FOcal RECurrent Assessment and Salvage Treatment

University College London Hospitals177 enrolled

Overview

Radiotherapy is the commonest form of prostate cancer treatment in the UK. In one in four men, radiotherapy will fail to control the cancer. These men are offered hormonal treatment which has significant side effects. Few men are offered a further treatment such as surgery, HIFU or cryotherapy. Only half of these men are cancer free at 5 years. The investigators believe this is due to poor imaging tests such as CT and Bone scan that cannot accurately detect whether cancer has come back inside or outside of the prostate or both. Also radiotherapy damages tissue surrounding the prostate which affects tissue healing for example after surgery. Treating just the cancer in the prostate only (focal treatment) rather than the whole prostate may limit this damage and cause fewer side-effects. The investigators want to see if new imaging tests can better identify cancer that has spread outside of the prostate and areas of cancer inside the prostate. Our new tests are whole-body MRI (for distant disease) and MRI guided biopsies (MRI-TB) (for local disease). First, the investigators will compare the results of whole-body MRI to existing imaging tests (bone-scan, and choline PET/CT) that try to find distant spread. Second, the investigators will compare the results of MRI-TB to a very detailed and accurate biopsy of the prostate called template prostate mapping which will show us where and how aggressive the cancer is. Third, if the cancer is confined to the prostate, the investigators will treat men using focal salvage therapies HIFU and cryotherapy. The investigators believe that these new imaging tests could better identify those who will benefit from early hormone treatment and those who will benefit from local salvage treatment. Our study may help justify carrying out a larger trial looking at how good the treatment is in controlling cancer in the medium and long-term.

Study Type

INTERVENTIONAL

Allocation

NON_RANDOMIZED

Purpose

DIAGNOSTIC

Masking

SINGLE

Enrollment

Interventions

Whole Body MRIDEVICE

Full parametric MRI using T1W, T2W, Diffusion-weighted and dynamic-contrast-enhanced images at 3Tesla

Focal Salvage TherapyPROCEDURE

Cryotherapy and HIFU will be used to targeted the areas of tumor only with a margin of normal tissue.

MRI Targeted biopsiesPROCEDURE

Image registration will be used to target biopsies followed by full mapping biopsies of the prostate. All biopsies will be carried out transperineally

Eligibility

Sex: MALEMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Previous external beam radiotherapy with or without neo-adjuvant/adjuvant hormone therapy 2. Biochemical failure as defined by the Phoenix criteria (PSA nadir + 2ng/ml) 3. Men considering local salvage treatment for radio-recurrent disease 4. Life expectancy of 5 years or more Exclusion Criteria: 1. Have taken any form of hormones (except 5-alpha reductase inhibitors) within the previous 6 months 2. Unable to have MRI scan as defined by standard care practice 3. Metallic implant likely to cause artefact and reduce scan quality 4. PSA doubling time of 3 months or less 5. PSA value 20ng/ml or greater 6. Prior prostate biopsies following biochemical failure 7. Any prior local intervention to the prostate (e.g., laser/electrical resection or incision, cryotherapy, HIFU, any other ablative modality, any other radiotherapy, any other prostate injection therapy for symptoms or cancer control) 8. Unable to have general or regional anaesthesia 9. Unable to give informed consent

Outcomes

Primary Outcomes

Accuracy of whole body MRI in identifying distant disease

Whole body MRI lesions suspicious of lymph node, visceral or bone metastases compared to standard care tests \- Sensitivity, specificity, negative and positive predictive values of whole-body MRI to detect distant disease compared to standard care tests (isotope bone-scan, PET/CT-scan, with skeletal survey where appropriate) and/or pelvic lymphadenectomy and/or biopsy of distant areas in indeterminate cases

Time frame: 2 years

Secondary Outcomes

Can multiparametric MRI accurately detect localised recurrent prostate cancer

Imaging of Local Disease Transperineal multi-parametric MRI targeted biopsies compared to Template Prostate Mapping biopsies in the detection of UCL definition 2 clinically significant prostate cancer (Gleason \>/=3+4 AND/OR Maximum Cancer Core Length \>/=4mm in any one biopsy)