Letter to the Editor
Reply to Runqiang Yuan and Hongxing Huang’s 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–
We thank Drs. Yuan and Huang for their interest in our
study on high-intensity focused ultrasound (HIFU) hemi-
ablation for prostate cancer
. While the authors have
raised some thoughtful questions, we feel the dynamics in
the concept of this novel treatment should be appreciated.
Focal therapy or partial gland ablation (PGA) is currently a
novel approach with the intent of providing curative
treatment in selected patients with localized prostate
. Within a short time span, we have seen
significant changes in many aspects of PGA, such as patient
selection criteria, the role of magnetic resonance imaging
(MRI), and improvements in image guidance technology
and surveillance strategies[3–5]
. As evident from the
literature and focal therapy consensus statements, there is a
clear shift in the target population for PGA from patients
eligible for active surveillance to selected patients with
intermediate-risk cancer. Our prospective study (2009) was
designed at the time when the first consensus statement on
focal therapy was published, and a 33% positive core cutoff
was a proposed recommendation for patient selection from
the consensus meeting
. This was based on the report by
Kestin et al
demonstrating that percentage positive
cores can be a powerful predictor of biochemical and
clinical outcome for prostate cancer. We performed at
least two sets of transrectal ultrasound biopsies before
focal therapy, which amounted to 20 or more biopsy
cores. However, with the current routine use of MRI
fusion biopsy, the biopsy criteria for selecting patients for
PGA are vastly different. The PGA selection criteria we
currently use are:
(1) Life expectancy
(2) Gleason score 7 (4 + 3).
(3) Prostate-specific antigen (PSA) 15 ng/ml.
(4) Biopsy proven concordant with the dominant region of
interest on MRI.
(5) No imaging evidence of extraprostatic extension,
seminal vesicle invasion, or lymph node involvement.
(6) In patients with a negative MRI finding, biopsy
positivity within one lobe of the prostate in the
contiguous segments is considered eligible.
(7) Presence of multifocal Gleason score 6 (3 + 3) disease
outside the index lesion is considered eligible.
We completely understand that prostate is a symmetric
organ, but there is an ascertainment bias as patients are
carefully selected based on biopsy and MRI characteristics
and consent for the procedure. If all consecutive patients
with prostate cancer were treated with PGA and a sufficient
sample size was attained, the symmetric distribution of
cancer could be observed. We believe that the highest rate
of tumor at the base is because thermal-based ablative
procedures (cryotherapy/HIFU) may not be an ideal energy
option for apical tumours. In accordance with our institu-
tional guidelines, we follow an ‘‘a` la carte’’ model to decide
the type of energy used for ablation on the basis of the
topographic location of the cancer within the prostate
Measuring patient-reported outcomes following PGA is
vital, and one of the limitations of our study at the time of
publication was the unavailability of 12-mo data. However,
the follow-up for functional outcomes in our cohort was very
similar to results reported in the literature .
To update the
functional outcomes, all patients were continent at 12 mo.
The mean International Prostate Symptom Score returned
almost to baseline, and potency was noted in 80% of
previously potent men. However, the mean age of this cohort
was 70.2 yr, and only 21/71 men had potency. Although
most men recovered their baseline International Index of
Erectile Function score at 12 mo, it is difficult to reach
conclusions because of the ‘‘poor’’ sexual activity of the
patients in this group. The adverse functional outcomes
observed after PGA are noted in the initial few months, with
a gradual return to baseline. A possible reason for this
observation is resulting prostatic inflammation and oedema.
Conflicts of interest:
The authors have nothing to disclose.E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) e 1 4 8 – e 1 4 9
available atwww.scienced irect.com
DOIs of original articles:http://dx.doi.org/10.1016/j.eururo.2016.10.044 , http://dx.doi.org/10.1016/j.eururo.2015.06.018
2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.