Cryosurgery for Prostate Cancer: an Update on Clinical Results of Modern Cryotechnology

Salvage prostate intensity modulated radiation therapy after cryotherapy failure

Cryotherapy is an ablative therapy that can be used to treat localized prostate cancer. In case of recurrence, treatment options are not well-defined, and their outcomes are unknown. We therefore collected all patients treated with radiotherapy after cryotherapy for prostate cancer recurrence in Nantes (France) between 2012 and 2019. We identified ten patients. After a median follow-up of 5 years, two patients presented late grade 3 toxicities; one patient presented a grade 3 rectal hemorrhage, and one had a grade 3 hematuria. Two patients relapsed at 61 and 62 months, and three patients died of other causes. Radiotherapy to treat local prostate cancer recurrence after cryotherapy seems feasible and effective in local control. These results do not allow us to recommend this technique in current practice but are encouraging for the conduct of prospective trials.

Salvage radiotherapy after initial cryotherapy for localized prostate cancer: A systematic review of the literature

The treatment of local prostate cancer recurrence after cryotherapy is challenging since the optimal management is unknown. We collected the available evidence to date to better define the risk and benefit of salvage radiotherapy (SRT) after cryotherapy failure for localized prostate cancer. This review confirms the feasibility of SRT in terms of biochemical control and late toxicity rate. However, the absence of comparative trials or prospective studies, coupled with the heterogeneity of patients treated and the variations in treatments delivered across the analyzed studies, highlights the need for cautious consideration when opting for salvage radiotherapy. Therefore, we highly recommend the inclusion of patients in dedicated clinical trials to comprehensively assess the efficacy and safety of this approach.

Prostate cryoablation combined with androgen deprivation therapy for newly diagnosed metastatic prostate cancer: a propensity score-based study

BACKGROUND

Several studies showed that androgen deprivation therapy (ADT) plus local treatment of prostate could improve metastatic prostate cancer (mPCa) patients' survival. To date there are few studies analyzed the value of prostate cryoablation in mPCa. The objective of our analysis is to evaluate the oncological results and clinical value of prostate cryoablation combined with ADT compared with ADT alone in newly diagnosed mPCa patients.

METHODS

Newly diagnosed mPCa patients undergoing cryoablation plus ADT (group A) between January 2011 and November 2018 were identified. Patients receiving ADT alone (group B) were selected from the same institutional prostate cancer database by propensity score matching based on clinical characteristics. Oncological results and clinical value in symptom control and primary lesion treatment were compared.

RESULTS

Fifty-four patients were included in each group. Prostate cryoablation was well tolerated. The median follow-up time was 40 (27-53) and 39 (31-54) months in group A and group B, respectively. Patients in group A had a lower median prostate-specific antigen (PSA) nadir (0.025 ng/mL vs. 0.230 ng/mL, p = 0.001), longer median failure-free survival (FFS) (39 months vs. 21 months, p = 0.005), and median metastatic castration-resistant prostate cancer (mCRPC)-free survival (39 months vs. 21 months, p = 0.007). No difference in cancer-specific survival and overall survival was found between the two groups. Multivariate Cox analysis showed combination therapy reduced the risk of FFS by 45.8% (HR = 0.542 [95% CI 0.329-0.893]; p = 0.016). Patients in group A had better clinical relief of urinary symptoms (79.1 vs. 59.1%, p = 0.044) and required less treatment of primary lesions for symptomatic relief (13.0 vs. 31.5%, p = 0.021).

CONCLUSIONS

Prostate cryoablation plus ADT decreases PSA nadir, prolongs FFS and mCRPC-free survival, relieves urinary symptoms and reduces the need for treating primary lesions in newly diagnosed mPCa patients compared to ADT alone.

Functional and oncological outcomes of salvage cryosurgery for radiorecurrent prostate cancer

OBJECTIVES

To evaluate the oncological and functional outcomes of salvage cryosurgery (SCS) for radiorecurrent prostate cancer (rrPCa).

PATIENTS AND METHODS

A total of 169 consecutive patients with biopsy confirmed rrPCa were retrospectively analysed. All patients underwent SCS in a single referral centre between 2006 and 2018. The primary outcome was biochemical recurrence-free survival (BRFS) according to the Phoenix definition (prostate-specific antigen [PSA] nadir +2 ng/mL). The secondary outcomes were overall survival, BRFS defined as a PSA level of >0.5 ng/mL, metastasis-free survival, androgen-deprivation therapy (ADT)-free survival, and functional outcomes. Complications were classified according to the Clavien-Dindo system. PSA was measured every 3-6 months postoperatively. Functional outcomes were scored as reported by patients at outpatient visits. Kaplan-Meier survival analysis and uni- and multivariable Cox regression were performed.

RESULTS

The median (interquartile range) follow-up was 36 (18-66) months. The BRFS after 5 and 8 years was 52% (95% confidence interval [CI] 43-62%) and 45% (95% CI 35-57%), respectively. At multivariable analysis PSA level at initial diagnosis, initial treatment, interval between primary treatment and SCS, age at SCS, and post-SCS PSA nadir were significant factors for BRFS. The 5-year ADT-free survival was 70% (95% CI 62-79%). Clavien-Dindo Grade ≥III complications occurred in 1.2% (two/169) of patients. In all, 19% (29/156) of patients had new-onset urinary incontinence defined as >1 pad/24 h and 92% (57/62) of patients had new-onset erectile dysfunction. Persistent urinary fistula occurred in 6.5% (11/169) of patients.

CONCLUSIONS

The present study shows acceptable oncological outcomes of SCS considering the salvage character of the treatment. The occurrence of serious complications such as urinary incontinence and fistula should not be underestimated.

Oncological outcomes of salvage cryotherapy after primary radiation therapy vs. primary cryotherapy: 10-year experience at a large Canadian referral center

INTRODUCTION

Salvage cryotherapy is a guideline-recommended treatment of localized prostate cancer recurrence after radiation therapy. There is little published evidence analyzing the outcomes of salvage cryotherapy for recurrent prostate cancer following different primary therapy energy modalities.

METHODS

We performed a retrospective analysis of patients who received whole gland salvage cryotherapy from 2007-2017 at a large tertiary referral center after either primary radiation therapy (RT) or primary whole gland cryotherapy. Primary outcome was biochemical failure, defined as per the Phoenix criteria (prostate-specific antigen [PSA] nadir + 2.0 ng/ml). Secondary outcomes included time to biochemical failure and development of metastatic disease.

RESULTS

Fifty-eight of 391 patients who received cryotherapy were identified as having received salvage cryotherapy (after RT, n=37; after primary cryotherapy, n=21). Biochemical recurrence occurred in 21 (57%) patients with previous RT and in 17 (81%) patients with previous cryotherapy (p=0.001). Median time to biochemical recurrence was 18 months for patients with previous RT and 13 months for patients with previous cryotherapy (p=0.002). The biochemical-free survival rate for primary radiation therapy patients was 71% at two years compared to 23% at two years for patients who underwent primary cryotherapy (p<0.01). There was no difference in the development of metastatic disease between groups (19% vs. 18%, cryo vs. radiation, p=0.34).

CONCLUSIONS

These results suggest that salvage cryotherapy may offer more durable oncological control to patients after radiation compared to primary cryotherapy, with a lower rate and longer duration before biochemical recurrence.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : cancer de la prostate French ccAFU guidelines – Update 2018–2020: Prostate cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.007. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.007. That newer version of the text should be used when citing the article.

Functional outcomes after prostatic cryosurgery

OBJECTIVE

To assess the functional effects of prostatic cryosurgery on micturition.

MATERIAL AND METHODS

Prospective study of men who underwent cryosurgery (CS) for prostate cancer between 2013 - 2015. Low urinary tract symptoms (LUTS) and quality of life (QoL) were assessed 1 month before surgery using IPSS questionnaire, a three-day voiding diary (3DVD) and uroflowmetry with ultrasound-measured postvoid residual volume. Need of medical treatment for LUTS was also recorded. The same assessment was performed at 3, 6 and 12 months after CS. Outcomes after surgery were compared to those prior to surgery.

RESULTS

Forty-five patients underwent a CS during the study period, of whom 25 patients could be recruited in the study. Mean age was 73.5 years (range 66-84). Nineteen CS (76%) were performed as a primary procedure, while 6 CS (24%) as a salvage procedure. No statistical differences were found comparing results of IPSS, QoL, D3vd or uroflowmetry and PVR at 3, 6 or 12 months after CS compared to before surgery. Before CS, 8 (32%) patients were on medical treatment for LUTS, while at 6 and 12 months after surgery, 3 (13.6%) and 2 (9.5%) patients required some medication, respectively.

CONCLUSION

According to the punctuation of IPSS, QoL questionnaire, and a 3-day voiding diary, LUTS does not worsen after CS. Prostatic cryosurgery does not seem to impact uroflowmetry results.

[Salvage cryotherapy of prostate cancer after failed external radiotherapy and brachytherapy: Morbidity and mid-term oncological results]

OBJECTIVE

To study the oncologic and functional results of salvage cryotherapy after failure of external radiotherapy and brachytherapy.

MATERIALS AND METHODS

Patients treated by total salvage cryotherapy (3rd generation) in 2 centers (Groupe Hospitalier Saint-Joseph in Paris and Clinique Jule-Verne Nantes) in between January 2008 and April 2016 were included. The biochemical recurrence-free survival (BRFS) was calculated using the Phoenix criteria (PSA>nadir+2ng/mL). The functional results were assessed clinically.

RESULTS

Ninety-seven patients with an average follow up of 39.4months were evaluated retrospectively. The 5-year biochemical recurrence-free survival (5y-BRFS) among all patients was 58.1% (IC à 95% [45.9-68.5]). Low and intermediate risk patients (d'Amico classification) were less prone to biochemical recurrence than high risk (81.05% (IC à 95% [64.1-90.5]) 5y-BRFS as opposed to 35.09% (IC à 95% [20.1-50.4]) respectively) (P<0.0001). As were patients with a Gleason score≤7 75.35% (IC à 95% [59.7-85.6]) compared to 32.31% (IC à 95% [16.5-49.2]) for higher Gleason (>7 scores [P=0.0002]). A Gleason score>7 (OR=6.9; P=0.002), PSA nadir>1ng/mL (OR=25.8; P=0.0026) and peri-urethral invasion (OR=35.8; P<0.001) were major risk factors for local recurrence in univariate analysis. In multivariate analysis, only PSA nadir>1ng/mL (OR=12.9; P=0.042) and peri-urethral invasion (OR=21.6; P=0.0003) remain major risk factors for recurrence. About 13 (16.46%) patients were incontinent of which 3 (3.79%) required placement of an artificial urinary sphincter. Erectile dysfunction was present in 66 (83.5%) patients. Recto-urethral fistula was uncommon in 1 patient (1.27%).

CONCLUSION

Salvage cryotherapy after failure of external radiotherapy and brachytherapy is a reliable and reproducible technique with promising oncological and functional results. Study of prognostic factors will help better select eligible patients in the future.

LEVEL OF EVIDENCE

4.

Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part II: Recommended Approaches and Details of Specific Care Options

PURPOSE

This guideline is structured to provide a clinical framework stratified by cancer severity to facilitate care decisions and guide the specifics of implementing the selected management options. The summary presented herein represents Part II of the two-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline discussing risk stratification and care options by cancer severity. Please refer to Part I for discussion of specific care options and outcome expectations and management.

MATERIALS AND METHODS

The systematic review utilized in the creation of this guideline was completed by the Agency for Healthcare Research and Quality and through additional supplementation by ECRI Institute. This review included articles published between January 2007 and March 2014 with an update search conducted through August 2016. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. Additional information is provided as Clinical Principles and Expert Opinions (table 2 in supplementary unabridged guideline, http://jurology.com/).

RESULTS

The AUA (American Urological Association), ASTRO, and SUO (Society of Urologic Oncology) formulated an evidence-based guideline based on a risk stratified clinical framework for the management of localized prostate cancer.

CONCLUSIONS

This guideline attempts to improve a clinician's ability to treat patients diagnosed with localized prostate cancer, but higher quality evidence in future trials will be essential to improve the level of care for these patients. In all cases, patient preferences should be considered when choosing a management strategy.

[CCAFU french national guidelines 2016-2018 on prostate cancer]

OBJECTIVES

The purpose of the guidelines national committee CCAFU was to propose updated french guidelines for localized and metastatic prostate cancer (PCa).

METHODS

A Medline search was achieved between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of PCa, to evaluate different references with levels of evidence.

RESULTS

Epidemiology, classification, staging systems, diagnostic evaluation are reported. Disease management options are detailed. Recommandations are reported according to the different clinical situations. Active surveillance is a major option in low risk PCa. Radical prostatectomy remains a standard of care of localized PCa. The three-dimensional conformal radiotherapy is the technical standard. A dose of > 74Gy is recommended. Moderate hypofractionation provides short-term biochemical control comparable to conventional fractionation. In case of intermediate risk PCa, radiotherapy can be combined with short-term androgen deprivation therapy (ADT). In case of high risk disease, long-term ADT remains the standard of care. ADT is the backbone therapy of metastatic disease. In men with metastases at first presentation, upfront chemotherapy combined with ADT should be considered as a new standard. In case of metastatic castration-resistant PCa (mCRPC), new hormonal treatments and chemotherapy provide a better control of tumor progression and increase survival.

CONCLUSIONS

These updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for prostate cancer. © 2016 Elsevier Masson SAS. All rights reserved.

The feasibility and safety of cryoablation as an adjuvant therapy with transurethral resection of bladder tumor: A pilot study

BACKGROUND

The potential for transurethral resection (TUR) to result in residual tumors in patients with muscle invasive or high-risk non-muscle invasive bladder cancer (NMIBC) may affect local recurrence or progression. This study attempted to evaluate the feasibility and safety of cryoablation as an adjuvant therapy with TUR to treat bladder tumor.

METHODS

Patients who met inclusion criteria between December 2014 and August 2015 in our institute was included. The inclusion criteria were as followed: 1) urothelial carcinoma; 2) non-muscle-invasive bladder cancer or 3) stage T2 muscle invasive bladder cancer meeting with the following two conditions, solitary and less than 3 cm in size. Ten patients underwent TUR followed by immediate transurethral cryoablation of the tumor resection bed. All patients underwent pathological re-evaluation during follow-up cystoscopy.

RESULTS

The cryoablation was successfully performed without bladder perforation during the procedures. No grade II-V complications were observed. Among these patients, two had T2a stage tumors, three had T1 stage tumors and five had Ta stage tumors. The median follow-up of cases was 9 months (range 9-14 months). During follow-up, tumor recurrence was observed in three patients. Only one recurrence occurred in the primary tumor site.

CONCLUSIONS

Cryoablation as an adjuvant therapy with TUR for bladder tumors was feasible and safe. The potential benefit was to eliminate the residual tumor to the greatest extent.

Cryosurgery would be An Effective Option for Clinically Localized Prostate Cancer: A Meta-analysis and Systematic Review

Cryosurgery (CS) has been used on patients with clinically localized PCa for more than 10 years. However, clinical studies evaluating its effectiveness and safety have reported conflicting results. This systematic assessment was performed to obtain comprehensive evidence regarding the potential benefits and safety of CS compared with those of radiotherapy (RT) and radical prostatectomy (RP), respectively. All controlled trials comparing CS with RT or RP and single-arm studies reporting results of CS therapy were identified through comprehensive searches of PubMed, the Cochrane Library and Embase. Ten publications from seven trials, with totally 1252 patients, were included in the meta-analysis, which revealed no significant differences in comparisons of CS vs RT and CS vs RP for overall survival and disease specific survival. However, a significantly lower disease-free survival could be observed for CS than RP. Moreover, a systematic review of literature focusing on comparative data of databases and materials of single-arm trials revealed satisfactory survival results in both primary and salvage CS. Our results showed that cryosurgery would be a relatively effective method for clinically localized prostate cancer with survival results comparable to radiotherapy and radical prostatectomy. However, the large percentage of complications caused by cryosurgery should be carefully monitored.

Cryotherapy in prostate cancer

Review objectives:

Cryotherapy use has increased due to technological advances. A review of the literature was performed to evaluate the efficacy and outcomes of whole gland, salvage and targeted focal cryotherapy in the management of prostate cancer.

Review findings:

Cryotherapy use has increased significantly over the last 10 years with a trend towards focal ablation. Whole gland cryotherapy, salvage cryotherapy and focal cryotherapy biochemical recurrence rates appear to be comparable to other treatment modalities for low risk disease, however biochemical failure remains difficult to compare across studies due to a lack of consensus regarding appropriate end points for evaluation of cryotherapy. Short-term focal cryotherapy outcomes are encouraging. Side effect profiles for cryotherapy have significantly improved with fourth generation systems while salvage cryotherapy continues to carry a slightly higher risk of incontinence than primary whole gland cryotherapy. The incidence of erectile dysfunction after focal cryotherapy is dramatically lower than that for whole gland ablation.

Conclusions:

Cryotherapy continues to have an active role in the primary and salvage treatment of prostate cancer. Targeted focal cryotherapy is a promising treatment with minimal morbidity. Further long-term data is needed to support targeted therapy in addition to direct comparison with other treatment modalities.

Cryotherapy and its applications in the management of urologic malignancies: a review of its use in prostate and renal cancers

Cryotherapy has been established as an ablative modality for the treatment of a wide range of malignancies. Being minimally invasive, it is associated with less morbidity than conventional extirpative surgical procedures. In recent years, it has been used with success for treating two of the common urologic malignancies, that is, prostate and renal cancer. In this review, we highlight the role of cryotherapy as a treatment modality, the proposed destructive mechanisms of action and the risks of its use in the management of prostate and renal malignancy.

New treatment strategy of cryosurgery and temperature control

Cryosurgery, recommended as an effective method for tumor treatment, has been widely used in clinics. However, it might lead to a high probability of tumor recurrence due to incomplete tumor damage. The treatment protocol for cryosurgery is essential to achieve the desired therapeutic effects. In this study, a new temperature fluctuation treatment method was proposed, and the fuzzy control method based on piecewise adjustment was developed for temperature control during the treatment. Ex vivo rat liver experiments were conducted and histopathology analysis used to study the therapeutic effects of the new treatment method.

Initial brazilian experience in the treatment of localized prostate cancer using a new generation cryotechnology: feasibility study

INTRODUCTION

The objective of our study is to present the first Brazilian cryoablation experience in the treatment of low and intermediate risk localized prostate cancer using 3rd generation cryoablation and real-time biplanar transrectal ultrasonography.

MATERIALS AND METHODS

Ten Brazilian patients underwent primary cryoablation for localized prostate cancer between October 2010 and June 2011. All patients consented for whole gland primary cryotherapy. The procedures were performed by 3rd generation cryoablation with the Cryocare System ® (Endocare, Irvine, California). Preoperative data collection included patient demographics along with prostate gland size, Gleason score, serum prostate specific antigen, and erectile function status. Operative and post--operative assessment involved estimated blood loss, operative time, complications, serum PSA level, erectile function status, urinary incontinence, biochemical disease free survival (BDFS), and follow-up time.

RESULTS

All patients in the study successfully underwent whole gland cryoablation. The mean of: age, prostate size, PSA level, and Gleason score, was 66.2 years old; 40.7 g; 7.8 ng/mL; and 6 respectively. All patients were classified as low or moderate D' Amico risk (5 low and 5 moderate). Erectile dysfunction was present in 50% of patients. The estimated blood loss was minimal, operative time was 46.1 minutes. All patients that developed erectile dysfunction post-treatment responded to oral or intracavernosal medications with early penile rehabilitation. All patients maintained urinary continence by the end of a 10 months evaluation period and none had biochemical relapse within the mean follow-up of 13 months (7-15 months).

CONCLUSION

Our initial experience shows that cryoablation is a minimally invasive option for the treatment of localized prostate cancer. Short term data seems to be promising but longer follow-up is necessary to verify oncological and functional results.

Histotripsy focal ablation of implanted prostate tumor in an ACE-1 canine cancer model

PURPOSE

Histotripsy is a nonthermal ablative focused ultrasound technology with possible future applications for prostate cancer focal therapy. We used the ACE-1 prostate tumor model and evaluated the feasibility of treating prostate tumors with histotripsy.

MATERIALS AND METHODS

A total of 10 immunosuppressed (cyclosporine treated) canine subjects received transrectal ultrasound guided percutaneous intraprostatic injection of ACE-1 canine prostate cancer cells. Prostates were serially imaged with transrectal ultrasound to monitor tumor growth. Subjects were sham treated (3) or underwent transabdominal histotripsy of the prostate, which targeted implanted tumor and adjacent parenchyma using a 750 kHz piezoelectric ultrasound therapy transducer. Prostates were examined histologically to confirm tumor and the histotripsy treatment effect.

RESULTS

ACE-1 tumors were visualized on transrectal ultrasound in all 10 subjects within 2 weeks of tumor injection. Lesions demonstrated growth in the prostatic capsule, glandular lobules, fibrous septa and periurethral stroma with significant desmoplastic reaction and areas of central necrosis on histology. Lymph node and/or pulmonary metastases developed in 4 subjects. Ultrasound tumor localization and initiation of cavitation during histotripsy therapy were feasible in all treated subjects. Histologically there was evidence of homogenization of tumor and prostatic parenchyma in all 4 acute subjects with necrosis and hemorrhage in the 3 chronic subjects.

CONCLUSIONS

This study shows the feasibility of histotripsy destruction of prostate tumors in a canine ACE-1 model. It suggests a potential role for histotripsy based focal therapy for prostate cancer. Further studies are needed to better characterize the effects of histotripsy on malignant tissues.

Focal therapy for prostate cancer: fact or fiction?

Prostate cancer is the commonest male cancer diagnosed in men in the UK, and the treatment of organ confined prostate cancer is a subject of much debate. Focal therapy for prostate cancer intends to treat the cancer within the prostate, whilst sparing the majority of the benign prostate tissue. In addition, the intention is to avoid treatment effects in the surrounding structures, the damage of which leads to the side effects commonly associated with radical whole gland therapies. This relies on accurate localization of the prostate cancer by biopsy and imaging followed by treatment using a modality capable of delivery to a focal area within the prostate. Focal therapy lies between the current extremes of radical whole gland treatment and active surveillance. There have been many articles reviewing the concept of focal therapy for organ confined prostate cancer, but with a paucity of data available for analysis. This is being addressed with an increase in the published data on focal therapy, using a number of different modalities. In this review, we address the question of whether the data currently published does in fact support the further development of the focal therapy approach, or whether it is a concept best relegated to the realms of fiction.