COMMENTARY

Unilateral HIFU: More Cons Than Pros(tate)?

Gerald Chodak, MD

Disclosures

March 11, 2016

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Hello. I'm Dr Gerald Chodak, for Medscape. Today I want to talk about a paper by van Velthoven and coworkers,[1] who reported on 50 men who were treated with unilateral high-intensity focused ultrasound (HIFU) for either low-risk or low- to intermediate-risk prostate cancer.

The men were followed for a median of 35 months, and the results found a biochemical recurrence rate of either 28% or 36%, depending on which definition was used.

Side effects included the following:

  • 20% [of men] who had good sexual function prior to the procedure became impotent;

  • 18% developed lower urinary tract symptoms, even though all men had a minimal transurethral resection of the prostate (TURP) as part of the HIFU procedure;

  • 6% developed persistent incontinence;

  • 4% developed a urethral stricture; and

  • 8% developed acute urinary retention.

The authors concluded that unilateral HIFU is a reasonable option to consider for minimally invasive therapy. But one could very easily argue that in a group of men who only had half their gland treated, this is not a fair conclusion—because of the recurrence rate for biochemical disease, brief survival, and the rather high side-effect profile.

Interestingly, of the eight men who had a prostate biopsy as part of their follow-up, only two were completely negative. Three men had cancer detected in the side not treated with HIFU, one was positive on the side that was treated with HIFU, and two were positive on both sides of the gland.

Selecting men clearly is a challenge, but we know from other studies that somewhere around 75% of men have bilateral disease. The idea of offering unilateral therapy seems to be not a very good way to manage men.

In addition, 60% of these men would have been good candidates for active surveillance. To offer them not only a 28%-36% biochemical recurrence rate, but also the side effects that go with it—when no therapy might have been a better or just as reasonable option—makes the argument against HIFU pretty strong.

The bottom line is that focal therapy is looking for an indication, but so far the data have been very weak, as shown here. The idea that you are going to be able to successfully manage men with focal therapy or unilateral therapy, when most of the men are going to have bilateral disease, just does not seem to be a good way to go.

I look forward to your comments. Thank you.

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