BERKELEY, CA (UroToday.com) - In 2012, 241 740 men were diagnosed with prostate cancer -- currently the most commonly diagnosed malignancy in men -- accounting for 29% of all male cancers and 9% of male cancer deaths. At the same time, in the USA, mortality from prostate cancer has been gradually decreasing -- mainly due to the wide implementation of CaP-screening practices. According to the SEER Registry there is a dramatic 75% reduction in metastatic disease and a 42% reduction in age-adjusted prostate cancer mortality. Therefore there is little doubt that currently CaP is a disease that, although it affects more men than before, causes serious morbidity or death to fewer men than before.
On the other hand, there is skepticism as to whether radical prostatectomy offers significant advantages with regard to survival and quality of life for men with low- to medium-risk prostate cancer. The emergence of minimally invasive, organ-sparing focal therapies has changes the scenery in prostate cancer treatment. High intensity focused ultrasound (HIFU) is a minimally invasive, thermal ablative, therapeutic method currently applied as first-line option for the treatment of localized prostate cancer. Contemporary indications of HIFU include patients with clinically localized (stage T1-T2, NXMO) low- to medium-risk prostate cancer -- although its indications are continuously expanding. Recently HIFU has been introduced as salvage therapy for patients with local relapse following such “radical” treatments as EBRT or radical prostatectomy.
Currently the use of HIFU in the setting of a salvage treatment option, following failure of other therapies, represents only 7% of its total use in prostate cancer. According to the majority of published trials, current indications of HIFU for the management of radiation-recurrent prostate cancer are limited to cases of T1-T2N0M0 disease, with a PSA < 20ng/ml and Gleason score < 8 and biopsy-proven local relapse of cancer, negative bone-scan and/or pelvic magnetic resonance imaging for macroscopic metastases. Although there are no randomized prospective trials, the limited number of available relevant studies have shown promising results for HIFU as salvage treatment in patients with local recurrence after failure of other primary treatments or incompletely treated tumors by radiotherapy.
The effectiveness of HIFU on localized prostate cancer, and the prediction of the outcome of therapy, cannot be made with pathological tumor characteristics because of the absence of tissue sample when using HIFU. For this reason, other parameters, such as the time of PSA nadir, are used as prognostic indicators of the efficacy of therapy. An ideal PSA nadir after HIFU is < 0.2ng /ml in 3-6 months. For patients with PSA nadir < 0.5ng/ml after HIFU, 5 year-survival reached 86%. An increase of PSA of 1.2ng/ml above nadir is considered as biochemical relapse.
Treatment of localized radiation-recurrent CaP by salvage HIFU is mainly associated with clinically significant reductions in urinary and sexual function and additional negative consequences in health-related quality of life (HRQOL). The most common complications after salvage HIFU include incontinence (10 - 49.5%), urinary retention due to urethral stricture or bladder neck contracture (17–17.6%) and erectile dysfunction (66.2 -100%). However the most worrisome and serious complication following salvage HIFU is recto-urethral fistula (3-6%), with a dramatic increase risk in cases of repeated salvage HIFU sessions.
The possibility to use HIFU as salvage treatment after radiotherapy is already considered an option, according to the EAU guidelines. Thanks to its minimal invasiveness and to the reduction of serious adverse events, with the use of the new devices, HIFU has the potential to become the first option treatment for local recurrence of prostate cancer after external beem radiotherapy or brachytherapy. Further controlled studies and a longer follow up are required in order to confirm the first encouraging data presented so far. Improvements in imaging methods for diagnosis of local and distant recurrences of prostate cancer could help in the use of HIFU in selected patients, thereby maximizing its curative potential.
Written by:
Petros Sountoulides, MD, PhD, FEBU and Alexandros Theodosiou, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Urology Department, General Hospital of Veria, Veria, Greece
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