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Ablatherm HIFU for Prostate Cancer: A 10year European Experience

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Recto-urethral fistula : 3.3 3.4 % (6) (4) Long, De La Taille, Pisters ... fistulas with the specific RBT. failure treatment protocol ... – PowerPoint PPT presentation

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Title: Ablatherm HIFU for Prostate Cancer: A 10year European Experience


1
Ablatherm - HIFU for Prostate CancerA 10-year
European Experience
A symposium sponsored by
2
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
3
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

4
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
5
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

6
Local Relapse After RBT
What are the current available options ?
7
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
8
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
9
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
10
Local Relapse After RBT Looking for a Better
Alternative Treatment with Curative Intent
Is HIFU the Solution ?
11
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

12
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
13
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
14
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

15
Salvage HIFU After RBT Complications

16
Salvage HIFU After RBT Uretro-rectal Fistula

No more uretro-rectalfistulas with the specific
RBTfailure treatment protocol
17
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

18
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
19
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 ?
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