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Creta M, Shariat SF, Marra G, Gontero P, Rossanese M, Morra S, Teoh J, Kishan AU, Karnes RJ, Longo N. Local salvage therapies in patients with radio-recurrent prostate cancer following external beam radiotherapy: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00883-3. [PMID: 39223232 DOI: 10.1038/s41391-024-00883-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/28/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION To date, radio-recurrent prostate cancer (PCa) ranks as the fourth most common urological malignancy when considering the number of men with localized PCa who undergo radiation treatment and subsequently experience a biochemical recurrence. This systematic review aimed to summarize available evidence about the outcomes of local salvage strategies in patients with local PCa recurrence following primary external-beam radiation therapy (EBRT). METHODS We conducted a comprehensive bibliographic search on MEDLINE, Scopus, and Web of Science Core Collection databases in October 2023 to identify studies published in the last 20 years evaluating outcomes of local salvage procedures in patients with locally radio-recurrent PCa following EBRT. The meta-analysis was performed using ProMeta 3 software when two or more studies reported the same outcome. The effect size (ES) was estimated using rates reported with its 95% confidence interval (CI). RESULTS Overall, 28 studies (6 prospective and 22 retrospective) including 1544 patients were included in the review. Two-year recurrence-free survival (RFS) was 84.0% (95% CI: 67.0-93.0%), 69.0% (95% CI: 42.0-87.0%), 58.0% (95% CI: 43.0-71.0%), and 45% (95% CI: 38.0-52.0%), for patients undergoing brachytherapy (BT), EBRT, Cryotherapy and High-Intensity Focused Ultrasound (HIFU), respectively. After salvage prostatectomy, RFS ranged from 75% to 78.5% at a median follow-up ranging from 18 to 35 months. Estimates for severe gastrointestinal toxicity were 2%, 3%, 3%, 4%, and 11% following cryotherapy, BT, HIFU, EBRT, and salvage radical prostatectomy, respectively. CONCLUSIONS In patients who underwent EBRT as primary treatment, prostate salvage re-irradiation through BT or EBRT represents the modality providing the best balance between efficacy and safety. Unfortunately, due to the low level of evidence, strong recommendations regarding the choice of any of these techniques cannot be made.
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Affiliation(s)
- Massimiliano Creta
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | | | - Giancarlo Marra
- Department of Urology, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Marta Rossanese
- Gaetano Barresi Department of Human and Paediatric Pathology, Urology Section, University of Messina, Messina, Italy
| | - Simone Morra
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy.
| | - Jeremy Teoh
- S.H. Ho Urology Centre, Department of Surgery, Chinese University of Hong Kong, Hong Kong, China
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | | | - Nicola Longo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
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Lee H, Thakker S, Pineault K, Wysock J, Tan WP. Salvage Cryoablation for Recurrent Prostate Cancer Following Radiation-A Comprehensive Review. Cancers (Basel) 2024; 16:2717. [PMID: 39123445 PMCID: PMC11312114 DOI: 10.3390/cancers16152717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/19/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
The treatment options for prostate cancer typically entail active surveillance, surgery, radiation, or a combination of the above. Disease recurrence remains a concern, with a wide range of recurrence rates having been reported in the literature. In the setting of recurrence, the salvage treatment options include salvage prostatectomy, salvage high-intensity focused ultrasound (HIFU), stereotactic body radiotherapy (SBRT), salvage brachytherapy, and salvage cryoablation. In this review, we analyze the currently available data related to salvage cryoablation for recurrent prostate cancer following radiation.
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Affiliation(s)
| | | | | | | | - Wei Phin Tan
- Department of Urology, NYU Langone Health, New York, NY 10016, USA
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3
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Abufaraj M, Siyam A, Ali MR, Suarez-Ibarrola R, Yang L, Foerster B, Shariat SF. Functional Outcomes after Local Salvage Therapies for Radiation-Recurrent Prostate Cancer Patients: A Systematic Review. Cancers (Basel) 2021; 13:E244. [PMID: 33440752 PMCID: PMC7826752 DOI: 10.3390/cancers13020244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To assess the rate and severity of functional outcomes after salvage therapy for radiation recurrent prostate cancer. METHODS This systematic review of the MEDLINE/PubMed database yielded 35 studies, evaluating salvage radical prostatectomy (RP), brachytherapy (BT), high-intensity focal ultrasound (HIFU) and cryotherapy (CT) after failure of primary radiation therapy. Data on pre- and post-salvage rates and severity of functional outcomes (urinary incontinence, erectile dysfunction, and lower urinary tract symptoms) were collected from each study. RESULTS The rates of severe urinary incontinence ranged from 28-88%, 4.5-42%, 0-6.5%, 2.4-8% post salvage RP, HIFU, CT and BT, respectively. The rates of erectile dysfunction were relatively high reaching as much as 90%, 94.6%, 100%, 62% following RP, HIFU, CT and BT, respectively. Nonetheless, the high pre-salvage rates of ED preclude accurate estimation of the effect of salvage therapy. There was an increase in the median IPSS following salvage HIFU, BT and CT ranging from 2.5-3.4, 3.5-12, and 2, respectively. Extended follow-up showed a return-to-baseline IPSS in a salvage BT study. The reported data suffer from selection, reporting, publication and period of study biases, making inter-study comparisons inappropriate. CONCLUSIONS local salvage therapies for radiation recurrent PCa affect continence, lower urinary tract symptoms and sexual functions. The use of local salvage therapies may be warranted in the setting of local disease control, but each individual decision must be made with the informed patient in a shared decision working process.
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Affiliation(s)
- Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, A-1080 Vienna, Austria;
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, 11942 Amman, Jordan; (A.S.); (M.R.A.)
| | - Abdelmuez Siyam
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, 11942 Amman, Jordan; (A.S.); (M.R.A.)
| | - Mustafa Rami Ali
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, 11942 Amman, Jordan; (A.S.); (M.R.A.)
| | - Rodrigo Suarez-Ibarrola
- Department of Urology, Faculty of Medicine, University of Freiburg—Medical Centre, 79098 Freiburg, Germany;
| | - Lin Yang
- Department of Cancer Epidemiology and Prevention, Cancer Care Alberta, Alberta Health Services, Calgary, AB T2S 3C3, Canada;
- Departments of Oncology and Community Health Sciences, Cumming school of medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Beat Foerster
- Department of Urology, Kantonsspital Winterthur, 8401 Winterthur, Switzerland;
| | - Shahrokh F. Shariat
- Department of Urology, Medical University of Vienna, A-1080 Vienna, Austria;
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, 11942 Amman, Jordan; (A.S.); (M.R.A.)
- Institute for Urology and Human Reproductive Health, I.M. Sechenov First Moscow State Medical University, 119992 Moscow, Russia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
- Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY 10075, USA
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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Chin JL, Donnelly BJ, Nair SM, Lavi A. The history of cryosurgery in Canada: A tale of two cities. Can Urol Assoc J 2020; 14:299-304. [PMID: 32569572 PMCID: PMC7716840 DOI: 10.5489/cuaj.6625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although not commonly available in Canada, cryosurgery (cryoablation) for prostate cancer has been practiced in many countries. The field of cryoablation has evolved significantly over the past 30 years. Two prostate cryoablation programs were started in Canada in the early 1990s, in London, ON and Calgary, AB, focusing, respectively, on salvage therapy following radiation failure and primary local treatment. This article chronicles the development of the two programs and outlines the scientific and clinical contributions by investigators at the two centers.
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Affiliation(s)
- Joseph L. Chin
- Urology Division, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Brian J. Donnelly
- Department of Surgery, University of Calgary, Calgary Regional Health Authority, Calgary, AB, Canada
| | - Shiva M. Nair
- Urology Division, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Arnon Lavi
- Urology Division, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Mantica G, Chierigo F, Suardi N, Gomez Rivas J, Kasivisvanathan V, Papalia R, Fiori C, Porpiglia F, Terrone C, Esperto F. Minimally invasive strategies for the treatment of prostate cancer recurrence after radiation therapy: a systematic review. MINERVA UROL NEFROL 2020; 72:563-578. [PMID: 32748617 DOI: 10.23736/s0393-2249.20.03783-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The aim of this review was to conduct a comprehensive analysis of the role of minimally invasive salvage modalities in radio-recurrent prostate cancer and the associated clinical outcomes and toxicity profiles. EVIDENCE ACQUISITION A systematic review of the current literature was conducted through the Medline and NCBI PubMed, Scopus databases in January 2020. All papers published after 2000, concerning studies conducted on humans for radio-recurrent prostate cancer were considered for the review. EVIDENCE SYNTHESIS Overall, 545 studies were identified. After duplicate exclusion, initial screening, and eligibility evaluation, a total of 80 studies were included in the qualitative analysis, corresponding to a cohort of 6681 patients. The median age at initial diagnosis ranged from 59 to 75.5. Pre-treatment PSA ranged from 6.2 to 27.4 ng/mL. All patients underwent primary radiotherapy for localized prostate cancer. Cryotherapy, Brachytherapy, EBRT, HIFU were the minimally invasive options mostly used as salvage therapy. They showed to be promising approaches for recurrent prostate cancer (PCa) control, with acceptable toxicities. CONCLUSIONS Minimally invasive therapeutic options offer promising results in terms of biochemical control in the local recurrence setting. Unfortunately, the absence of high quality and comparative studies makes it difficult to establish which method is the best in terms of oncological and safety outcomes.
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Affiliation(s)
- Guglielmo Mantica
- Department of Urology, San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Francesco Chierigo
- Department of Urology, San Martino University Hospital, University of Genoa, Genoa, Italy -
| | - Nazareno Suardi
- Department of Urology, San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Juan Gomez Rivas
- Department of Urology, La Paz University Hospital, Madrid, Spain.,Instituto de Investigación Sanitaria La Paz (IdiPAZ), Madrid, Spain
| | - Veeru Kasivisvanathan
- UCL Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Rocco Papalia
- Department of Urology, Campus Bio-Medico University, Rome, Italy
| | - Cristian Fiori
- Division of Urology, Department of Oncology, San Luigi Hospital, School of Medicine, University of Turin, Orbassano, Turin, Italy
| | - Francesco Porpiglia
- Division of Urology, Department of Oncology, San Luigi Hospital, School of Medicine, University of Turin, Orbassano, Turin, Italy
| | - Carlo Terrone
- Department of Urology, San Martino University Hospital, University of Genoa, Genoa, Italy
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6
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Safavy S, Jabaji RB, Lu SM, Slezak JM, Cosmatos HA, Williams SG, Finley DS. Salvage Cryoablation for Radiorecurrent Prostate Cancer: Initial Experience at a Regional Health Care System. Perm J 2020; 23:18-153. [PMID: 31050644 DOI: 10.7812/tpp/18-153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Local recurrence after radiotherapy for prostate cancer remains challenging to treat effectively. Although oncologic control is highest with salvage prostatectomy, the procedure is associated with substantial morbidity. OBJECTIVE To identify factors associated with successful salvage cryoablation for radiorecurrent prostate cancer. DESIGN We retrospectively reviewed the medical records of patients who underwent salvage cryoablation at our institution between 2005 and 2015. All patients had biopsy-proven local recurrence after radiotherapy. Patients with seminal vesicle invasion or metastases were excluded. Complete follow-up was obtained for all patients. MAIN OUTCOME MEASURES Primary study endpoint was biochemical progression-free survival based on the Phoenix criteria. RESULTS Seventy-five patients underwent salvage cryotherapy. Mean patient age was 69.3 years. The overall biochemical salvage rate was 50.7% at a median follow-up of 3.9 years. The following factors were independently associated with successful cryotherapy: Precryotherapy Gleason score of 3 + 3 or 3 + 4, low precryotherapy prostate-specific antigen (PSA), low precryotherapy PSA density, longer time to PSA nadir after radiotherapy, and low postcryotherapy PSA nadir. A postcryotherapy PSA nadir of 0.5 ng/mL or less was associated with a biochemical progression-free survival of 79.7% at 3 years and 64.7% at 5 years, whereas a postcryotherapy PSA nadir above 0.5 was associated with a biochemical progression-free survival of 5.6% at 3 years and 0% at 5 years (p < 0.0001). CONCLUSION Approximately 50% of the patients achieved biochemical salvage with cryoablation at 5 years. Nadir PSA after salvage was the strongest predictor of biochemical progression-free survival in our cohort.
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Affiliation(s)
- Seena Safavy
- Department of Urology, Los Angeles Medical Center, CA
| | | | - Sharon M Lu
- Department of Urology, Los Angeles Medical Center, CA
| | | | - Harry A Cosmatos
- Department of Radiation Oncology, Los Angeles Medical Center, CA
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de Marini P, Cazzato RL, Garnon J, Shaygi B, Koch G, Auloge P, Tricard T, Lang H, Gangi A. Percutaneous MR-guided prostate cancer cryoablation technical updates and literature review. BJR Open 2019; 1:20180043. [PMID: 33178928 PMCID: PMC7592492 DOI: 10.1259/bjro.20180043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 03/25/2019] [Accepted: 05/16/2019] [Indexed: 11/05/2022] Open
Abstract
Prostate cancer (PCa) is the most common malignant tumor in males. The benefits in terms of overall reduction in specific mortality due to the widespread use of Prostate Specific Antigen (PSA) screening and the advancements in the curative treatments (radical prostatectomy or radiotherapy) appear to have reached a plateau. There remains, however, the questions of overdiagnosis and overtreatment of such patients. Currently, the main challenge in the treatment of patients with clinically organ-confined PCa is to offer an oncologically efficient treatment with as little morbidity as possible. Amongst the arising novel curative techniques for PCa, cryoablation (CA) is the most established one, which is also included in the NICE and AUA guidelines. CA is commonly performed under ultrasound guidance with the inherent limitations associated with this technique. The recent advancements in MRI have significantly improved the accuracy of detecting and characterizing a clinically significant PCa. This, alongside the development of wide bore interventional MR scanners, has opened the pathway for in bore PCa treatment. Under MRI guidance, PCa CA can be used either as a standard whole gland treatment or as a tumor targeted one. With MR-fluoroscopy, needle guidance capability, multiplanar and real-time visualization of the iceball, MRI eliminates the inherent limitations of ultrasound guidance and can potentially lead to a lower rate of local complications. The aim of this review article is to provide an overview about PCa CA with a more specific insight on MR guided PCa CA; the limitations, challenges and applications of this novel technique will be discussed.
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Affiliation(s)
- Pierre de Marini
- Department of Interventional Radiology, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg Cedex, France
| | - Roberto Luigi Cazzato
- Department of Interventional Radiology, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg Cedex, France
| | - Julien Garnon
- Department of Interventional Radiology, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg Cedex, France
| | - Behnam Shaygi
- Department of Radiology, King's College Hospital, Denmark Hill, London, UK
| | - Guillaume Koch
- Department of Interventional Radiology, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg Cedex, France
| | - Pierre Auloge
- Department of Interventional Radiology, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg Cedex, France
| | - Thibault Tricard
- Department of Urology, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg Cedex, France
| | - Hervé Lang
- Department of Urology, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg Cedex, France
| | - Afshin Gangi
- Department of Interventional Radiology, University Hospital of Strasbourg, 1 Place de l'Hôpital, Strasbourg Cedex, France
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Ingrosso G, Becherini C, Lancia A, Caini S, Ost P, Francolini G, Høyer M, Bottero M, Bossi A, Zilli T, Scartoni D, Livi L, Santoni R, Giacomelli I, Detti B. Nonsurgical Salvage Local Therapies for Radiorecurrent Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Oncol 2019; 3:183-197. [PMID: 31411996 DOI: 10.1016/j.euo.2018.12.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/06/2018] [Accepted: 12/20/2018] [Indexed: 11/30/2022]
Abstract
CONTEXT Different nonsurgical therapeutic strategies can be adopted for intraprostatic relapse of prostate cancer after primary radiotherapy, including re-irradiation (with brachytherapy [BT] or external beam radiotherapy [EBRT]), high-intensity focused ultrasound (HIFU), and cryotherapy. The main issues to consider when choosing nonsurgical salvage local therapies are local tumor control and significant genitourinary toxicity. OBJECTIVE To conduct a systematic review and meta-analysis of the role of nonsurgical salvage modalities in patients with radiorecurrent prostate cancer and associated clinical outcomes and toxicity profiles. EVIDENCE ACQUISITION We performed a critical review of the Medline, Scopus, and ClinicalKey databases from January 1, 2000 through February 1, 2018 according to the Preferred Reporting Items and Meta-Analyses statement. To assess the overall quality of the literature reviewed, we used a modified Delphi tool for case-series studies. EVIDENCE SYNTHESIS A total of 64 case-series studies were included, corresponding to a cohort of 5585 patients. The modified Delphi checklist evidenced high methodological quality overall (mean quality score of 80.6%). Biochemical control rates were lowest for patients treated with HIFU (58%, 95% confidence interval [CI] 47-68%) and highest for patients treated with BT (69%, 95% CI 62-76%) and EBRT (69%, 95% CI 53-83%). The lowest prevalence of incontinence was for patients treated with BT (3%, 95% CI 0-6%; I2=63.4%) and the highest was among patients treated with HIFU (28%, 95% CI 19-38%; I2=89.7%). CONCLUSIONS Nonsurgical therapeutic options, especially BT, showed good outcomes in terms of biochemical control and tolerability in the local recurrence setting. PATIENT SUMMARY The current analysis demonstrated that nonsurgical salvage local therapies offer a chance of a curative local approach in radiorecurrent prostate cancer. However, high-quality data from prospective trials are needed to validate long-term outcomes from nonsurgical strategies for the treatment of intraprostatic recurrence after previous radiotherapy.
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Affiliation(s)
- Gianluca Ingrosso
- Department of Radiation Oncology, Tor Vergata General Hospital, University of Rome "Tor Vergata", Rome, Italy
| | - Carlotta Becherini
- Department of Radiation Oncology, A.O.U. Careggi, University of Florence, Florence, Italy
| | - Andrea Lancia
- Radiation Oncology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Networking, Florence, Italy
| | - Piet Ost
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Giulio Francolini
- Department of Radiation Oncology, A.O.U. Careggi, University of Florence, Florence, Italy
| | - Morten Høyer
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Marta Bottero
- Department of Radiation Oncology, Tor Vergata General Hospital, University of Rome "Tor Vergata", Rome, Italy
| | - Alberto Bossi
- Department of Radiotherapy, Gustave-Roussy Institute, Villejuif, France
| | - Thomas Zilli
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Daniele Scartoni
- Proton Treatment Center, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Lorenzo Livi
- Department of Radiation Oncology, A.O.U. Careggi, University of Florence, Florence, Italy
| | - Riccardo Santoni
- Department of Radiation Oncology, Tor Vergata General Hospital, University of Rome "Tor Vergata", Rome, Italy
| | - Irene Giacomelli
- Proton Treatment Center, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Beatrice Detti
- Department of Radiation Oncology, A.O.U. Careggi, University of Florence, Florence, Italy
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Markovina S, Meeks MW, Badiyan S, Vetter J, Gay HA, Paradis A, Michalski J, Sandhu G. Superior metastasis-free survival for patients with high-risk prostate cancer treated with definitive radiation therapy compared to radical prostatectomy: A propensity score-matched analysis. Adv Radiat Oncol 2017; 3:190-196. [PMID: 29904744 PMCID: PMC6000029 DOI: 10.1016/j.adro.2017.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/18/2017] [Accepted: 12/06/2017] [Indexed: 11/26/2022] Open
Abstract
Purpose For high-risk prostate cancer (HR-PCa) in men with a life expectancy of at least 10 years, the National Comprehensive Cancer Network recommends radiation therapy (RT) plus androgen deprivation therapy (ADT) with category 1 evidence or radical prostatectomy (RP) as an acceptable initial therapy. Randomized evidence regarding which therapy is optimal for disease control is lacking for men with HR-PCa. We performed a propensity-score-matched comparison of outcomes for men with localized HR-PCa treated with primary RT or RP. Methods and materials The medical records of patients with localized HR-PCa who were treated at our institution between 2002 and 2011 were reviewed. Patient and disease characteristics, treatment details, and outcomes were collected. A combination of nearest-neighbor propensity score matching on age, Adult Comorbidity Evaluation-27 comorbidity index, prostate-specific antigen, biopsy Gleason scores, and clinical T-stage as well as exact matching on prostate-specific antigen, biopsy Gleason scores, and clinical T-stage was performed. Outcomes were measured from diagnosis. Multivariate Cox proportional hazards regression was used to compare metastasis-free and overall survival. Results A total of 246 patients were identified with 62 propensity-score-matched pairs. ADT was administered to 6.5% and 80.6% of patients receiving RP and RT, respectively. Five-year rates of metastasis for RP and RT were 33% and 8.9%, respectively (P = .003). Overall survival was not different. Delay of salvage therapy was longer for patients undergoing primary RT (P < .001). Findings were similar when only those patients who did not receive ADT were compared. Conclusions At our institution, treatment with primary RT resulted in superior metastasis-free survival over RP. This was not accompanied by an improvement in OS.
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Affiliation(s)
- Stephanie Markovina
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Marshall W Meeks
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Shahed Badiyan
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joel Vetter
- Division of Urologic Surgery, Washington University, St. Louis, Missouri
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Alethea Paradis
- Division of Urologic Surgery, Washington University, St. Louis, Missouri
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Gurdarshan Sandhu
- Division of Urologic Surgery, Washington University, St. Louis, Missouri
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10
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Fakhrejahani F, Madan RA, Dahut WL. Management Options for Biochemically Recurrent Prostate Cancer. Curr Treat Options Oncol 2017; 18:26. [PMID: 28434181 DOI: 10.1007/s11864-017-0462-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Prostate cancer is the most common solid tumor malignancy in men worldwide. Treatment with surgery and radiation can be curative in organ-confined disease. Unfortunately, about one third of men develop biochemically recurrent disease based only on rising prostate-specific antigen (PSA) in the absence of visible disease on conventional imaging. For these patients with biochemical recurrent prostate cancer, there is no uniform guideline for subsequent management. Based on available data, it seems prudent that biochemical recurrent prostate cancer should initially be evaluated for salvage radiation or prostatectomy, with curative intent. In selected cases, high-intensity focused ultrasound and cryotherapy may be considered in patients that meet very narrow criteria as defined by non-randomized trials. If salvage options are not practical or unsuccessful, androgen deprivation therapy (ADT) is a standard option for disease control. While some patients prefer ADT to manage the disease immediately, others defer treatment because of the associated toxicity. In the absence of definitive randomized data, patients may be followed using PSA doubling time as a trigger to initiate ADT. Based on retrospective data, a PSA doubling time of less than 3-6 months has been associated with near-term development of metastasis and thus could be used signal to initiate ADT. Once treatment is begun, patients and their providers can choose between an intermittent and continuous ADT strategy. The intermittent approach may limit side effects but in patients with metastatic disease studies could not exclude a 20% greater risk of death. In men with biochemical recurrence, large studies have shown that intermittent therapy is non-inferior to continuous therapy, thus making this a reasonable option. Since biochemically recurrent prostate cancer is defined by technological limitations of radiographic detection, as new imaging (i.e., PSMA) strategies are developed, it may alter how the disease is monitored and perhaps managed. Furthermore, patients have no symptoms related to their disease and thus many prefer options that minimize toxicity. For this reason, herbal agents and immunotherapy are under investigation as potential alternatives to ADT and its accompanying side effects. New therapeutic options combined with improved imaging to evaluate the disease may markedly change how biochemically recurrent prostate cancer is managed in the future.
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Affiliation(s)
- Farhad Fakhrejahani
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Dr, MSC 1906, Bethesda, 20892, USA
| | - Ravi A Madan
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Dr, MSC 1906, Bethesda, 20892, USA
| | - William L Dahut
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Dr, MSC 1906, Bethesda, 20892, USA.
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Rutenberg MS, Meister M, Amin PP, Hussain A, Naslund MJ, Kwok Y. Salvage external beam radiotherapy for locally recurrent prostate cancer after definitive brachytherapy. Brachytherapy 2016; 15:722-729. [DOI: 10.1016/j.brachy.2016.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 07/29/2016] [Accepted: 08/05/2016] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW This article discusses etiologic considerations, evaluation, and contemporary approaches to managing rectourethral fistula (RUF) with particular emphasis on geriatric patients. RECENT FINDINGS With the advent of multimodal approaches to treating prostate cancer, such as radiation and ablative therapies, the incidence of RUF is increasing, especially in the geriatric population. Surgical repair and healing of RUF in patients with prior radiation is more challenging than in those without prior radiation or ablation because of fibrotic and ischemic changes in surrounding tissues. There is, at present, a lack of consensus over a standardized approach to RUF management because of the heterogeneity in presentation and limited, primarily retrospective, experience in the literature. Nonetheless, an evolving array of surgical approaches now exists for fistula excision and tissue interposition. SUMMARY Immediate recognition and management of RUF is paramount to prevent related complications. Patient selection and counseling are key to selecting the best approach for repair, whereas a multidisciplinary team, including colorectal and plastic surgery colleagues, may optimize outcomes.
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Baust JG, Gage AA, Klossner D, Clarke D, Miller R, Cohen J, Katz A, Polascik T, Clarke H, Baust JM. Issues Critical to the Successful Application of Cryosurgical Ablation of the Prostate. Technol Cancer Res Treat 2016; 6:97-109. [PMID: 17375972 DOI: 10.1177/153303460700600206] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The techniques of present-day cryosurgery performed with multiprobe freezing apparatus and advanced imaging techniques yield predictable and encouraging results in the treatment of prostatic and renal cancers. Nevertheless, and not unique to cryosurgical treatment, the rates of persistent disease demonstrate the need for improvement in technique and emphasize the need for proper management of the therapeutic margin. The causes of persistent disease often relate to a range of factors including selection of patients, understanding of the extent of the tumor, limitations of the imaging techniques, and failure to freeze the tumor periphery in an efficacious manner. Of these diverse factors, the one most readily managed, but subject to therapeutic error, is the technique of freezing the tumor and appropriate margin to a lethal temperature [Baust, J. G., Gage, A. A. The Molecular Basis of Cryosurgery. BJU Int 95, 1187–1191 (2005)]. This article describes the recent experiments that examine the molecular basis of cryosurgery, clarifies the actions of the components of the freeze-thaw cycle, and defines the resultant effect on the cryogenic lesion from a clinical perspective. Further, this review addresses the important issue of management of the margin of the tumor through adjunctive therapy. Accordingly, a goal of this review is to identify the technical and future adjunctive therapeutic practices that should improve the efficacy of cryoablative techniques for the treatment of malignant lesions.
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Affiliation(s)
- J G Baust
- Institute of Biomedical Technology, SUNY Binghamton, Binghamton, NY, USA.
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Salvage cryotherapy with third-generation technology for locally recurrent prostate cancer after radiation therapy. Int Urol Nephrol 2016; 48:1461-6. [DOI: 10.1007/s11255-016-1339-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
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15
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Chipollini J, Punnen S. Salvage Cryoablation of the Prostate. Prostate Cancer 2016. [DOI: 10.1016/b978-0-12-800077-9.00058-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Vora A, Agarwal V, Singh P, Patel R, Rivas R, Nething J, Muruve N. Single-institution comparative study on the outcomes of salvage cryotherapy versus salvage robotic prostatectomy for radio-resistant prostate cancer. Prostate Int 2015; 4:7-10. [PMID: 27014657 PMCID: PMC4789332 DOI: 10.1016/j.prnil.2015.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 11/14/2015] [Accepted: 11/22/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Although primary treatment of localized prostate cancer provides excellent oncologic control, some men who chose radiotherapy experience a recurrence of disease. There is no consensus on the most appropriate management of these patients after radiotherapy failure. In this single-institution review, we compare our oncologic outcome and toxicity between salvage prostatectomy and cryotherapy treatments. METHODS From January 2004 to June 2013, a total of 23 salvage procedures were performed. Six of those patients underwent salvage prostatectomy while 17 underwent salvage cryotherapy by two high-volume fellowship-trained urologists. Patients being considered for salvage therapy had localized disease at presentation, a prostate-specific antigen (PSA) < 10 ng/mL at recurrence, life expectancy > 10 years at recurrence, and a negative metastatic workup. Patients were followed to observe cancer progression and toxicity of treatment. RESULTS Patients who underwent salvage cryotherapy were statistically older with a higher incidence of hypertension than our salvage prostatectomy cohort. With a mean follow up of 14.1 months and 7.2 months, the incidence of disease progression was 23.5% and 16.7% after salvage cryotherapy and prostatectomy, respectively. The overall complication rate was also 23.5% versus 16.7%, with the most frequent complication after salvage cryotherapy being urethral stricture and after salvage prostatectomy being severe urinary incontinence. There were no rectal injuries with salvage prostatectomy and one rectourethral fistula in the cohort after salvage cryotherapy. CONCLUSION While recurrences from primary radiotherapy for prostate cancer do occur, there is no consensus on its management. In our experience, salvage procedures were generally safe and effective. Both salvage cryotherapy and salvage prostatectomy allow for adequate cancer control with minimal toxicity.
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Affiliation(s)
- Anup Vora
- Chesapeake Urology Associates, Silver Spring, MD, USA
| | - Vidhi Agarwal
- Cleveland Clinic Florida, Department of Urology, Weston, FL, USA
| | - Prabhjot Singh
- Cleveland Clinic Florida, Department of Urology, Weston, FL, USA
| | - Rupen Patel
- Eastern Carolina University, Greenville, NC, USA
| | - Rodolfo Rivas
- Cleveland Clinic Florida, Department of Urology, Weston, FL, USA
| | - Josh Nething
- Cleveland Clinic Florida, Department of Urology, Weston, FL, USA
| | - Nic Muruve
- Cleveland Clinic Florida, Department of Urology, Weston, FL, USA
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Philippou Y, Parker RA, Volanis D, Gnanapragasam VJ. Comparative Oncologic and Toxicity Outcomes of Salvage Radical Prostatectomy Versus Nonsurgical Therapies for Radiorecurrent Prostate Cancer: A Meta-Regression Analysis. Eur Urol Focus 2015; 2:158-171. [PMID: 28723532 DOI: 10.1016/j.euf.2015.09.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 08/20/2015] [Accepted: 09/08/2015] [Indexed: 01/20/2023]
Abstract
CONTEXT In the absence of randomised controlled trials comparing the oncologic, toxicity, and functional outcomes of salvage radical prostatectomy (SRP), salvage high-intensity focused ultrasound (SHIFU), salvage brachytherapy (SBT), and salvage cryotherapy (SCT), controversy exists as to the optimal salvage modality in radiorecurrent prostate cancer. OBJECTIVE We carried out a meta-regression analysis to determine whether there is a difference in oncologic, toxicity, and functional outcomes using data from original publications of salvage modalities in the postradiation setting. EVIDENCE ACQUISITION We performed a systematic review of PubMed/Medline citations according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. We included 63 articles in the analysis (25 on SRP, 8 on SHIFU, 16 on SCT, 14 on SBT). EVIDENCE SYNTHESIS Median values of the following variables were extracted from each study: patient age, length of follow-up, prostate-specific antigen (PSA) before radiotherapy (RT), PSA before salvage therapy, Gleason score before RT, and time interval between RT and salvage therapy. Functional, toxicity, and oncologic outcomes were measured according to rates of impotence, incontinence, fistula formation, urethral strictures, and biochemical recurrence. Meta-regression adjusting for confounders found no significant difference in oncologic outcomes between SRP and nonsurgical salvage modalities. SBT, SCT, and SHIFU appeared to have better continence outcomes than SRP. No significant difference in toxicity outcomes between modalities was found, although limitations such as reporting, selection, and publication bias and between-study heterogeneity must also be considered with these conclusions. CONCLUSIONS Oncologic outcomes are comparable for SRP and all three nonsurgical salvage modalities. We found no significant differences in toxicity outcomes among modalities; however, SRP appears to be associated with worse rates of urinary incontinence than SBT, SCT, and SHIFU. PATIENT SUMMARY We performed a meta-regression analysis to compare oncologic, functional, and toxicity outcomes between salvage radical prostatectomy and nonsurgical salvage modalities. Oncologic and toxicity outcomes appear to be similar; however, all nonsurgical salvage modalities may be associated with better continence outcomes.
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Affiliation(s)
- Yiannis Philippou
- Department of Surgery, Basildon and Thurrock University Hospital, Essex, UK
| | - Richard A Parker
- Health Services Research Unit University of Edinburgh, Edinburgh, UK
| | - Dimitrios Volanis
- Department of Urology, Addenbrooke's University Hospital, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Urology, Addenbrooke's University Hospital, Cambridge, UK; Academic Urology Group, Department of Surgery and Oncology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.
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Matei DV, Ferro M, Jereczek-Fossa BA, Renne G, Crisan N, Bottero D, Mazzarella C, Terracciano D, Autorino R, De Cobelli O. Salvage radical prostatectomy after external beam radiation therapy: a systematic review of current approaches. Urol Int 2015; 94:373-82. [PMID: 25765848 DOI: 10.1159/000371893] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Radical external beam radiotherapy (EBRT) is a standard treatment for prostate cancer patients. Despite this, the rate of intraprostatic relapses after primary EBRT is still not negligible. There is no consensus on the most appropriate management of these patients after EBRT failure. For these patients, local salvage therapy such as radical prostatectomy, cryotherapy, and brachytherapy may be indicated. OBJECTIVE The objectives of this review were to analyze the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method. METHODS A review of the literature was performed to identify studies of local salvage therapy for patients who had failed primary EBRT for localized prostate cancer. RESULTS Most studies demonstrated that local salvage therapy after EBRT may provide long-term local control in appropriately selected patients, although toxicity is often significant. CONCLUSIONS Our results suggest that for localized prostate cancer recurrence after EBRT, the selection of a local treatment modality should be made on a patient-by-patient basis. An improvement in selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological outcome and least comorbidity.
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Phillips JM, Catarinicchia S, Krughoff K, Barqawi AB. Cryotherapy in prostate cancer. JOURNAL OF CLINICAL UROLOGY 2014. [DOI: 10.1177/2051415814521806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Al B Barqawi
- Division of Urology, University of Colorado, USA
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20
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Focal salvage therapy for locally recurrent prostate cancer: a review. Urologia 2013; 79:219-231. [PMID: 24122479 DOI: 10.5301/ru.2012.9908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2012] [Indexed: 11/20/2022]
Abstract
Objectives: To evaluate the current status of focal therapy as the salvage treatment option for patients with recurrent prostate cancer after established therapy (radiation, surgery) failure for localized tumor.
Methods: A MedLine search using specified search terms was done on December 23, 2011. This research rendered 346 papers related to High-Intensity Focused Ultrasound (HIFU), 644 papers related to cryosurgery, 180 related to photodynamic therapy and 3 articles related to radio frequency ablation. Very few of these papers presented original outcome data and are included in the present review.
Results: No controlled trial was available for analysis.
Conclusions: Salvage HIFU in patients with local recurrence of prostate cancer after radical EBRT indicate is a reasonable treatment option, but better patient selection criteria are needed. It is a promising treatment option for local recurrence after radiation therapy, with morbidity comparable with other forms of salvage treatment. The side effects are not negligible but comparable with other forms of salvage treatment. Photodynamic therapy is a new option that could be suitable for organ-confined PC recurrence after radiotherapy, but the data are very few.
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Zaorsky NG, Raj GV, Trabulsi EJ, Lin J, Den RB. The dilemma of a rising prostate-specific antigen level after local therapy: what are our options? Semin Oncol 2013; 40:322-36. [PMID: 23806497 DOI: 10.1053/j.seminoncol.2013.04.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Prostate cancer is the most common solid tumor diagnosed in men in the United States and Western Europe. Primary treatment with radiation or surgery is largely successful at controlling localized disease. However, a significant number (up to one third of men) may develop biochemical recurrence (BR), defined as a rise in serum prostate-specific antigen (PSA) level. A general presumption is that BR will lead to overt progression in patients over subsequent years. There are a number of factors that a physician must consider when counseling and recommending treatment to a patient with a rising PSA. These include the following (1) various PSA-based definitions of BR; (2) source of PSA (ie, local or distant disease, residual benign prostate); (3) available modalities to treat the disease with the least morbidity; and (4) timing of therapy. In this article we review the current and future factors that clinicians should consider in the diagnosis and treatment of recurrent prostate cancer.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
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22
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Parekh A, Graham PL, Nguyen PL. Cancer Control and Complications of Salvage Local Therapy After Failure of Radiotherapy for Prostate Cancer: A Systematic Review. Semin Radiat Oncol 2013; 23:222-34. [DOI: 10.1016/j.semradonc.2013.01.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Matsushita K, Ginsburg L, Mian BM, De E, Chughtai BI, Bernstein M, Scardino PT, Eastham JA, Bochner BH, Sandhu JS. Pubovesical Fistula: A Rare Complication After Treatment of Prostate Cancer. Urology 2012; 80:446-51. [DOI: 10.1016/j.urology.2012.04.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 04/16/2012] [Accepted: 04/20/2012] [Indexed: 11/28/2022]
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Autran-Gomez AM, Scarpa RM, Chin J. High-Intensity Focused Ultrasound and Cryotherapy as Salvage Treatment in Local Radio-Recurrent Prostate Cancer. Urol Int 2012; 89:373-9. [DOI: 10.1159/000339616] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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25
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Gangi A, Tsoumakidou G, Abdelli O, Buy X, de Mathelin M, Jacqmin D, Lang H. Percutaneous MR-guided cryoablation of prostate cancer: initial experience. Eur Radiol 2012; 22:1829-35. [PMID: 22752525 DOI: 10.1007/s00330-012-2411-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/19/2011] [Accepted: 12/29/2011] [Indexed: 01/12/2023]
Abstract
OBJECTIVE We report our initial experience and the technical feasibility of transperineal prostate cryoablation under MR guidance. METHODS Percutaneous MR-guided cryoablation was performed in 11 patients with prostatic adenocarcinoma contraindicated for surgery (mean age: 72 years, mean Gleason score: 6.45, mean prostate-specific antigen (PSA): 6.21 ng/ml, T1-2c/N0/M0, mean: prostate volume 36.44 ml). Free-hand probe positioning was performed under real-time MR imaging. Four to seven cryoprobes were inserted into the prostate, depending on gland volume. The ice ball was monitored using real-time and high-resolution BLADE multi-planar imaging. Patients were followed at 1, 3, 6, 9 and 12 months after the procedure with serum PSA level and post-ablation MRI. RESULTS Prostate cryoablation was technically feasible in 10/11 patients. The ice ball was clearly and sharply visualised in all cases as a signal-void area. Mean ice-ball volume was 53.3 ml. Mean follow-up was 15 months (range: 1-25). Mean PSA nadir was 0.33 ng/ml (range: 0.02-0.94 ng/ml). Mean hospitalisation was 5 days (range: 3-13). Complications included a urethro-rectal fistula, urinary infection, transient dysuria and scrotal pain. CONCLUSIONS MR-guided prostate cryoablation is feasible and promising, with excellent monitoring of the ice ball. Future perspectives could include the use of MR guidance for focal prostate cancer cryotherapy. KEY POINTS • Magnetic resonance allows precise positioning of cryoprobes with real-time imaging. • High-resolution MRI allows excellent monitoring of the developing ice ball. • Cryoablation of prostate cancer under MR guidance is technically feasible. • Further work will refine the procedure and make it even safer.
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Affiliation(s)
- Afshin Gangi
- Department of Interventional Radiology, University Hospital of Strasbourg, 1 Place de l'Hôpital, 67091 Strasbourg, France.
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Abstract
Many management options are available to patients with newly diagnosed prostate cancer. Magnetic resonance (MR) imaging plays an important role in initial staging of prostate cancer, but it also aids in tumor detection when there is clinical or biochemical suspicion of residual or recurrent disease after treatment. The purpose of this review is to describe the normal appearances of the prostatic region after different kinds of treatment for prostate cancer and to discuss how these appearances differ from those of recurrent and residual disease. Several MR imaging techniques used in evaluating patients with prostate cancer are described, including conventional MR imaging sequences (mainly T1- and T2-weighted sequences), MR spectroscopic imaging, diffusion-weighted imaging, and dynamic contrast agent-enhanced MR imaging. Clinical considerations, together with the different approaches for interpreting serum prostate-specific antigen values in the posttreatment setting, are also presented. All forms of treatment alter the MR imaging features of the prostatic region to a greater or lesser extent, and it is important to be able to recognize expected posttreatment appearances and distinguish them from the features of recurrent or residual cancer to aid subsequent clinical management.
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Affiliation(s)
- Hebert Alberto Vargas
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Radiology Academic Offices, New York, NY 10065, USA.
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27
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Philippou P, Yap T, Chinegwundoh F. Third-Generation Salvage Cryotherapy for Radiorecurrent Prostate Cancer: A Centres Experience. Urol Int 2012; 88:137-44. [DOI: 10.1159/000332220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 08/01/2011] [Indexed: 11/19/2022]
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28
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Finley DS, Belldegrun AS. Salvage cryotherapy for radiation-recurrent prostate cancer: outcomes and complications. Curr Urol Rep 2011; 12:209-15. [PMID: 21394596 PMCID: PMC3090573 DOI: 10.1007/s11934-011-0182-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Potentially curative salvage options for radio-recurrent prostate cancer include prostatectomy, brachytherapy, high-intensity focused ultrasound, and cryotherapy. Salvage cryoablation technology, surgical technique, oncologic outcomes, and complication rates have improved dramatically over the past few decades, shifting this treatment modality from investigational status to an established therapeutic option. In this review, we focus on the most up-to-date oncologic and functional outcomes, as well as complications of salvage cryotherapy for radiation-recurrent prostate cancer.
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Affiliation(s)
- David S Finley
- Institute of Urologic Oncology, David Geffen School of Medicine at UCLA, 924 Westwood Boulevard, Suite 1050, Box 957207, Los Angeles, CA 90095-7207, USA.
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29
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Management of prostate cancer recurrence after definitive radiation therapy. Cancer Treat Rev 2010; 36:91-100. [DOI: 10.1016/j.ctrv.2009.06.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 06/08/2009] [Accepted: 06/21/2009] [Indexed: 11/18/2022]
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Affiliation(s)
- David Levy
- Department of Urology, Cleveland Clinic, Cleveland, OH, USA.
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31
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32
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Weber DC, Wang H, Cozzi L, Dipasquale G, Khan HG, Ratib O, Rouzaud M, Vees H, Zaidi H, Miralbell R. RapidArc, intensity modulated photon and proton techniques for recurrent prostate cancer in previously irradiated patients: a treatment planning comparison study. Radiat Oncol 2009; 4:34. [PMID: 19740429 PMCID: PMC2749024 DOI: 10.1186/1748-717x-4-34] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 09/09/2009] [Indexed: 11/27/2022] Open
Abstract
Background A study was performed comparing volumetric modulated arcs (RA) and intensity modulation (with photons, IMRT, or protons, IMPT) radiation therapy (RT) for patients with recurrent prostate cancer after RT. Methods Plans for RA, IMRT and IMPT were optimized for 7 patients. Prescribed dose was 56 Gy in 14 fractions. The recurrent gross tumor volume (GTV) was defined on 18F-fluorocholine PET/CT scans. Plans aimed to cover at least 95% of the planning target volume with a dose > 50.4 Gy. A maximum dose (DMax) of 61.6 Gy was allowed to 5% of the GTV. For the urethra, DMax was constrained to 37 Gy. Rectal DMedian was < 17 Gy. Results were analyzed using Dose-Volume Histogram and conformity index (CI90) parameters. Results Tumor coverage (GTV and PTV) was improved with RA (V95% 92.6 ± 7.9 and 83.7 ± 3.3%), when compared to IMRT (V95% 88.6 ± 10.8 and 77.2 ± 2.2%). The corresponding values for IMPT were intermediate for the GTV (V95% 88.9 ± 10.5%) and better for the PTV (V95%85.6 ± 5.0%). The percentages of rectal and urethral volumes receiving intermediate doses (35 Gy) were significantly decreased with RA (5.1 ± 3.0 and 38.0 ± 25.3%) and IMPT (3.9 ± 2.7 and 25.1 ± 21.1%), when compared to IMRT (9.8 ± 5.3 and 60.7 ± 41.7%). CI90 was 1.3 ± 0.1 for photons and 1.6 ± 0.2 for protons. Integral Dose was 1.1 ± 0.5 Gy*cm3 *105 for IMPT and about a factor three higher for all photon's techniques. Conclusion RA and IMPT showed improvements in conformal avoidance relative to fixed beam IMRT for 7 patients with recurrent prostate cancer. IMPT showed further sparing of organs at risk.
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Affiliation(s)
- Damien C Weber
- Department of Radiation Oncology, University Hospital of Geneva, Geneva, Switzerland.
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33
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Affiliation(s)
- John F Ward
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA.
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34
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Cryosurgery for Prostate Cancer: an Update on Clinical Results of Modern Cryotechnology. Eur Urol 2009; 55:76-86. [DOI: 10.1016/j.eururo.2008.08.063] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 08/26/2008] [Indexed: 12/29/2022]
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35
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Babaian RJ, Donnelly B, Bahn D, Baust JG, Dineen M, Ellis D, Katz A, Pisters L, Rukstalis D, Shinohara K, Thrasher JB. Best Practice Statement on Cryosurgery for the Treatment of Localized Prostate Cancer. J Urol 2008; 180:1993-2004. [PMID: 18817934 DOI: 10.1016/j.juro.2008.07.108] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - Bryan Donnelly
- American Urological Association Education and Research, Inc
| | - Duke Bahn
- American Urological Association Education and Research, Inc
| | - John G. Baust
- American Urological Association Education and Research, Inc
| | - Martin Dineen
- American Urological Association Education and Research, Inc
| | - David Ellis
- American Urological Association Education and Research, Inc
| | - Aaron Katz
- American Urological Association Education and Research, Inc
| | - Louis Pisters
- American Urological Association Education and Research, Inc
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Salvage Prostate Cryoablation: Initial Results From the Cryo On-Line Data Registry. J Urol 2008; 180:559-63; discussion 563-4. [PMID: 18554664 DOI: 10.1016/j.juro.2008.04.005] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Indexed: 11/20/2022]
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Tharp M, Hardacre M, Bennett R, Jones WT, Stuhldreher D, Vaught J. Prostate high-dose-rate brachytherapy as salvage treatment of local failure after previous external or permanent seed irradiation for prostate cancer. Brachytherapy 2008; 7:231-6. [DOI: 10.1016/j.brachy.2008.03.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Revised: 03/24/2008] [Accepted: 03/26/2008] [Indexed: 10/21/2022]
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38
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Pisters LL. Treatment failure after primary and salvage therapy for prostate cancer. Cancer 2008; 112:225-7. [DOI: 10.1002/cncr.23158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yan JF, Wang HW, Liu J, Deng ZS, Rao W, Xiang SH. Feasibility study on using an infrared thermometer for evaluation and administration of cryosurgery. MINIM INVASIV THER 2007; 16:173-80. [PMID: 17573622 DOI: 10.1080/13645700701384074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Successful performance of cryosurgery relies heavily on a quick, efficient, safe and economic imaging way to monitor the surgical advancement and then to evaluate the curative effect. However, there is currently a lack of such an imaging modality. As for the commonly adopted imaging devices such as X-CT, MRI and PET, in addition their high cost and complexity in operation, they often induce additional scathe to the patients due to their potential radiation effects. Besides, in cryosurgery, the most important parameter - temperature - can not be directly detected by these methods. Considering the above factors, infrared thermography (IRT), a rather useful yet often neglected functional imaging technique in clinics, is proposed in this paper as an efficient tool for the quick evaluation and administration of a cryosurgical treatment of tumors. Based on skin surface temperature mapping, the degree of damage to the target tissue site caused by different freezing/heating protocols, as well as the states of blood circulation and metabolic heat generation within the treated region can possibly be identified. Further, through recording the temperature variation feature at the skin surface before and after cryosurgery, IRT would help to quickly evaluate the curative effect, which is very beneficial for later treatment planning. By detecting the surface infrared image and analyzing its digital values, the patient's invisible focus and abnormal physiological states, e.g. inflammations or pneumothorax, often accompanied by cryosurgical output yet difficult to determine via conventional imaging, could also possibly be diagnosed. To test the above concepts, both typical animal and clinical experiments were performed to demonstrate the feasibility and advantages of IRT-guided cryosurgery. This study may help push forward a novel, low-cost and non-contact way for an efficient performance of cryosurgery.
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Affiliation(s)
- Jing-Fu Yan
- Cryogenics Lab, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing, PR China
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Bostwick DG, Meiers I. Diagnosis of prostatic carcinoma after therapy. Arch Pathol Lab Med 2007; 131:360-71. [PMID: 17516739 DOI: 10.5858/2007-131-360-dopcat] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2006] [Indexed: 11/06/2022]
Abstract
CONTEXT Prostate cancer is the most common cancer of men in the United States and is third only to lung and colon cancer as a cause of cancer death. In 2006, 27,350 Americans will die of prostate cancer, and 234,460 new cases will be diagnosed. Treatment changes in the benign and cancerous prostate create diagnostic challenges in pathologic interpretation, particularly in needle biopsy specimens and in evaluation of extraprostatic metastases. OBJECTIVE To summarize therapy-related pathologic findings in the prostate with emphasis on recognition of treated adenocarcinoma. DATA SOURCES Extensive review of published literature and the authors' experience. CONCLUSIONS Following therapy for prostate cancer, it is critical that the clinician provide the pertinent history of androgen deprivation or radiation therapy to assist the pathologist in rendering the correct diagnosis.
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Affiliation(s)
- David G Bostwick
- Bostwick Laboratories, 4355 Innslake Dr, Glen Allen, VA 23060, USA.
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Huang WC, Lee CL, Eastham JA. Locally ablative therapies for primary radiation failures: a review and critical assessment of the efficacy. Curr Urol Rep 2007; 8:217-23. [PMID: 17459271 DOI: 10.1007/s11934-007-0009-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A significant number of men with prostate cancer will experience biochemical failure following treatment with primary radiation therapy. For patients with biopsy-proven recurrent cancer confined to the prostate, local salvage therapy may be a potentially curative treatment option. Most men, however, do not undergo local salvage therapy owing to difficulties in diagnosis as well as concerns over treatment-related complications in the salvage setting. Recently, improvements in technique and technology have substantially reduced the morbidity associated with locally ablative therapies, resulting in an increased interest in the use of minimally invasive therapies such as brachytherapy, cryotherapy, and high-intensity focused ultrasound in the salvage setting. Although these treatments are well tolerated, concerns remain over incomplete and inadequate treatment with locally ablative therapies. Future studies are required to appropriately select candidates for salvage ablative therapies and to determine the long-term oncologic efficacy of these treatments.
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Affiliation(s)
- William C Huang
- Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Marberger M. Energy-based ablative therapy of prostate cancer: high-intensity focused ultrasound and cryoablation. Curr Opin Urol 2007; 17:194-9. [PMID: 17414518 DOI: 10.1097/mou.0b013e3280dd8a65] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review is an update on the role of the two minimally invasive techniques in primary therapy of organ-confined prostate cancer: as a salvage option after standard-therapy failure and for focal ablation of index tumors. RECENT FINDINGS Energy-based ablative techniques are of growing interest for today's heterogeneous spectrum of prostate cancer. At present, primary high-intensity focused ultrasound appears to be a valid alternative to active surveillance protocols in low-risk cancers and, in older patients, to standard therapy. Morbidity is low, although postoperative impotence occurs frequently. Cryoablation has higher morbidity, even with third-generation conformal technology. With radiorecurrent cancer the potential radiation damage of the rectal wall renders transrectal high-intensity focused ultrasound more hazardous. Third-generation cryoablation seems to give better cancer control with lower morbidity in this situation. Unfortunately, long-term outcome data from controlled trials are not available. SUMMARY These minimally invasive techniques are not magic bullets, and patients must be informed accordingly. Focal ablation of the prostate segment with the index cancer would minimize morbidity and therefore appears highly appealing. Its success depends on correct localization of the lesion. Until this is achieved with sufficient reliability by appropriate biopsy or imaging techniques it remains strictly experimental.
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Affiliation(s)
- Michael Marberger
- Department of Urology, Medical University of Vienna, Vienna, Austria.
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Robinson JW, Donnelly BJ, Coupland K, Siever JE, Saliken JC, Scott C, Brasher PMA, Ernst DS. Quality of life 2 years after salvage cryosurgery for the treatment of local recurrence of prostate cancer after radiotherapy. Urol Oncol 2007; 24:472-86. [PMID: 17138127 DOI: 10.1016/j.urolonc.2006.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Revised: 03/27/2006] [Accepted: 03/28/2006] [Indexed: 11/17/2022]
Abstract
PURPOSE Previous research has raised concerns that although salvage cryosurgery may be an effective treatment to prevent the progression of prostate cancer after radiotherapy failure, the quality of life cost many be so severe as to prevent its acceptance as a viable treatment. The present study's purpose was to further the understanding of the quality of life outcomes of salvage cryosurgery. MATERIALS AND METHODS A total of 46 men with locally recurrent prostate cancer after radiotherapy were recruited to participate in a prospective Phase II clinical trial using salvage cryosurgery. There were 2 questionnaires (i.e., the European Organization of Research and Treatment of Cancer QLQ C30 and the Prostate Cancer Index) administered before cryosurgery, and at 1.5, 3, 6, 12, 18, and 24 months after treatment. RESULTS Quality of life returned to preoperative levels by 24 months after cryosurgery in all domains, with the exception of urinary and sexual functioning. At 24 months, 29% of men reported urinary bother as a moderate-to-big problem, and 56% reported sexual bother as a moderate-to-big problem. CONCLUSIONS To our knowledge, this is the first study to evaluate prospectively men's quality of life for 2 years after salvage cryosurgery for locally recurrent prostate cancer after radiotherapy. Long-term impairments in quality of life appear to be limited to the sexual and urinary function domains. Overall quality of life appears to be high. These results support salvage cryosurgery as a viable treatment option.
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Affiliation(s)
- John W Robinson
- Department of Oncology and Program in Clinical Psychology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada.
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Nguyen PL, D'Amico AV, Lee AK, Suh WW. Patient selection, cancer control, and complications after salvage local therapy for postradiation prostate-specific antigen failure. Cancer 2007; 110:1417-28. [PMID: 17694553 DOI: 10.1002/cncr.22941] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Among men who experience prostate-specific antigen (PSA) failure after external beam radiation or brachytherapy (RT), many will harbor occult micrometastases; however, a significant minority will have a true local-only failure and, thus, potentially may benefit from a salvage local therapy. Those most likely to have a local-only failure initially have low-risk disease (PSA < 10 ng/mL, Gleason score < or =6, clinical T1c or T2a tumor status), pretreatment PSA velocity < 2.0 ng/mL per year at the time of initial presentation, interval to PSA failure > 3 years, PSA doubling time > 12 months, negative bone scan and pelvic imaging, and positive rebiopsy. In addition, men with presalvage PSA levels > 10 ng/mL, presalvage T3/T4 disease, or presalvage Gleason scores > or =7 on a rebiopsy sample without significant RT effects are unlikely to be cured by salvage local therapy. Based on a review of all series of post-RT salvage prostatectomy, cryosurgery, and brachytherapy published in English since 1990, morbidity can be substantial. Although urinary incontinence appeared to be greater after salvage prostatectomy (41%) or cryosurgery (36%) than after brachytherapy (6%), patients who received salvage brachytherapy faced a 17% risk of grade 3 or 4 genitourinary complications and a fistula risk that averaged 3.4% across all series. From this review, the authors concluded that prospective randomized studies are needed to determine the relative efficacy of the 3 major local salvage modalities and that additional research is needed to identify factors associated with an increased risk of significant complications to improve patient selection and to augment the benefit/risk ratio associated with attempts to cure local-only recurrences after radiation therapy.
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Affiliation(s)
- Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Allen GW, Howard AR, Jarrard DF, Ritter MA. Management of prostate cancer recurrences after radiation therapy-brachytherapy as a salvage option. Cancer 2007; 110:1405-16. [PMID: 17685384 DOI: 10.1002/cncr.22940] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Depending on initial prognostic factors, an estimated 10%-60% of men who undergo definitive radiation therapy for prostate cancer may experience a biochemical recurrence. Even though hormonal therapy is standard for metastatic recurrences, no consensus exists on optimal salvage therapy for those recurrences thought confined to the prostate. Salvage treatment options for these local recurrences have historically been limited to salvage prostatectomy, hormonal therapy, or cryotherapy. Salvage prostate brachytherapy, however, uses a widely available technique and may provide another option for attaining disease control in patients with localized failures, although only about 110 cases have been reported in the literature. In this report, the authors have described their own series of salvage brachytherapy cases as well as presented a review of other such series reported in the literature. In addition, the authors included a comprehensive review of published experiences with surgery and cryotherapy as salvage options. It appears that salvage brachytherapy, when combined with careful patient selection, is at least as effective as other salvage options with comparable or potentially fewer treatment-related side effects.
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Affiliation(s)
- Gregory W Allen
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792, USA
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Abstract
PURPOSE OF REVIEW With the recent introduction of novel, minimally invasive procedures for the treatment of prostate cancer, cryotherapy has become a feasible option as a viable alternative to traditional radical surgery and radiation therapy. In this review we update recent data concerning the basic science of cryobiology, technical trends, oncologic results and complications of this procedure. RECENT FINDINGS As a result of better understanding of tumor cryodestruction at a molecular level, refinements in cryotechniques and improved patient selection, the results of cryotherapy are becoming more promising. Furthermore, the dramatic decrease in the number of complications after modern cryotherapy leads to a better quality of life, which may be a preferable option, especially for elderly patients with comorbidities. Current trends towards nerve-sparing and focal cryoablation are also discussed. Recent advances in cryobiology open up new opportunities to apply cryotherapy in combination with chemotherapy or radiotherapy for patients with intermediate or high-risk cancers. SUMMARY Potential directions for future developments in cryosurgery include concepts to reduce side effects such as minimizing cryodamage of the neurovascular bundles (nerve-sparing procedure), and focal ablation of a specific tumor site in patients in whom saturation biopsy supports unifocal prostate cancer.
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Affiliation(s)
- Vladimir Mouraviev
- Division of Urologic Surgery and Duke Prostate Center, Department of Surgery, Duke University Medical Center, 3116 North Duke Street, Durham, NC 27704, USA
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Heidenreich A, Ohlmann C, Ozgür E, Engelmann U. Radikale Salvageprostatektomie bei lokalem Prostatakarzinomrezidiv nach Strahlentherapie. Urologe A 2006; 45:474-81. [PMID: 16465521 DOI: 10.1007/s00120-006-0995-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although technically challenging, salvage radical prostatectomy (SRP) for radiorecurrent prostate cancer (PCA) is an effective option in carefully selected patients and offers the chance for cure and long-term survival. Sometimes local progression of PCA with subvesical obstruction following radiation therapy requires radical cystoprostatectomy or bladder-preserving urinary diversion. We present our experience with salvage radical prostatectomy in a group of 28 consecutive patients. PATIENTS AND METHODS Between January 2003 and August 2005, 25 patients underwent radical salvage surgery for locally recurrent PCA following external beam radiation (n=14), high-dose brachytherapy (n=8), and low-dose brachytherapy (n=6). All men had biopsy-proved recurrent or persistent PCA associated with PSA progression following radiation therapy. Preoperative imaging studies included bone scintigraphy and computed tomography without evidence of metastatic disease. Of the 28 men, 11 (39%) presented with bothersome irritative voiding dysfunction and rectal discomfort. Life expectancy was >10 years in all cases. We analyzed preoperative symptoms, treatment-associated morbidity, pathohistological findings, and functional and oncological outcome after a mean follow-up of 12.5 (2-29) months. RESULTS SRP was performed in all cases without significant intra- and perioperative complications: no rectal lacerations or ureteral lesions were encountered and mean blood loss was 520 (200-950) ml. A total of 21 (75%) men underwent SRP: in 4 cases radical cystoprostatectomy was necessary due to bladder neck infiltration and in 3 men SRP with bladder neck closure and continent appendicovesicostomy was performed due to preexisting urinary stress incontinence. All men with subvesical obstruction experienced significant relief of urgency and significant irritative voiding dysfunction following radical salvage surgery. Pathohistological analysis of the prostatectomy specimen revealed pT1-2b PCA in 19 (67.8%), pT3a/b PCA in 5 (17.8%), and lymph node metastasis or positive surgical margins in 7% of the patients. Two patients demonstrated a pT0 despite positive preoperative biopsies, and 20% demonstrated a Gleason score 8-10. With regard to functional outcome, 25% of the men need 2-3 pads daily whereas 78% of the men are continent. After a mean follow-up of 12.5 (2-29) months, two patients with pT3b and pN1 status exhibit a PSA relapse. CONCLUSION Salvage RP or RCx is a technically challenging but feasible surgical approach with curative intent for the treatment of locally recurrent PCA in well selected patients preventing significant local complications such as subvesical obstruction, ureteral obstruction, hematuria, and rectal infiltration. Surgery-associated morbidity and complications are low and not comparable to earlier series. The indication for salvage RP requires positive biopsy and negative imaging studies.
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Affiliation(s)
- A Heidenreich
- Sektion für Urologische Onkologie, Klinik und Poliklinik für Urologie, Universität Köln.
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