HIFU Treatment for Recurrent Prostate Cancer

Efficacy and Safety

The European Urology Oncology guidelines recommend that HIFU should not be considered as a first-line treatment for recurrent prostate cancer, as it has inferior oncological outcomes compared to salvage radiation therapy (SBRT or HDR brachytherapy) and radical salvage prostatectomy 1, 2, 3
A meta-analysis of over 11,000 patients with 150 studies demonstrated that the 5-year recurrence-free survival rate with HIFU salvage therapy ranges from 50% to 60%, with no significant difference in survival between HIFU and other salvage modalities 2, 3, 4
The European Urology Oncology guidelines state that the toxicidade geniturinária profile of HIFU is comparable to other ablative modalities, but superior to salvage radiation therapy 5, 6, 7
Incontinence occurs in approximately 12% of patients, and erectile dysfunction develops in 61% of cases 5, 6, 7

The European Urology Oncology guidelines recommend that before any salvage therapy with HIFU, histological confirmation of recurrence is mandatory 2, 3, 4
PET-PSMA and multiparametric magnetic resonance imaging should be performed for staging 2, 3, 4
Systematic and targeted prostate biopsy is mandatory, as up to 59% of patients may have occult lesions if only targeted biopsies are performed 3, 4
The patient's life expectancy should be greater than 5-10 years, and the recurrence should be Grade Group ≥2 1, 8, 9

The European Urology Oncology guidelines recommend that HIFU salvage therapy should only be considered when the competitive risk of death or distant metastases is low, and the toxicity of previous radiation therapy was minimal or resolved 2, 3, 4
The patient should desire local salvage therapy, and have a life expectancy greater than 5-10 years 2, 3, 4

The European Urology Oncology guidelines recommend prioritizing SBRT or HDR brachytherapy as preferred salvage therapies, due to their favorable toxicity profiles and equivalent oncological efficacy 2, 3, 4
Radical salvage prostatectomy remains an option for selected patients 1, 8, 9

For confirmed focal recurrences, whole-gland treatment (prostatectomy or radiation therapy) should be offered as the standard 1, 8
Focal HIFU may be considered only in well-designed clinical trials or prospective registries 5, 6, 7

HIFU should never be performed based solely on positive imaging findings, due to the 8% false-positive rate of PET-PSMA, mainly due to post-treatment changes 4
Approaches that combine biopsy and focal ablation simultaneously should be avoided, as histological confirmation should always precede treatment 2, 3
The Phoenix criterion (nadir + 2 ng/mL) should not be used to define failure after HIFU, as it was validated for radiation therapy, not ablation 1