HIFU in der Salvage Behandlung von Patienten mit Prostatakarzinom-Rezidiv nach primärer externer Bestrahlungstherapie – Status 2012

Zusammenfassung

Hintergrund:

Bei einem (Lokal)Rezidiv nach Bestrahlungstherapie eines Prostatakarzinoms stehen Therapeut und Patient vor der Herausforderung der adäquaten Diagnostik und Therapiewahl. Viele Patienten erhalten in dieser Krankheitssituation eine alleinige palliative Androgenentzugstherapie mit fraglichem Einfluss auf das Gesamtüberleben. Bei isoliertem Lokalrezidiv jedoch steht mit der Salvage-Prostatektomie ein potentiell kuratives Verfahren mit allerdings hoher Nebenwirkungsrate zur Verfügung. Diesen Patienten kann als lokale Therapiealternative ebenfalls die Salvage-HIFU-Therapie angeboten werden.

Material und Methoden:

Die Salvage-HIFU-Therapie basiert auf einer thermischen Schädigung des Gewebes durch das Erzeugen von Hitze mittels Intensivierung und Fokussierung von Ultraschallwellen. Weiterhin kommt es zur Bildung von Gasbläschen, bei deren Kollaps immense Drücke entstehen die zur mechanischen Zerstörung des Zielgewebes führen (Kavitation).

Ergebnisse:

Es werden die Ergebnisse von 6 monozentrischen Studien (2004–2011) mit insgesamt 408 Patienten (22–167 Patienten) präsentiert und kritisch bewertet. Das mediane Follow-up betrug 18,71 Monate (7,4–39 Monate). Das 3-Jahres progressionsfreie Überleben lag je nach Risikogruppe und Risikogruppenstratifizierung bei 25% (high-risk nach D’Amico) bis 53% (low-risk nach D’Amico), das Gesamtüberleben nach 5 Jahren bei 90%. Die Inkontinenzrate lag bei 7–60% über alle Schweregrade (III°iger Inkontinenz: 0–9,5%). Bei 22 Patienten wurde eine operative Inkontinenztherapie durchgeführt. 53 Patienten entwickelten postinterventionell eine behandlungsbedürftige urethrale Stenose. In 0–7% entwickelten sich behandlungsbedürftige rektourethrale Fisteln.

Schlussfolgerung:

Die aktuelle Datenlage zur Salvage-HIFU-Therapie ist als unzureichend zu bewerten. Wichtigste Kritikpunkte sind die fehlende Randomisierung, die monozentrischen und retrospektiv erhobenen Daten, sowie die uneinheitliche Risikogruppenstratifizierung und Definition des Therapieversagens postinterventionell. Die Studien deuten an, dass die Salvage-HIFU-Therapie hinsichtlich der mittelfristigen Krankheitsfreiheit sowie der Nebenwirkungsrate den anderen Salvage-Lokaltherapien nicht unterlegen zu sein scheint. Es bedarf jedoch einer randomisierten multizentrischen Validierung der Ergebnisse.

Abstract

Background:

Patients with (local) recurrence of prostate cancer after radiation therapy face the question of the appropriate diagnostic and possible therapeutic options. Many patients in this setting receive palliative androgen deprivation therapy alone, with arguable impact on overall cancer survival. In the case of an isolated local recurrence, salvage prostatectomy represents a potentially curative therapeutic option, albeit with a high complication rate. Alternatively, these patients can be offered a local treatment with salvage HIFU therapy.

Material and Methods:

Salvage HIFU therapy is based on the thermal ablation of tissue through high-intensity focused ultrasound. In addition, the formation of microbubbles (cavitation) and their implosion lead to an enhancement of tissue ablation.

Results:

The results of 6 monocentric studies (2004–2011) with an overall number of 408 patients (22–167 patients) are presented and critically reviewed. The median follow-up was 18.71 months (7.4–39). The 3-year progression free survival (PFS) varied from 25% (D’Amico high risk) to 53% (D’Amico low-risk), the 5-year overall survival was 90%. The rate of urinary incontinence varied between 7 and 60% in all grades (grade III urinary incontinence 0–9.5%). In 22 cases surgical incontinence treatment was performed. 53 patients developed a urethral stricture or stenosis leading to surgical treatment. Urethral-rectal fistulae were seen in 0–7%.

Conclusions:

The current data on salvage HIFU can be evaluated as insufficient. The main criticisms can be seen in the lack of randomization, the monocentric and retrospective analyses of the data, the heterogeneous stratification of risk groups as well as inadequate definition of postinterventional treatment failure. The studies indicate that salvage HIFU therapy leads to a mid-term overall survival with complication rates that are comparable to those of other local salvage therapies. Randomized multicentric studies are needed to further validate the results of salvage HIFU therapy.

Schlüsselwörter

Prostatakarzinom - Rezidiv nach perkutaner Radiatio - Salvage-HIFU-Therapie

Key words

prostate cancer - recurrence after radiation therapy - salvage HIFU therapy

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