Abstract
Background:Treatment options for radio-recurrent prostate cancer are either androgen-deprivation therapy or salvage prostatectomy. Whole-gland high-intensity focussed ultrasound (HIFU) might have a role in this setting.Methods:An independent HIFU registry collated consecutive cases of HIFU. Between 2005 and 2012, we identified 50 men who underwent whole-gland HIFU following histological confirmation of localised disease following prior external beam radiotherapy (2005–2012). No upper threshold was applied for risk category, PSA or Gleason grade either at presentation or at the time of failure. Progression was defined as a composite with biochemical failure (Phoenix criteria (PSA>nadir+2 ng ml−1)), start of systemic therapies or metastases.Results:Median age (interquartile range (IQR)), pretreatment PSA (IQR) and Gleason score (range) were 68 years (64–72), 5.9 ng ml−1 (2.2–11.3) and 7 (6–9), respectively. Median follow-up was 64 months (49–84). In all, 24/50 (48%) avoided androgen-deprivation therapies. Also, a total of 28/50 (56%) achieved a PSA nadir <0.5 ng ml−1, 15/50 (30%) had a nadir ⩾0.5 ng ml−1 and 7/50 (14%) did not nadir (PSA non-responders). Actuarial 1, 3 and 5-year progression-free survival (PFS) was 72, 40 and 31%, respectively. Actuarial 1, 3 and 5-year overall survival (OS) was 100, 94 and 87%, respectively. When comparing patients with PSA nadir <0.5 ng ml−1, nadir ⩾0.5 and non-responders, a statistically significant difference in PFS was seen (P<0.0001). Three-year PFS in each group was 57, 20 and 0%, respectively. Five-year OS was 96, 100 and 38%, respectively. Early in the learning curve, between 2005 and 2007, 3/50 (6%) developed a fistula. Intervention for bladder outlet obstruction was needed in 27/50 (54%). Patient-reported outcome measure questionnaires showed incontinence (any pad-use) as 8/26 (31%).Conclusions:In our series of high-risk patients, in whom 30–50% may have micro-metastases, disease control rates were promising in PSA responders, however, with significant morbidity. Additionally, post-HIFU PSA nadir appears to be an important predictor for both progression and survival. Further research on focal salvage ablation in order to reduce toxicity while retaining disease control rates is required.
Highlights
In the United Kingdom, every year up to one-quarter of men diagnosed with prostate cancer undergo external beam radiotherapy (EBRT).[1]
We offered all patients biopsy, our data mirrors practice where patients with a stable PSA tend to refuse biopsy and even a proportion of patients with clinical suspicion for recurrence choose not to undergo biopsy and rather opt for continued PSA surveillance or proceed directly to line treatment, that is, hormones
In our series of high-risk patients, in whom we estimate, based on the literature, that 30–50% may have micro-metastases at the time of presentation, disease control rates were promising in PSA responders.[17,21,22,23,31]
Summary
In the United Kingdom, every year up to one-quarter of men diagnosed with prostate cancer undergo external beam radiotherapy (EBRT).[1]. It is estimated that up to 50% may have localised recurrence, which could be suitable for local salvage treatment.[2,3,4] the majority receive androgen-deprivation therapy (ADT) alone,[3] which can confer systemic harms as well as cost, especially when castrate resistance occurs after a median of approximately 2–3 years.[5,6]. Local salvage treatment options include salvage radical prostatectomy (SRP), cryotherapy, brachytherapy and highintensity focussed ultrasound (HIFU) These options could provide a further curative strategy but defer the commencement of ADT, which would in turn delay the onset of castrate resistance and confer a cost benefit.[7,8,9] These salvage options are at various stages of evaluation. Further research on focal salvage ablation in order to reduce toxicity while retaining disease control rates is required
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