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assessment [1]. No androgen deprivation therapy was con-
tinued after HIFU treatment. Prostate biopsies after HIFU
were reported for 60% of patients, and the negative biopsy
rate was 74%. The 5-yr biochemical failure–free survival was
49%, ranging from 58% in low-risk disease at diagnosis to 36%
in high-risk disease. Second HIFU treatment was performed in
12% of cases, and 47% of patients received androgen deprivation
therapy on progression. Factors significantly influencing the
success rate were a low Gleason score, pre-HIFU prostate-spe-
cific antigen (PSA) of < 4 ng/ml, and the absence of a previous
history of androgen deprivation therapy.
Expert's comments:
Salvage HIFU is a recommended treatment or retreatment
option for local recurrence after failure of external-beam
radiotherapy [2] . It has been reported that this technique
is associated with less functional harm than salvage radical
prostatectomy [3] . These results published for this largest case
series confirm the role of HIFU in the management of locally
recurrent prostate cancer. Globally, oncologic outcomes were
interesting showing a not negligible cure rate (in terms of
biochemical recurrence/negative biopsy rate) with an accept-
able toxicity. Unfortunately, no strong survival endpoint has
been reported and no control arm has been used. The other
interest of this study is the long-termmedian follow-up in the
recurrent cancer setting (7 yr).
What can we learn from this study? First, it is evident
that we need to improve patient selection and shorten the
time to recurrence treatment. The mean pre-HIFU PSA was
6.8 ng/ml in the cohort, which means that treatment was
started too late for the majority of the patients. Radiation
oncologists and urologists should be aware of this need for
early management of recurrence to avoid any delay in
treatment initiation. New imaging modalities such as
magnetic resonance imaging and positron emission
tomography/computed tomography with choline or a
prostate-specific membrane antigen ligand in association
with targeted biopsies can identify intraprostatic recur-
rence, even in the case of low PSA values, and their use
should not be postponed when PSA recurrence (nadir + 2)
occurs.
Second, the study shows that experience and technique
improvements clearly matter. The safety profile was
acceptable, with an incontinence rate of 19%, but only for
the most recent procedures. Thus, after the integration of
specific postradiotherapy parameters in 2002, the rate of
rectourethra fistula dropped from 9% to 0.6% in the
contemporary cohort. Imaging-directed HIFU treatment
(hemiablation, focal treatment) and the use of next-
generation devices could also contribute to improvements
in functional outcomes without negatively influencing
oncologic results .
Conflicts of interest: The author has nothing to disclose.
References
[1]
.
[2]
.
[3]
.
[4]
[5]
Guillaume Ploussarda,b,*
aDivision of Uro-Oncology, Institut Universitaire du Cancer Toulouse
Onocopole, Toulouse, France
bDepartment of Urology, Saint Jean Languedoc Hospital, Toulouse, France
*Department of Urology, Saint Jean Languedoc Hospital, 20 route de
Revel, Toulouse 31400, France.
E-mail address: .
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Metastasis-free Survival Is a Strong Surrogate
of Overall Survival in Localized Prostate Cancer
Xie W, Regan MM, Buyse M, et al
J Clin Oncol 2017;35:3097–104
Expert's summary:
The Intermediate Clinical Endpoints in Cancer of the Prostate
working group analyzed data from 28 randomized controlled
trials comparing treatments in localized prostate cancer
(PCa). Disease-free survival (DFS) was determined for
21 140 patients from 24 trials and metastasis-free survival
(MFS) for 12 712 patients from 19 trials [1]. The surrogacy of
DFS and MFS for overall survival (OS) was evaluated using a
meta-analytical two-stage validation model in which two
conditions must hold to claim DFS and MFS as a surrogate
for OS. After median follow-up of 10 yr, 45% of the study
populations experienced a DFS or MFS event, and 63% and
66% of these patients, respectively, had high-risk disease.
MFS is a strong surrogate for OS (at a patient level, Kendall's g
for correlation with OS was 0.91; at a trial level, R 2 was 0.83,
with 95% confidence interval 0.71– 0.88) in a patient popula-
tion with clinically localized PCa with an approximate 15%
risk of dying from PCa over 10 yr despite potentially curative
local therapy.
Expert's comments:
Despite great improvements in drug development that have
prolonged the life of men with metastatic castration-resistant
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