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Letter to the Editor

Re: Ernesto R. Cordeiro Feijoo, Arjun Sivaraman,

Eric Barret, et al. Focal High-intensity Focused

Ultrasound Targeted Hemiablation for Unilateral

Prostate Cancer: A Prospective Evaluation of Oncologic

and Functional Outcomes. Eur Urol 2016;69:214–20

We read the article by Cordeiro Feijoo et al


with great

interest. This was a prospective study in a single center

evaluating oncologic and functional outcomes for 67 patients

with unilateral organ-confined prostate cancer treated with

focal high-intensity focused ultrasound hemiablation.

Results in terms of post-treatment control biopsies and

prostate-specific antigen (PSA) indicated that this treatment

yielded satisfactory tumor control over short-term follow-

up. Meanwhile, recovery data for urinary and erectile

functions demonstrated minimal postoperative functional

changes. We would like to pose some questions about the

study in the hope of gaining a better understanding of the

relevant application of focal therapy in prostate cancer.

On the basis of recent studies, focal therapy is

recommended for patients with low- and intermediate-

risk disease. The inclusion criteria adopted by Cordeiro

Feijoo et al


were similar to the current expert consensus


. One of the inclusion criteria was maximum positive



33%. However, the authors did not report a

specific upper limit and there was no relevant information

about positive biopsies in the article. Given that the median

number of biopsy cores was 22, 33% of this should equate to

approximately seven. According to the Epstein criteria,

tumors with three or more positive biopsy cores should be

classified as clinically significant

[3] .

The aim of focal

therapy is eradication of all identifiable significant tumor


. We would like to know why maximum positive



33% rather than fewer than three positive biopsy

cores was selected as the study inclusion criterion.

The prostate is a bilaterally symmetric organ. There

should be no significant difference in tumor incidence rates

between the left and right sides of the prostate. However,

the tumor distribution results reported by Cordeiro Feijoo

et al


were 37.3% for the left side and 62.7% for the right.

We wonder if this resulted from a small sample size or

selection bias. Some studies have revealed that in the early

stage of prostate cancer, the tumor incidence rate is higher

in the apex than in the basal part of the gland


. However,

the results described by Cordeiro Feijoo et al


show the

opposite. We are curious about the reasons for this

difference. Side effects are usually apparent within 3 mo

after focal therapy, and it is recommended that functional

assessments are carried out at 12 mo after treatment

[4] .


the study by Feijoo et al


, median follow-up was 12 mo,

but functional outcomes were evaluated at 3 mo. We

wonder why the authors did not evaluate functional

outcomes at 12-mo follow-up.

Conflicts of interest:

The authors have nothing to disclose.



Cordeiro Feijoo ER, Sivaraman A, Barret E, et al. Focal high-intensity focused ultrasound targeted hemiablation for unilateral prostate cancer: a prospective evaluation of oncologic and functional out- comes. Eur Urol 2016;69:214–20



van den Bos W, Muller BG, Ahmed H, et al. Focal therapy in prostate cancer: international multidisciplinary consensus on trial design. Eur Urol 2014;65:1078–83



Oon SF, Watson RW, O’Leary JJ, Fitzpatrick JM. Epstein criteria for insignificant prostate cancer. BJU Int 2011;108:518–25.


Postema AW, De Reijke TM, Ukimura O, et al. Standardization of definitions in focal therapy of prostate cancer report from a Delphi consensus project. World J Urol 2016;34:1373–82



Takashima R, Egawa S, Kuwao S, Baba S. Anterior distribution of stage T1c nonpalpable tumors in radical prostatectomy specimens. Urology 2002;59:692–7


Runqiang Yuan

Hongxing Huang*

Department of Urology, Zhongshan City People’s Hospital, Zhongshan,

Guangdong, People’s Republic of China

*Corresponding author. Department of Urology, Zhongshan City People’s

Hospital, 2 Sun Wen Zhong Road, Zhongshan, Guangdong 528403,

People’s Republic of China.

E-mail address:

(H. Huang).

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) e 1 4 7

ava ilable at

journal homepage:

DOI of original article:




2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.