High- Intensity Focused Ultrasound as a Salvage Therapy for Patients with Recurrent Prostate Cancer
Men who have tried External Beam Radiation Therapy (EBRT) or Interstitial Brachytherapy for clinically localized prostate cancer possess a 20-30% greater probability of having prostate-specific antigen (PSA) failure. Salvage therapy is indicated when men are treated with radiotherapy, brachytherapy, or a combination of these for presumed localized prostate cancer and have a recurrence. The success rates after salvage procedures are considerably less than those that have been reported after more fundamental treatments. The results of the use of HIFU as a salvage therapy for patients with recurrent prostate cancer have been good, with negative biopsy rates as elevated as 80% and 61% achieving a PSA nadir of <0.5 g/L (n = 71); 44% were reported as freed from biochemical relapse at the follow up exam, at an average follow-up of 14.8 (6-86) months.
To analyze the usage of high-intensity focused ultrasound (HIFU) as a salvage therapy in patients with a recurrence of localized prostate cancer after external beam radiation (EBRT), brachytherapy, or proton therapy, the charts of all patients who had undergone salvage HIFU for biopsy-proven prostate cancer after primary radiation therapy, were reviewed retrospectively. Patient characteristics and oncological effects were assessed
Records of 22 patients with a median (range) follow-up of 24 (5-80) months were reviewed. Patients were men with presumed organ-confined disease who were treated with salvage HIFU following recurrent disease after EBRT (fourteen patients), brachytherapy (five patients: four with high-dose brachytherapy using In (192); and one with low-dose brachytherapy applying Au (98)) or proton therapy (three patients). The median (range) age at salvage HIFU was 65 (52-80) years, with a median (range) prostate-specific antigen (PSA) level before radiation therapy of 14.3 (5.7-118) ng/mL and an average (range) PSA level of 4.0 (1.2-30.1) ng/mL before HIFU. The median (range) period to HIFU after radiation therapy was 36 (4-96) months. The biochemical disease-free survival (bDFS) rate in all patients at 5 years was 52%. Rates of bDFS in low-, intermediate- and high-risk groups were 100%, 86%, and 14%, respectively. One among the twelve patients who received post-HIFU prostate biopsy showed malignancy. Side effects included urethral stricture in four patients, grade I urinary incontinence in four patients, rectourethral fistula and epididymitis in one of each patient.
This preliminary data recommend that high intensity focused ultrasound represents a legitimate alternative treatment strategy for patients with localized prostate cancer. Salvage HIFU is often a promising treatment option for local recurrence after radiation therapy, with morbidity comparable with other types of salvage treatment. A careful choice by the patient is imperative depending upon the aforementioned prognostic factors.
Frequently Asked Questions
What do you think of the NHS denying Hifu to victims of prostate cancer?
In the U.K., the NHS (National Health Services) has denied Hifu (High Intensity Focused Ultrasound) to victims of prostate cancer.
The U-turn comes despite the research published last month in the European Journal of Urology which found that eight out of 10 men were healthy five years after being treated with Hifu.
That seems like a scary and irrational way to save money. Sounds to me like if more men had that treatment to cure their cancer it would possibly save money on other therapies in the long run. Not to mention the benefits to quality of life.
Also, I like your new avatar! 🙂
Post Prostate Cancer Surgery Problem – Bladder Neck Contracture. Please Help Me.?
I am looking for some information that can help my father in law’s urological problem.
14 months ago he was diagnosed with prostate cancer and underwent High Intensity Focused Ultrasound (HIFU).
His PSA levels have remained very low but he had developed a nasty side effect from the procedure, a bladder neck contracture. It is scar tissue. It makes him leak, and a very proud man very unhappy.
It shuts off his urine passage and puts his kidneys as risk.
He has undergone 3, maybe 4 surgeries called a bladder neck incision, to reopen the obstructing scar tissue. He did fine for about a month or so, but the contracture returned.
My wife and I are at our wits end because he has to wear an indwelling foley catheter all the time now.
His new urologist is recommending a permanent Urolume prostate stent be placed to keep his bladder neck open. The urologist warned us that it could make him leak urine but that can be fixed later with an artificial sphincter implant. I have read some really nasty things about these online. I just don’t know where we can get help or the information we need to find a better alternative. There just must be something??
My father has gone from an robust, active father and grandfather to a shell of a man.
Depression has set in and drugs barely make a difference. He can’t go on this way. We’ve gone from an easy treatment for his prostate cancer to a living nightmare.
Does anybody have personal experience with this terrible situation and will you share how you handled it? We really need some good advice.
This is a difficult situation. HIFU is a destructive energy source which can leave the affected area with decreased blood supply and prone to scarring. One question that would help clarify the situation a bit is whether he only had transurethral INCISIONS of this bladder neck contracture or if he had a real transurethral RESECTION (removal) of the scar tissue. If he only had bladder neck incisions, then an aggressive transurethral resection would be a reasonable option, recognizing that it places him at high risk of incontinence. I would try to use the Urolume only as a last resort. As you have read, it has a high incidence of complications and is often uncomfortable or downright painful for the person in whom it is placed. Think about where that metal mesh scaffold is placed…right in front of the anus, right where you sit.
If he has already had a good transurethral resection of the scar tissue and it contracted down again, another option is to repeat the resection and have him keep it open by performing self-cath at regular intervals.
NHS denying prostate cancer victims help?
In the U.K., the NHS (National Health Services) has denied Hifu (High Intensity Focused Ultrasound) to victims of prostate cancer.
The U-turn comes despite the research published last month in the European Journal of Urology which found that _eight_ out of 10 men were healthy five years after being treated with Hifu.
The groundbreaking ultrasound therapy has been shown to kill _nine_ out of 10 prostate tumours, and five years after treatment, 80 per cent of patients show no sign of the cancer recurring.
(inspired by the same question asked elsewhere)
Good point mattcy… I knew I’d forgotten something in that.
So my question is:
How do *you* feel knowing that men are being killed off when a treatment is available that could save their lives?
OK, so it may not affect all of you (e.g. those in another country) but if you were in England, or had a very close relative (Brother, Father, Uncle, Nephew, etc.) who did live here – would you think it ok that the UK government spend endless amounts of money on Breast cancer – but won’t give a proven treatment to men?
As a Man I am appalled. As a Nurse I am disgusted. As a Human Being I am ashamed of my entire species for the way in which ‘Men’s Health’ issues are allowed to be ignored, and the way some members of our society profit from the promotion of ‘Women’s Heath’ projects at the expense of men.
If I were to tell you that only 1/9 th of 1 cent out of every 0.00 raised for cancer research is spent on all three of the “Male Gender Specific Cancers” (Prostate, Penile and Testicular) people would think that I was mad. More men die each year from prostate cancer than do women from Breast Cancer, yet the ‘women’s movement’ only gives support to this issue when it is ‘politically expedient’ for them to do so. How many companies sponsor ‘Breast Cancer’ related research and detection programs, yet turn a blind eye to the needs of men? I once commented the men’s health was a feminist issue, and was laughed at. Go figure.
what is HIFU?
High Intensity Focussed Ultrasound
High intensity focused ultrasound
HIFU (high intensity focused ultrasound) (sometimes FUS or HIFUS) is a highly precise medical procedure using high-intensity focused ultrasound to heat and destroy pathogenic tissue rapidly. It is one modality of therapeutic ultrasound, and although it induces hyperthermia it should not be confused with this technique which heats much less rapidly and to much lower therapeutic temperatures (generally < 45oC). This is typically under computerized MRI guidance, when it is sometimes called Magnetic Resonance guided Focused Ultrasound, often shortened to MRgFUS. Magnetic resonance imaging (MRI) is used to identify tumors or fibroids in the body, before they are destroyed by the ultrasound. MRgFUS is currently used in the US, Israel, Europe, and Asia to treat uterine fibroids. Current clinical trials are underway, examining the possible use of the technique in the treatment of cancers of the brain, breast, liver, and bone. Therapeutic ultrasound is a minimally invasive or non-invasive method to deposit acoustic energy into tissue. Applications include tissue ablation (HIFU) (for tumor treatments, for example), hyperthermia treatments (low-level heating combined with radiation or chemotherapy), or the activation or enhanced delivery of drugs. The Foundation for Focused Ultrasound Research is promoting research into medical uses of high intensity focused ultrasound. The International Society of Therapeutic Ultrasound may be found at: www.itsu.org Aiming The ultrasound beam can be focused in these ways:- Geometrically, for example with a lens or with a spherically curved transducer. Electronically, by adjusting the relative phases of elements in an array of transducers (a "phased array"). By dynamically adjusting the electronic signals to the elements of a phased array, the beam can be steered to different locations, and aberrations due to tissue structures can be corrected. How HIFUS works As an acoustic wave propagates through the tissue, part of it is absorbed and converted to heat. With focused beams, a very small focus can be achieved deep in tissues. When hot enough, the tissue is thermally coagulated. By focusing at more than one place or by scanning the focus, a volume can be thermally ablated. At high enough acoustic intensities, cavitation (microbubbles forming and interacting with the ultrasound field) can occur. Microbubbles produced in the field oscillate and grow (due to factors including rectified diffusion), and eventually implode (inertial or transient cavitation). During inertial cavitation, very high temperatures inside the bubbles occur, and the collapse is associated with a shock wave and jets that can mechanically damage tissue. Because the onset of cavitation and the resulting tissue damage can be unpredictable, it has generally avoided in clinical applications. However, cavitation is currently being investigated as a means to enhance HIFU ablation and for other applications. Method of use In HIFU therapy, ultrasound beams are focused on diseased tissue, and due to the significant energy deposition at the focus, temperature within the tissue rises to 65° to 85°C, destroying the diseased tissue by coagulation necrosis. Each "sonication" of the beams treats a precisely defined portion of the targeted tissue. The entire therapeutic target is treated by moving the applicator on its robotic arm in order to juxtapose multiple shots, according to a protocol designed by the physician. This technology can achieve precise "ablation" of diseased tissue, therefore being called HIFU surgery. Because it destroys the diseased tissue non-invasively, it is also known as "Non-invasive HIFU surgery". Anesthesia is not required. The treatment can be combined with radiotherapy or chemotherapy. Uses Uterine fibroids Development of this therapy significantly broadened the range of treatment options for patients suffering from uterine fibroids. HIFU treatment for uterine fibroids was approved by the Food and Drug Administration (FDA) in October 2004. Cancer HIFU has been successfully applied in treatment of cancer to destroy solid tumors of the bone, brain, breast, liver, pancreas, rectum, kidney, testes, prostate.  A lot of the initial studies have been performed by F. Wu and coworkers at the Chongqing Medical University, Chongqing, China. At this stage cancer treatments are still in the investigatory phases as there is a need to find more about their effectiveness. The earliest widespread use of HIFU ablation was as a treatment for prostate cancer. Developed and refined by two companies in Europe and the United States, this treatment is administered through a trans-rectal probe and relies on heat developed by focusing ultrasound waves into the prostate to kill the tumor. Promising results approaching those of surgery have been reported in large series of prostate cancer patients. These treatments are performed under ultrasound imaging guidance, which allows for treatment planning and some minimal indication of the energy deposition. In addition, several thousand patients with different types of tumors have been treated in China with HIFU using ultrasound imaging-guided devices built by several different companies. Currently, one of these devices is undergoing clinical trials in Europe. History The first investigations of HIFU for non-invasive ablation were reported by Lynn et al in the early 1940's. Important early work was performed in the 1950's and 1960's by William and Francis Fry at the University of Illinois, culminating in clinical treatments of neurological disorders. Until recently, clinical trials of HIFU for ablation were few (although significant work in hyperthermia was performed with ultrasonic heating), perhaps due to the complexity of the treatments and the difficulty of targeting the beam noninvasively. With recent advances in medical imaging and ultrasound technology, interest in HIFU ablation of tumors has increased. The first commercial HIFU machine, called the Ablatherm, was developed by the French company EDAP-TMS (NASDAQ: EDAP) and launched in Europe in 2001 after receiving CE approval, bringing a first medical validation of the technology for localized prostate cancer. Comprehensive studies by practitioners at more than one site using the device have demonstrated clinical efficacy at more than 8 years with limited occurrence of side effects. Studies by Murat and colleagues at the Eduard Herriot Hospital in Lyon in 2006 showed that after treatment with Ablatherm, progression-free survival rates are very high for low- and intermediate- risk patients with recurrent prostate cancer (70% and 50% respectively) HIFU treatment of prostate cancer is currently an approved therapy in Europe, Canada, South Korea, Australia, and elsewhere. Clinical trials in the United States are expected to begin in 2006. Advantages over other techniques High Intensity Focused Ultrasound is often considered a promising technology within the non-invasive or minimally invasive therapy segments of medical technology. HIFU’s capacity to generate in-depth precise tissue necrosis using an external applicator, with no effect on the surrounding structures, is unique. The history of using therapeutic ultrasound dates back to early in the 20th century. Technology has continually improved and additional clinical applications, both diagnostic and therapeutic, have become an integral part of medicine today. An important difference between HIFU and many other forms of focused energy, such as radiation therapy or radio surgery, is that the passage of ultrasound energy through intervening tissue has no apparent cumulative effect on that tissue. Discoveries during use Currently, the only proven imaging method to accurately quantify the heating produced during HIFU in vivo is Magnetic Resonance Imaging (MRI). MRI also has superior soft tissue contrast and can image in any orientation, making it the state of the art for guiding HIFU treatments. Clinically, MRI-guided HIFU treatments have been tested for uterine fibroids, breast fibroadenomas, breast cancer, bone metastases, and liver tumors. Clinical trials of MRI-guided transcranial HIFU of brain tumors started in 2004. The largest number of patients treated with MRI-guided HIFU have been with uterine fibroids. Ultrasound-guided HIFU treatments have been approved in Europe and Asia. MRI-guided treatments of uterine fibroids have been approved in Europe and Asia, and were granted FDA approval in the US in 2004.
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