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MRI after HIFU Treatment is not a Reliable Determinant for Clinically Significant Prostate Cancer
Ignacio San Francisco, MD, Ra'ad Al-Faouri, MD, MMSc,
Agustin Perez-Londono, MD., Andrew A. Wagner, MD, Peter Chang, MD, MPH, Boris Gershman, MD, Aria F. Olumi, MD.
Beth Israel Deaconess Medical Center, Boston MA, MA, USA.
BACKGROUND:Focal therapy is gaining popularity as an alternative between active surveillance and radical therapy for localized, intermediate-risk prostate cancer (PCa). High-Intensity Focused Ultrasound (HIFU), a form of focal therapy for management of prostate cancer, has gained popularity for treatment of intermediate risk prostate cancer, however, post-treatment management is not standardized and there is no consensus on follow-up protocols, including the role and accuracy of imaging and biopsies.
METHODS: Men with biopsy-proven, intermediate-risk, localized PCa were offered HIFU therapy. Prior to treatment, patients underwent template prostate biopsy, prostate MRI, and genomic testing (OncotypeDX). Baseline IPSS, PSA, and PIRADS scores were recorded. Follow-up included post-treatment MRI and biopsy one year after HIFU.
RESULTS: We treated 39 men, with ISUP Grade groups as follows: 1 (2.6%), 2 (66.7%), 3 (25.6%), and 4 (5%). Mean follow-up time was 6.6 months. Median PSA decreased from 6.4 ng/ml to 2.6 ng/ml at first follow-up (p<0.01). Post-HIFU MRI and biopsy were performed in 16 (41%) and 11 (28%) men, respectively. Among those who had a biopsy, 8 had evidence of prostate cancer, with 6 (55%) having clinically significant disease. Only 6 (37%) MRIs showed suspicious lesions. Among patients with positive MRIs (all PIRADS 4), only one had clinically significant disease at the original biopsy site. Of the 10 patients with negative MRIs, 2 (20%) had clinically significant cancer in the same location, and there were two new contralateral lesions (NPV: 60%). There was no significant difference in pre- and post-HIFU IPSS scores (p = 0.15).
CONCLUSIONS: HIFU is a promising approach for selected PCa patients. Despite a significant PSA decline, clinically significant PCa persisted in 20% of treated areas. MRI had a low negative predictive value, making it unreliable for determining clinically significant prostate cancer after HIFU. Repeat biopsies remain crucial for effective surveillance.
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