński S, Dębowska M, Rajwa P, Baboudjian M, Klemm J, Rivas JG, Modzelewska E, Tayara O, Malewski W, Szostek P, Poletajew S, Kryst P, Sosnowski R, Nyk Ł. Quantification of Gleason Pattern 4 at MRI-Guided Biopsy to Predict Adverse Pathology at Radical Prostatectomy in Intermediate-Risk Prostate Cancer Patients. Cancers (Basel) 2023; 15:5462. [PMID: 38001723 PMCID: PMC10670701 DOI: 10.3390/cancers15225462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/28/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Data on Gleason pattern 4 (GP4) amount in biopsy tissue is important for prostate cancer (PC) risk assessment. We aim to investigate which GP4 quantification method predicts adverse pathology (AP) at radical prostatectomy (RP) the best in men diagnosed with intermediate-risk (IR) PC at magnetic resonance imaging (MRI)-guided biopsy. METHODS We retrospectively included 123 patients diagnosed with IR PC (prostate-specific antigen <20 ng/mL, grade group (GG) 2 or 3, no iT3 on MRI) at MRI-guided biopsy, who underwent RP. Twelve GP4 amount-related parameters were developed, based on GP4 quantification method (absolute, relative to core, or cancer length) and site (overall, targeted, systematic biopsy, or worst specimen). Additionally, we calculated PV×GP4 (prostate volume × GP4 relative to core length in overall biopsy), aiming to represent the total GP4 volume in the prostate. The associations of GP4 with AP (GG ≥ 4, ≥pT3a, or pN1) were investigated. RESULTS AP was reported in 39 (31.7%) of patients. GP4 relative to cancer length was not associated with AP. Of the 12 parameters, the highest ROC AUC value was seen for GP4 relative to core length in overall biopsy (0.65). an even higher AUC value was noted for PV × GP4 (0.67), with a negative predictive value of 82.8% at the optimal threshold. CONCLUSIONS The lack of an association of GP4 relative to cancer length with AP, contrasted with the better performance of other parameters, indicates directions for future research on PC risk stratification to accurately identify patients who may not require immediate treatment. Incorporating formulas aimed at GP4 volume assessment may lead to obtaining models with the best discrimination ability.
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Affiliation(s)
- Hubert Kamecki
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Łukasz Mielczarek
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Stanisław Szempliński
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Małgorzata Dębowska
- Nałęcz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 02-109 Warsaw, Poland
| | - Paweł Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria
- Department of Urology, Medical University of Silesia, 41-800 Zabrze, Poland
| | | | - Jakob Klemm
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria
- Department of Urology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Juan Gómez Rivas
- Department of Urology, Hospital Clinico San Carlos, 28040 Madrid, Spain
| | - Elza Modzelewska
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Omar Tayara
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Wojciech Malewski
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Przemysław Szostek
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Sławomir Poletajew
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Piotr Kryst
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Roman Sosnowski
- Department of Urology and Oncological Urology, Warmian-Masurian Cancer Center, 10-228 Olsztyn, Poland
| | - Łukasz Nyk
- Second Department of Urology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
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Gandaglia G, Leni R, Plagakis S, Stabile A, Montorsi F, Briganti A. Active surveillance should not be routinely considered in ISUP grade group 2 prostate cancer. BMC Urol 2023; 23:153. [PMID: 37777767 PMCID: PMC10542696 DOI: 10.1186/s12894-023-01315-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/03/2023] [Indexed: 10/02/2023] Open
Abstract
Active surveillance has been proposed as a therapeutic option in selected intermediate risk patients with biopsy grade group 2 prostate cancer. However, its oncologic safety in this setting is debated. Therefore, we conducted a non-systematic literature research of contemporary surveillance protocols including patients with grade group 2 disease to collect the most recent evidence in this setting. Although no randomized controlled trial compared curative-intent treatments, namely radical prostatectomy and radiotherapy vs. active surveillance in patients with grade group 2 disease, surgery is associated with a benefit in terms of disease control and survival when compared to expectant management in the intermediate risk setting. Patients with grade group 2 on active surveillance were at higher risk of disease progression and treatment compared to their grade group 1 counterparts. Up to 50% of those patients were eventually treated at 5 years, and the metastases-free survival rate was as low as 85% at 15-years. When considering low- and intermediate risk patients treated with radical prostatectomy, grade group 2 was one of the strongest predictors of grade upgrading and adverse features. Available data is insufficient to support the oncologic safety of active surveillance in all men with grade group 2 prostate cancer. Therefore, those patients should be counselled regarding the oncologic efficacy of upfront active treatment modalities and the lack of robust long-term data supporting the safety of active surveillance in this setting.
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Affiliation(s)
- Giorgio Gandaglia
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Riccardo Leni
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Armando Stabile
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Pekala KR, Bergengren O, Eastham JA, Carlsson SV. Active surveillance should be considered for select men with Grade Group 2 prostate cancer. BMC Urol 2023; 23:152. [PMID: 37777716 PMCID: PMC10541702 DOI: 10.1186/s12894-023-01314-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/03/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Treatment decisions for localized prostate cancer must balance patient preferences, oncologic risk, and preservation of sexual, urinary and bowel function. While Active Surveillance (AS) is the recommended option for men with Grade Group 1 (Gleason Score 3 + 3 = 6) prostate cancer without other intermediate-risk features, men with Grade Group 2 (Gleason Score 3 + 4 = 7) are typically recommended active treatment. For select patients, AS can be a possible initial management strategy for men with Grade Group 2. Herein, we review current urology guidelines and the urologic literature regarding recommendations and evidence for AS for this patient group. MAIN BODY AS benefits men with prostate cancer by maintaining their current quality of life and avoiding treatment side effects. AS protocols with close follow up always allow for an option to change course and pursue curative treatment. All the major guideline organizations now include Grade Group 2 disease with slightly differing definitions of eligibility based on risk using prostate-specific antigen (PSA) level, Gleason score, clinical stage, and other factors. Selected men with Grade Group 2 on AS have similar rates of deferred treatment and metastasis to men with Grade Group 1 on AS. There is a growing body of evidence from randomized controlled trials, large observational (prospective and retrospective) cohorts that confirm the oncologic safety of AS for these men. While some men will inevitably conclude AS at some point due to clinical reclassification with biopsy or imaging, some men may be able to stay on AS until transition to watchful waiting (WW). Magnetic resonance imaging is an important tool to confirm AS eligibility, to monitor progression and guide prostate biopsy. CONCLUSION AS is a viable initial management option for well-informed and select men with Grade Group 2 prostate cancer, low volume of pattern 4, and no other adverse clinicopathologic findings following a well-defined monitoring protocol. In the modern era of AS, urologists have tools at their disposal to better stage patients at initial diagnosis, risk stratify patients, and gain information on the biologic potential of a patient's prostate cancer.
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Affiliation(s)
- Kelly R Pekala
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, 1133 York Avenue, New York, NY, 10065, USA
| | - Oskar Bergengren
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, 1133 York Avenue, New York, NY, 10065, USA
- Department of Urology, Uppsala University, Uppsala, Sweden
| | - James A Eastham
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, 1133 York Avenue, New York, NY, 10065, USA
| | - Sigrid V Carlsson
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, 1133 York Avenue, New York, NY, 10065, USA.
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
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Ehdaie B, Sonn GA, Ghanouni P. Tempering optimism for MRI-guided focused ultrasound therapy – Authors' reply. Lancet Oncol 2022; 23:e439. [DOI: 10.1016/s1470-2045(22)00557-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022]
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