Focal therapy for localized prostate cancer: a phase I/II trial.
Journal - The Journal of urology (United States )
Men with localized prostate cancer currently face a number of treatment options that treat the entire prostate. These can cause significant sexual and urinary side effects. Focal therapy offers a novel strategy that targets the cancer rather than the prostate in an attempt to preserve tissue and function.A prospective, ethics committee approved trial was conducted to determine the side effects of focal therapy using high intensity focused ultrasound. Multiparametric magnetic resonance imaging (T2-weighted, dynamic contrast enhanced, diffusion-weighted) and template transperineal prostate mapping biopsies were used to identify unilateral disease. Genitourinary side effects and quality of life outcomes were assessed using validated questionnaires. Posttreatment biopsies were performed at 6 months and followup was completed to 12 months.A total of 20 men underwent high intensity focused ultrasound hemiablation. Mean age was 60.4 years (SD 5.4, range 50 to 70) with mean prostate specific antigen 7.3 ng/ml (SD 2.8, range 3.4 to 11.8). Of the men 25% had low risk and 75% had intermediate risk cancer. Return of erections sufficient for penetrative sex occurred in 95% of men (19 of 20). In addition, 90% of men (18 of 20) were pad-free, leak-free continent while 95% were pad-free. Mean prostate specific antigen decreased 80% to 1.5 ng/ml (SD 1.3) at 12 months. Of the men 89% (17 of 19, 1 refused biopsy) had no histological evidence of any cancer, and none had histological evidence of high volume or Gleason 7 or greater cancer in the treated lobe. In addition, 89% of men achieved the trifecta status of pad-free, leak-free continence, erections sufficient for intercourse and cancer control at 12 months.Our results appear sufficiently promising to support the further evaluation of focal therapy as a strategy to decrease some of the harms and costs associated with standard whole gland treatments.Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
|ISSN : ||1527-3792|
|Mesh Heading : ||Aged Humans Male Middle Aged Prospective Studies Prostatic Neoplasms|
|Mesh Heading Relevant : ||Ultrasound, High-Intensity Focused, Transrectal therapy|
Testicular and paratesticular tumours in the prepubertal population.
Journal - The lancet oncology
Prepubertal testicular and paratesticular tumours are a rare group of tumours, distinct from postpubertal paediatric and adult tumours of this region. Tumours within this group are testicular germ-cell tumours (such as benign teratoma, epidermoid cyst and malignant yolk-sac tumours) and stromal tumours (such as juvenile granulosa-cell, leydig-cell, and sertoli-cell tumours). Paratesticular tumours can be benign (lipoma, leiomyoma, haemangioma) or malignant (rhabdomyosarcoma, melanotic neuroectodermal tumour of infancy). Because of their rarity, centralised pathology and treatment, and national collaborative clinical trials have been important in establishing the optimum management of malignant tumours in this group. We provide an up-to-date and comprehensive review of the clinical presentation, imaging, pathology, and clinical management of prepubertal paratesticular and testicular tumours.Copyright © 2010 Elsevier Ltd. All rights reserved.
Benchmarks for success in focal therapy of prostate cancer: cure or control?
Journal - World journal of urology
BACKGROUND: The place of focal therapy in prostate cancer management requires further evaluation within randomized comparative clinical trials. METHODS: This review article discusses the place of focal therapy and asks whether it is an alternative to active surveillance or radical therapy. This question therefore is at the heart of whether this proposed paradigm shift should be delivered with the intent of cure or cancer control. RESULTS: For such trials to report on outcomes that have meaningful utility in the clinic, it is necessary to discuss whether focal ablation should be delivered with intent to eradicate all cancer foci ('cure') or ablate all clinically significant lesions with surveillance of all remaining tissue (benign or harboring clinically insignificant cancer). While the former will inevitably mean that fewer men will be appropriate for focal therapy were it to become standard care, it is the safest approach. The latter strategy will open focal therapy to the majority of men with low- to intermediate-risk disease with the potential of offering a treatment strategy that treats important cancer while preserving function with a high degree of probability. CONCLUSION: A pragmatic randomized controlled clinical in which focal therapy is randomized against standard of care may be feasible. The pragmatic nature of such a trial would allow eligibility criteria, localization of cancer to reflect local practice (novel imaging and transrectal biopsy or template prostate mapping), and the focal intervention (ablative modality, intent to ablate all cancer foci or all clinically significant foci) to be kept broad to reflect clinical practice. Further, it would satisfy individual equipoise by allowing either active surveillance or radical therapy in the standard care arm, to be decided on by patient and physician.
Rectal fistulae after salvage high-intensity focused ultrasound for recurrent prostate cancer after combined brachytherapy and external beam radiotherapy.
Journal - BJU international (England )
OBJECTIVE: To report on the high rectal fistula rate associated with salvage high-intensity focused ultrasound (HIFU) after the failure of combined brachytherapy and external beam radiotherapy (EBRT) for prostate cancer; salvage ablative therapy for prostate cancer is indicated when there is local recurrence after RT, brachytherapy or their combination. PATIENTS AND METHODS: We retrospectively reviewed all men with prostate cancer treated with HIFU between 1 March 2005 and 31 May 2007, and identified five men treated after the failure of both brachytherapy and EBRT for localized prostate cancer. RESULTS: Three of the five men had iodine-seed implantation brachytherapy combined with EBRT as primary treatment, one had high-dose rate brachytherapy combined with EBRT and one had salvage iodine-seed brachytherapy for failed EBRT. Three of the five patients developed a recto-urethral fistula after HIFU. CONCLUSIONS: The high rate of recto-urethral fistula formation in this group might reflect an impaired blood supply or HIFU-associated near-field heating of the rectal wall. Tissue viability and healing might affect this group regardless of the salvage method. Careful patient selection and avoidance of rectal diagnostic biopsies might minimize the risk. Emerging ablative therapies regarded as less invasive than traditional therapies must be used with caution.
|ISSN : ||1464-410X|
|Mesh Heading : ||Aged Brachytherapy Combined Modality Therapy Humans Male Middle Aged Neoplasm Recurrence, Local Prostatic Neoplasms Rectal Fistula Rectum Retrospective Studies Risk Factors Salvage Therapy Ultrasound, High-Intensity Focused, Transrectal complications complications blood supply|
|Mesh Heading Relevant : ||therapy therapy etiology adverse effects adverse effects|
Is it time to consider a role for MRI before prostate biopsy?
Journal - Nature reviews. Clinical oncology (England )
The use of MRI in prostate cancer management is controversial and current guidelines underplay its role. Technological advances over the past 5 years, however, demand a re-evaluation of this position. In this article, we propose an increased use of MRI, not only in those with a diagnosis of prostate cancer but also for men before a prostate biopsy. The use of MRI before a biopsy can serve as a triage test in men with raised serum prostate-specific antigen levels, in order to select those for biopsy with significant cancer that requires treatment. This strategy could avoid biopsy, and hence unnecessary treatment, in those with no disease or insignificant cancer. In addition, avoidance of postbiopsy artifact caused by hemorrhage will lead to better local staging accuracy, while determining more accurately the disease burden. This approach could improve risk stratification by selecting those who require adjuvant therapy or dose escalation. Furthermore, MRI evaluation of cancer burden could be important in active surveillance regimens to select those needing intervention.
|ISSN : ||1759-4782|
|Mesh Heading : ||Biopsy, Needle Endosonography Humans Magnetic Resonance Imaging Male Mass Screening Neoplasm Staging Prognosis Prostate Prostate-Specific Antigen Prostatic Neoplasms Risk Assessment Sensitivity and Specificity methods methods methods blood immunology pathology methods|
|Mesh Heading Relevant : ||Early Detection of Cancer pathology diagnosis surgery|
High-intensity-focused ultrasound in the treatment of primary prostate cancer: the first UK series.
Journal - British journal of cancer (England )
BACKGROUND: The use of minimally invasive ablative therapies in localised prostate cancer offer potential for a middle ground between active surveillance and radical therapy. METHODS: An analysis of men with organ-confined prostate cancer treated with transrectal whole-gland HIFU (Sonablate 500) between 1 February 2005 and 15 May 2007 was carried out in two centres. Outcome data (side-effects using validated patient questionnaires, biochemical, histology) were evaluated. RESULTS: A total of 172 men were treated under general anaesthetic as day-case procedures with 78% discharged a mean 5 h after treatment. Mean follow-up was 346 days (range 135-759 days). Urethral stricture was significantly lower in those with suprapubic catheter compared with urethral catheters (19.4 vs 40.4%, P=0.005). Antibiotics were given to 23.8% of patients for presumed urinary tract infection and the rate of epididymitis was 7.6%. Potency was maintained in 70% by 12 months, whereas mild stress urinary incontinence (no pads) was reported in 7.0% (12 out of 172) with a further 0.6% (1 out of 172) requiring pads. There was no rectal toxicity and no recto-urethral fistulae. In all, 78.3% achieved a PSA nadir < or =0.5 microg ml(-1) at 12 months, with 57.8% achieving < or =0.2 microg ml(-1). Then, 8 out of 13 were retreated with HIFU, one had salvage external beam radiotherapy and four chose active surveillance for small-volume low-risk disease. Overall, there was no evidence of disease (PSA <0.5 microg ml(-1) or negative biopsy if nadir not achieved) after one HIFU session in 92.4% (159 out of 172) of patients. CONCLUSION: HIFU is a minimally invasive, day-case ablative technique that can achieve good biochemical outcomes in the short term with minimal urinary incontinence and acceptable levels of erectile dysfunction. Long-term outcome needs further evaluation and the inception of an international registry for cases treated using HIFU will significantly aid this health technology assessment.
|ISSN : ||1532-1827|
|Mesh Heading : ||Adenocarcinoma Aged Aged, 80 and over Biopsy Disease-Free Survival Great Britain Humans Male Middle Aged Neoplasm Staging Prostate-Specific Antigen Prostatic Neoplasms Treatment Outcome Ultrasound, High-Intensity Focused, Transrectal Urinary Catheterization blood pathology blood blood pathology adverse effects adverse effects|
|Mesh Heading Relevant : ||surgery surgery methods|