UROLOGICAL ONCOLOGY

Multicentric oncologic outcomes of high-intensity focused ultrasound for localized prostate cancer in 803 patients
Crouzet S, Rebillard X, Chevallier D, Rischmann P, Pasticier G, Garcia G, Rouviere O, Chapelon JY, Gelet A
Department of Urology, Edouard Herriot Hospital, Lyon, France
Eur Urol. 2010; 58: 559-66

• Background: High-intensity focused ultrasound (HIFU) is an emerging treatment for select patients with localized prostate cancer (PCa).
  Objectives: To report the oncologic outcome of HIFU as a primary care option for localized prostate cancer from a multicenter database.
  Design, Setting, and Participants: Patients with localized PCa treated with curative intent and presenting at least a 2-yr follow-up from February 1993 were considered in this study. Previously irradiated patients were excluded from this analysis. In case of any residual or recurrent PCa, patients were systematically offered a second session. Kaplan-Meier analysis was performed to determine disease-free survival rates (DFSR).
  Measurements: Prostate-specific antigen (PSA), clinical stage, and pathologic results were measured pre- and post-HIFU.
  Results and Limitations: A total of 803 patients from six urologic departments met the inclusion criteria. Stratification according to d’Amico’s risk group was low, intermediate, and high in 40.2%, 46.3%, and 13.5% of patients, respectively. Mean follow-up was 42+/-33 mo. Mean PSA nadir was 1.0+/-2.8 ng/ml with 54.3% reaching a nadir of < or =0.3 ng/ml. Control biopsies were negative in 85% of cases. The overall and cancer-specific survival rates at 8 yr were 89% and 99%, respectively. The metastasis-free survival rate at 8 yr was 97%. Initial PSA value and Gleason score value significantly influence the DFSR. The 5- and 7-yr biochemical-free survival rates (Phoenix criteria) were 83-75%, 72-63%, and 68-62% (p=0.03) and the additional treatment-free survival rates were 84-79%, 68-61%, and 52-54% (p<0.001) for low-, intermediate-, and high-risk patients, respectively. PSA nadir was a major predictive factor for HIFU success: negative biopsies, stable PSA, and no additional therapy.
  Conclusions: Local control and DFSR achieved with HIFU were similar to those expected with conformal external-beam radiation therapy (EBRT). The excellent cancer-specific survival rate is also explained by the possibility to repeat HIFU and use salvage EBRT.

• Editorial Comment
  High-intensity focused ultrasound (HIFU) is not regarded an established treatment in prostate cancer patients as radical prostatectomy and radiation therapy are. Therefore, reports on the long-term outcomes of patients treated with HIFU are very interesting and should be analyzed carefully. Here, the authors report on 803 patients treated with HIFU against localized primary prostate cancer. Forty percent, 46% and 14% were of low, intermediate and high-risk group according to Amico, respectively. If only the outcomes of the most recently treated patients is regarded, only 57% had a nadir PSA < 0.3, 19% had a nadir PSA between 0.3 and 1, and 19% had a nadir PSA of > 1. The biochemical-free survival rates of these groups are important for the assessment of the curative efficacy. After 7 years of follow-up roughly 90% of patients with a PSA nadir of < 0.3 remained biochemically recurrence-free, whereas these figures were much lower for patients with a PSA nadir of 0.3-1 (~ 50% recurrence-free) and with a PSA nadir of > 1 (~ 40% recurrence-free).
  These and other figures show that the cure rate of patients with localized prostate cancer after HIFU treatment to my opinion is not yet comparable to the outcome after radical prostatectomy or modern radiation therapy.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de