High rate of adverse features at salvage radical prostatectomy compared to initial diagnosis in men who experience recurrence following high intensity focused ultrasound as primary treatment of localized prostate cancer
BAUS ePoster online library. Thompson J.
Jun 26, 2018; 211351
James Thompson
James Thompson
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Introduction: Our objective was to describe the pathologic recurrence patterns at salvage robot-assisted radical prostatectomy (sRARP) post-HIFU.

Patients and Methods: Retrospective analysis, 34 men who underwent sRARP after primary HIFU, single institution 2012-2017. Clinico-pathological characteristics pre-HIFU and pre-sRARP were compared against final sRARP histology. In-field recurrence (IFR), out-of-field disease (OFD), PSMs and MRI accuracy were assessed.

Results: Median age 64yrs, PSA 7.8ng/dL, ISUP 2 (70.6%), MCCL 7mm. 55.9% had multifocal disease pre-HIFU. 47.1% had known 'insignificant' cancer outside the treatment field. Median time to failure was 16 months. Oncologic indications for sRARP were IFR 55.8%, OFD 20.6%, both 23.5%. No men were suitable for bilateral nerve sparing: 16% underwent unilateral nerve-sparing, 84% bilateral wide excision. On sRARP histology, disease was multi-focal in 94.2%; most frequently apical PZ (85.3%). Significant (ISUP≥2) IFR, OFD or both were found in 97.1%, 81.3% and 79.4% respectively. 82.4% experienced adverse reclassification at sRARP versus pre-HIFU, 67.6% versus pre-sRARP.
The PSM rate was 38.2% (30.8% pT2, 42.9% pT3; 14.7% apical, 23.5% posterolateral), 85% were in-field or at HIFU margins, despite wide excision of the HIFU-field. The sensitivities of post-HIFU MRI for IFR, OFD and T3a/b were 81.8%, 65.4% and 10% respectively.

Conclusions: In men failing primary HIFU, rates of upgrading, upstaging and PSMs were high; nerve sparing was infrequently feasible. Disease was under-estimated by MRI/ targeted biopsy. This may inform primary treatment and sRARP counselling. The high IFR rate demonstrates HIFU occasionally fails to ablate the tumour in vivo, in addition to the risk of OFD.
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