- Email: [email protected]
Re: Tumor Target Volume for Focal Therapy of Prostate Cancer—Does Multiparametric Magnetic Resonance Imaging Allow for a Reliable Estimation?
Letters to the Editor/Errata Re: Tumor Target Volume for Focal Therapy of Prostate CancerdDoes Multiparametric Magnetic Resonance Imaging Allow for a Reliable Estimation? F. Cornud, G. Khoury, N. Bouazza, F. Beuvon, M. Peyromaure, T. Flam, M. Zerbib, P. Legmann and N. B. Delongchamps J Urol 2014; 191: 1272e1279.
To the Editor: Cornud et al address the value of preoperative multiparametric magnetic resonance imaging (mpMRI) for determining a focal therapeutic treatment plan. By taking whole mount radical prostatectomy specimens as the reference standard, the authors calculated the accuracy of single mpMRI sequences alone or in combination to determine which predicted better actual tumor volume. They found that the use of “target volume,” defined using the largest tumor area visible on any mpMRI sequence, reduced volume underestimation to a minimum of 17% but in turn led to an overestimation of actual tumor volume in 44% of cases. We would like to highlight some issues that may have affected the results. In this study no mpMRI scoring system was used. Indeed, PI-RADS (Prostate Imaging Reporting and Data System) and other scoring systems have been strongly recommended by international societies and consensus panels to maximize the usefulness of preoperative mpMRI.1,2 This assessment is important, as no definitive conclusion can be derived without knowing the radiological likelihood of disease. In addition, it is increasingly accepted that the primary aim of focal therapy is to decrease the toxicity of active treatments while preserving overall survival in men who are likely to benefit from active treatment (ie those with intermediate to high risk localized disease).3 In this series mpMRI was able to detect 83 of 99 clinically significant tumors (83.8%). However, the key finding is that tumors that remained undetected were significantly smaller. Furthermore, of the 16 tumors that were not visible (16.2%) 7 were Gleason 6, and none of the remaining 9 demonstrated primary Gleason pattern 4. If the aim of mpMRI is to detect only tumors that are likely to impact survival, it could be argued that almost all of these tumors were detected. Finally, in every tissue preserving surgery for cancer the key aspect is the extent of the margin required. Considerable work has gone into defining surgical margin extent for partial nephrectomy, segmental ureterectomy and partial penectomy as these operations have evolved from whole organ procedures. In each of these procedures it is recommended that a defined surgical margin be included, which is guided by but not rigidly dependent on imaging. Focal therapy in prostate cancer will not differ from other oncologic tissue preserving procedures. Therefore, while mpMRI is an excellent tool for detection of suspicious clinically significant prostate cancer, and tools to improve surgical decision making such as fusion software or in gantry interventions are likely to increase the precision of detection and treatments, surgical margins will ultimately remain the preserve of the surgeon who during the operation needs to determine exactly how wide to take the cryotherapy ice ball or the high intensity focused ultrasound sonications to impart the most effective therapeutic ratio for the individual patient. There is yet much to be done to provide an evidential basis for the extent of the margin, just as there was in the evolution from total prostatectomy to nerve preserving prostatectomy.
0022-5347/14/1924-1297/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.04.102 Vol. 192, 1297-1301, October 2014 Printed in U.S.A.
www.jurology.com
j
1297
LETTERS TO THE EDITOR/ERRATA
1298
Respectfully, Massimo Valerio Department of Urology Centre Hospitalier Universitaire Vaudois Lausanne, Switzerland e-mail: [email protected] and
Hashim U. Ahmed Division of Surgery and Interventional Science University College London London, United Kingdom
1. Barentsz JO, Richenberg J, Clements R et al: ESUR prostate MR guidelines 2012. Eur Radiol 2012; 22: 746.
cancer: recommendations from a European consensus meeting. Eur Urol 2011; 59: 477.
2. Dickinson L, Ahmed HU, Allen C et al: Magnetic resonance imaging for the detection, localisation, and characterisation of prostate
3. van den Bos W, Muller BG, Ahmed H et al: Focal therapy in prostate cancer: international multidisciplinary consensus on trial design. Eur Urol 2014; 65: 1078.
Re: Prevalence and Management of Lower Urinary Tract Symptoms in Methamphetamine Abusers: An Under-Recognized Clinical Identity K. C. Koo, D. H. Lee, J. H. Kim, K. H. Rha, B. H. Chung, S. J. Hong and S. Y. Mah J Urol 2014; 191: 722e726.
To the Editor: We read this article with great interest. The authors evaluated the prevalence and management of lower urinary tract symptoms (LUTS) in methamphetamine (METH) abusers. They conclude that LUTS are highly prevalent in METH abusers and pathological dopaminergic mechanisms may have a fundamental role in METH associated LUTS. There are several concerns about these conclusions that require further discussion. LUTS are an important clinical manifestation of diseases of the prostate (benign prostatic hyperplasia, prostatitis, prostate cancer) and bladder (aging related bladder conditions, bladder obstruction, neurogenic bladder).1 Although the authors excluded most of these factors that may cause LUTS, we believe that conditions with a possible link to LUTS, such as accessory gland infection and inflammation, should be among the exclusion criteria. Prostatitis is frequently encountered in daily urology practice, and it has been reported that LUTS may also be associated with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).2 Moreover, the odds of a documented prostatitis diagnosis in younger men are twice those seen in men 51 years or older.1 Therefore, LUTS may simply be secondary to inflammation in patients with concomitant CP/CPPS, which in turn weakens the proposed association of LUTS and METH abuse by the authors. These patients should have at least been administered a National Institutes of Health Chronic Prostatitis Symptom Index questionnaire to exclude CP/CPPS. Baseline I-PSS (International Prostate Symptom Score), quality of life indexes and individual consultations for all participants were used to define LUTS. The I-PSS has been most commonly used for symptom assessment in men with LUTS. However, LUTS in men are so variable that they may not be fully captured by the I-PSS questionnaire alone.3 In addition, uroflowmetry is a frequently used and simple test for diagnosis and followup of LUTS. Although uroflowmetry is a nonspecific test, it can give valuable objective data for readers in this type of study with a small sample size. Finally, in addition to dopamine, several other central nervous system transmitters (eg noradrenaline and g-aminobutyric acid) can modulate voiding. Central dopaminergic pathways exhibit different effects on voiding via actions on multiple receptors at different sites in the
To the Editor: Cornud et al address the value of preoperative multiparametric magnetic resonance imaging (mpMRI) for determining a focal therapeutic treatment plan. By taking whole mount radical prostatectomy specimens as the reference standard, the authors calculated the accuracy of single mpMRI sequences alone or in combination to determine which predicted better actual tumor volume. They found that the use of “target volume,” defined using the largest tumor area visible on any mpMRI sequence, reduced volume underestimation to a minimum of 17% but in turn led to an overestimation of actual tumor volume in 44% of cases. We would like to highlight some issues that may have affected the results. In this study no mpMRI scoring system was used. Indeed, PI-RADS (Prostate Imaging Reporting and Data System) and other scoring systems have been strongly recommended by international societies and consensus panels to maximize the usefulness of preoperative mpMRI.1,2 This assessment is important, as no definitive conclusion can be derived without knowing the radiological likelihood of disease. In addition, it is increasingly accepted that the primary aim of focal therapy is to decrease the toxicity of active treatments while preserving overall survival in men who are likely to benefit from active treatment (ie those with intermediate to high risk localized disease).3 In this series mpMRI was able to detect 83 of 99 clinically significant tumors (83.8%). However, the key finding is that tumors that remained undetected were significantly smaller. Furthermore, of the 16 tumors that were not visible (16.2%) 7 were Gleason 6, and none of the remaining 9 demonstrated primary Gleason pattern 4. If the aim of mpMRI is to detect only tumors that are likely to impact survival, it could be argued that almost all of these tumors were detected. Finally, in every tissue preserving surgery for cancer the key aspect is the extent of the margin required. Considerable work has gone into defining surgical margin extent for partial nephrectomy, segmental ureterectomy and partial penectomy as these operations have evolved from whole organ procedures. In each of these procedures it is recommended that a defined surgical margin be included, which is guided by but not rigidly dependent on imaging. Focal therapy in prostate cancer will not differ from other oncologic tissue preserving procedures. Therefore, while mpMRI is an excellent tool for detection of suspicious clinically significant prostate cancer, and tools to improve surgical decision making such as fusion software or in gantry interventions are likely to increase the precision of detection and treatments, surgical margins will ultimately remain the preserve of the surgeon who during the operation needs to determine exactly how wide to take the cryotherapy ice ball or the high intensity focused ultrasound sonications to impart the most effective therapeutic ratio for the individual patient. There is yet much to be done to provide an evidential basis for the extent of the margin, just as there was in the evolution from total prostatectomy to nerve preserving prostatectomy.
0022-5347/14/1924-1297/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.04.102 Vol. 192, 1297-1301, October 2014 Printed in U.S.A.
www.jurology.com
j
1297
LETTERS TO THE EDITOR/ERRATA
1298
Respectfully, Massimo Valerio Department of Urology Centre Hospitalier Universitaire Vaudois Lausanne, Switzerland e-mail: [email protected] and
Hashim U. Ahmed Division of Surgery and Interventional Science University College London London, United Kingdom
1. Barentsz JO, Richenberg J, Clements R et al: ESUR prostate MR guidelines 2012. Eur Radiol 2012; 22: 746.
cancer: recommendations from a European consensus meeting. Eur Urol 2011; 59: 477.
2. Dickinson L, Ahmed HU, Allen C et al: Magnetic resonance imaging for the detection, localisation, and characterisation of prostate
3. van den Bos W, Muller BG, Ahmed H et al: Focal therapy in prostate cancer: international multidisciplinary consensus on trial design. Eur Urol 2014; 65: 1078.
Re: Prevalence and Management of Lower Urinary Tract Symptoms in Methamphetamine Abusers: An Under-Recognized Clinical Identity K. C. Koo, D. H. Lee, J. H. Kim, K. H. Rha, B. H. Chung, S. J. Hong and S. Y. Mah J Urol 2014; 191: 722e726.
To the Editor: We read this article with great interest. The authors evaluated the prevalence and management of lower urinary tract symptoms (LUTS) in methamphetamine (METH) abusers. They conclude that LUTS are highly prevalent in METH abusers and pathological dopaminergic mechanisms may have a fundamental role in METH associated LUTS. There are several concerns about these conclusions that require further discussion. LUTS are an important clinical manifestation of diseases of the prostate (benign prostatic hyperplasia, prostatitis, prostate cancer) and bladder (aging related bladder conditions, bladder obstruction, neurogenic bladder).1 Although the authors excluded most of these factors that may cause LUTS, we believe that conditions with a possible link to LUTS, such as accessory gland infection and inflammation, should be among the exclusion criteria. Prostatitis is frequently encountered in daily urology practice, and it has been reported that LUTS may also be associated with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).2 Moreover, the odds of a documented prostatitis diagnosis in younger men are twice those seen in men 51 years or older.1 Therefore, LUTS may simply be secondary to inflammation in patients with concomitant CP/CPPS, which in turn weakens the proposed association of LUTS and METH abuse by the authors. These patients should have at least been administered a National Institutes of Health Chronic Prostatitis Symptom Index questionnaire to exclude CP/CPPS. Baseline I-PSS (International Prostate Symptom Score), quality of life indexes and individual consultations for all participants were used to define LUTS. The I-PSS has been most commonly used for symptom assessment in men with LUTS. However, LUTS in men are so variable that they may not be fully captured by the I-PSS questionnaire alone.3 In addition, uroflowmetry is a frequently used and simple test for diagnosis and followup of LUTS. Although uroflowmetry is a nonspecific test, it can give valuable objective data for readers in this type of study with a small sample size. Finally, in addition to dopamine, several other central nervous system transmitters (eg noradrenaline and g-aminobutyric acid) can modulate voiding. Central dopaminergic pathways exhibit different effects on voiding via actions on multiple receptors at different sites in the