Ablatherm HIFU for Prostate Cancer: A 10year European Experience

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Ablatherm - HIFU for Prostate CancerA 10-year
European Experience
A symposium sponsored by
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Salvage High Intensity Focused Ultrasound for
Prostate Cancer Local Relapse After Radiation
Beam Therapy
F-J. Murat, Lyon (FR) Hôpital Edouard Herriot,
Lyon
Ablatherm- HIFU for prostate cancer a 10-year
European experience
A symposium sponsored by
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Local Relapse After RBT How To Affirm it?

• lt2 years post RBT  Blind period 
•  bounce effect  PSA non interpretable
• Prostate biopsy non interpretable
• gt2 years post RBT
• Trans-rectal prostate biopsy positive for
  cancer
• Minimal imaging evaluation negative for
  metastasis
• Bone CT
• TAP CT
• Prostate MRI

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Local Relapse After RBT An Underestimated
Problem !

• Overall, 30 50 of positive biopsies
• gt 2 years after BRT (1)
• For patients with a rising PSA and a negative
  metastatic evaluation
• 60 72 of biopsy proven recurrence (2)

(1) Cox, Crook, Pollack, Zagars, Zelefsky (2)
Zagars, Zelefsky
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Local Relapse After RBT A Therapeutical Dilemna!

• Most patients will receive a palliative treatment
  with androgen deprivation therapy
• However, a local salvage therapy may cure
  patients with isolated local relapse

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Local Relapse After RBT
What are the current available options ?
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Local Relapse After RBT Salvage Radical
Prostatectomy

• For surgeons
• A technical challenge
• 5 year biochemical No Evidence of Disease
  (5ybNED) 47 65 (1)
• Significant complications
• rectal injuries 5 19 (2)
• bladder neck contractures 30 (2)
• urinary incontinence 45 - 68 (3)
• For patients
• High motivation and acceptance of increased
  surgicalmorbidity

(1) Amling, Bianco, Gheiler, Stephenson,
Ward (2) Amling, Neerhut, Rogers (3) Gheiler,
Shekarriz, Stephenson, Ward
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Local Relapse After RBT Salvage Cryotherapy

• Technically demanding technique with a long
  learning curve
• 5ybNED 40 (1)
• Limited capacity for complete prostate
  cryoablation
• Positive biopsy 14 -37 (2)
• 59 of residual viable benign or malignant
  tissue (3)
• Complications
• Pelvic pain 18 37 (4)
• Urinary incontinence 9 83 (5)
• Recto-urethral fistula 3.3 3.4 (6)

(4) Long, De La Taille, Pisters (5) Chin, Long,
De La Taille, Pisters (6) Bahn, Chin
(1) Isawa (2) Chin, Miller (3) Chin
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Local Relapse After RBT Salvage Brachytherapy

• Difficult follow-up nadir PSA gt 36 months
• Small series with short follow-up
• 5ybNED 34 (1)
• Complications
• LUTS 6 (2)
• Urinary incontinence 24 (2)
• Rectal ulcers 4 (1)
• Rectal bleeding with colostomy 2 (1)

(1) Grado (2) Beyer
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Local Relapse After RBT Looking for a Better
Alternative Treatment with Curative Intent
Is HIFU the Solution ?
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Salvage HIFU Post RBT Patient Characteristics

• 1995 2006
• 152 pts with RBT failure
• Age 68,4 6 years
• Pre HIFU
• PSA 7,35 8,03 ng/ml (median 4,86 ng/ml)
• Gleason score
• lt 7 55 patients 7 35 patients gt 7 62
  patients
• Prostate volume 17,9 8,75 cc (median 18 cc)
• Negative metastatic evaluation

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Salvage HIFU Post RBT Results

• Mean follow-up 17 months 3 120 months
• Retreatment rate 10
• CONTROL BIOPSIES negatives in 76,5
• PSA
• nadir at 3 months post HIFU

pts
pts
pre HIFU PSA median PSA 4.86 ng/ml
post HIFU PSA median PSA 0.19 ng/ml
PSA
ng/ml
ng/ml
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Salvage HIFU After RBT Stratified DFR() by
Pre-RBT Risk Level
Pre RBT risk level (dAmico et al., Cancer, 2002)
Low risk 56()
DFS ()
DFS ()
High risk 9 ()
Medium risk 47()
pts
75 44 29 16 8 4
2
pts
77 31 14 9 9 6
2
() Log rank p0.0004
() Log rank p0.0004
months
() negative biopsy PSAlt1ng/ml and stable no
adjuvant therapy
Ablatherm- HIFU for prostate cancer a 10-year
European experience
A symposium sponsored by
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Salvage HIFU After RBT Protocol Improvements

• 2 periods
• 1995 2002 no specific treatment
  parameters for RBT failures (56 patients) ?
  complication rate to be improved
• 2002 today specific treatment
  parameters (96 patients)
• ? lower complication rate

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Salvage HIFU After RBT Complications

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Salvage HIFU After RBT Uretro-rectal Fistula

No more uretro-rectalfistulas with the specific
RBTfailure treatment protocol
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Salvage HIFU After RBT
General Conclusions

• Local tumor control in 76.5 of the cases
• Cancer control is higly correlated with the pre
  RBT risk level
• The lower the risk level, the higher the HIFU
  efficacy
• ? Patient selection should be based on the pre
  RBT level
• Complications have decreased with specific
  post-radiation treatment parameters
• Urinary incontinence dominates
• No uretro-rectal fistula

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Salvage HIFU After RBT
Conclusions for high risk patients
HIFU a valid indication ? Some patients may
benefit from this treatment but they need to be
carefully selected in order to avoid any silent
metastasis ? F18 FC PET Scan benefits?


F18 fluorocholinePET scan
Bone CT
Ablatherm- HIFU for prostate cancer a 10-year
European experience
A symposium sponsored by
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Salvage HIFU After RBT
Conclusions for low / medium risk patients

• HIFU offers for patients with local relapse after
  RBT
• A high tumor local control
• A high oncological efficacy
• An acceptable morbidity with no UR fistulas with
• the specific RBT failures treatment
  parameters
• ? A major indication for HIFU
• The future gold standard for treatmentof RBT
  failures ?