title: Whole-gland salvage high-intensity focused ultrasound therapy for localized prostate cancer recurrence after external beam radiation therapy.
abstract: BACKGROUND
  Whole-gland high-intensity focused ultrasound (HIFU) has been used as salvage therapy for local recurrence following external beam radiation therapy for decades. This article describes the use of the Sonablate 500 HIFU system in the salvage setting.
  
  
  METHODS
  An evaluation was performed of a consecutive group of men with biochemical failure after external beam radiation therapy with histologically proven local recurrence and bone-scan and pelvic magnetic resonance imaging to exclude macroscopic metastases, and who chose to have whole-gland salvage HIFU (Sonablate 500) at 2 centers (3 expert HIFU surgeons at each center). The modified Clavien system was used to categorize adverse events and validated questionnaires for functional outcomes. Progression following HIFU treatment was defined as ASTRO-Phoenix criteria (prostate serum antigen [PSA] >nadir+2 ng/mL) and/or a positive biopsy and/or start of hormone therapy.
  
  
  RESULTS
  Eighty-four men underwent whole-gland salvage HIFU (2004-2009). Median age, pretreatment serum PSA, and biopsy Gleason score was 68 years (range, 64-72 years), 4.3 ng/mL (range, 1.9-7.9 ng/mL), and 7 (range, 6-7), respectively. Mean follow-up was 19.8 months (range, 3.0-35.1 months). After salvage HIFU, 62% of the men were pad-free and leak-free. Mean International Index of Erectile Function-5 point score fell from 8.8 to 4.7 (P < .001). International Prostate Symptoms Score and RAND-SF36 scores were not affected. Two men developed rectourethral fistulae after 1 salvage procedure. A further 2 fistulae occurred in the 6 men undergoing a second salvage HIFU. Intervention for bladder outlet obstruction was needed in 20% (17 of 84 patients). If PSA nonresponders were included, 1- and 2-year progression-free survival rates were 59% (50 of 84 patients) and 43% (36 of 84 patients), respectively. If PSA nonresponders were excluded, 1- and 2-year progression-free survival rates were 62% (48 of 77 patients) and 48% (37 of 77 patients), respectively.
  
  
  CONCLUSIONS
  Salvage whole-gland HIFU is a high-risk procedure. Although its use in early cancer control is promising, strategies to better identify metastatic disease prior to salvage therapy and reduce local toxicity are needed to improve on this.
authors.affiliation: Division of Surgery and Interventional Science, University College London, London, UK. hashim.ahmed@ucl.ac.uk
authors.forename: Hashim
authors.initials: H
authors.lastname: Uddin Ahmed
authors.forename: Paul
authors.initials: P
authors.lastname: Cathcart
authors.forename: Venu
authors.initials: V
authors.lastname: Chalasani
authors.forename: Andrew
authors.initials: A
authors.lastname: Williams
authors.forename: Neil
authors.initials: N
authors.lastname: McCartan
authors.forename: Alex
authors.initials: A
authors.lastname: Freeman
authors.forename: Alex
authors.initials: A
authors.lastname: Kirkham
authors.forename: Clare
authors.initials: C
authors.lastname: Allen
authors.forename: Joseph
authors.initials: J
authors.lastname: Chin
authors.forename: Mark
authors.initials: M
authors.lastname: Emberton
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018572:Disease-Free Survival; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000628:therapy; D011471:Prostatic Neoplasms / Q000532:radiotherapy / Q000601:surgery*; D019233:Retreatment / Q000379:methods; D016879:Salvage Therapy / Q000379:methods; D016896:Treatment Outcome; D036761:Ultrasound, High-Intensity Focused, Transrectal / Q000379:methods*