Cryotherapy for prostate cancer
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Abstract:
Cryotherapy, or the use of freezing, is a long-established method of tumor cell destruction. Although in the past cryotherapy was widely used as a local treatment for prostate cancer, this technique was abandoned not due to lack of efficacy but because the complication rate was unacceptably high. However, there has been a re-emergence in the popularity of cryotherapy for the treatment of localized prostate cancer due to improvements in instrumentation, tumor localization and treatment delivery. Using transrectal ultrasound imaging, prostate cryotherapy is currently delivered with multiple probes via a percutaneous transperineal approach. The extent of freezing can be precisely controlled and monitored with thermocouples and tissue destruction is monitored with real-time visualization of the prostate and surrounding structures. The role of cryotherapy in localized prostate cancer is reviewed.Keywords:
Cryotherapy
Cryosurgery
Cryotherapy
Cryoablation
Cryosurgery
Ablative case
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Cryotherapy—the ablation of tissue through the induction of extremely cold tissue temperatures—is the oldest of the ablative therapies currently used to achieve selective prostate tissue destruction. Therefore, most reports of subtotal prostate gland treatment for prostate cancer have employed cryoablation. This chapter reviews the history of cryotherapy, cryobiology, and the currently published literature supporting its use as an effective and safe means of treating prostate cancer.
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During the past decade, cryoablation has been applied to benign and malignant conditions within the prostate and kidney. The essence of cryosurgery lies in producing temperatures low enough to cause necrosis in target tissues while avoiding lethal conditions in healthy peripheral tissues. It works by two main mechanisms: (1) at the cellular level via solute damage and intracellular ice formation; and (2) at the vascular level as a result of thrombosis and subsequent coagulative and ischemic necrosis. Investigation of cryoablation for renal tumors began in 1964, and by the 1990s, attention was turning to its use as a means of treating renal tumors. Modern renal cryosurgery is applied using minimally invasive techniques. Cryotherapy was first applied in the prostate in 1966 and soon thereafter was used to treat prostate cancer. Today, prostate cryosurgical techniques employ ultrasound monitoring and urethral warming to minimize urethral and rectal complications.
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Cryotherapy, or the use of freezing, is a long-established method of tumor cell destruction. Although in the past cryotherapy was widely used as a local treatment for prostate cancer, this technique was abandoned not due to lack of efficacy but because the complication rate was unacceptably high. However, there has been a re-emergence in the popularity of cryotherapy for the treatment of localized prostate cancer due to improvements in instrumentation, tumor localization and treatment delivery. Using transrectal ultrasound imaging, prostate cryotherapy is currently delivered with multiple probes via a percutaneous transperineal approach. The extent of freezing can be precisely controlled and monitored with thermocouples and tissue destruction is monitored with real-time visualization of the prostate and surrounding structures. The role of cryotherapy in localized prostate cancer is reviewed.
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Introduction:Technological advancements have reduced the morbidity associated with cryosurgery, leading to an increased interest in this modality for the treatment of organ-confined prostate cancer. In this study, we critically examine the current role of cryoablation of the prostate to better understand how to counsel patients regarding this treatment option.Methods:A database was compiled over a 3-year period (2008–2011) of 30 patients who underwent cryoablation for organ-confined prostate cancer. Indications for cryosurgery included primary treatment, focal treatment (institutional review board–approved prospective study), and salvage cryotherapy for radiation failure. The primary outcomes were biochemical response via prostate-specific antigen (PSA) measurement and morbidity associated with cryoablation. Cryotherapy failure was defined as an increasing postcryotherapy PSA level ≥ 2 ng/mL above the post-treatment nadir, a positive prostate biopsy, or radiographic evidence of metastatic disease.Results:Of the 30 patients who underwent cryoablation from 2008 to 2011, 26 patients had complete follow-up data for analysis. Of these patients, 17 (65.38%) had total gland cryotherapy, 5 (19.23%) had salvage cryotherapy for radiation failure, and 4 (15.38%) had focal cryotherapy. The mean patient age was 68 years (54–89); median preoperative PSA was 5.5 ng/mL (1.7–15.9); median prostate volume was 35 mL (15–54); mean Gleason score was 7; and the median PSA at study conclusion was 0.7 (0.02–3.4) ng/mL. Of the 17 patients who had total prostate cryotherapy, 11 (64.7%) had significant factors precluding primary treatment by a surgical and/or radiation approach, including neurological disorders (2), morbid obesity (1), rectal cancer treated with radiation (1), kidney/pancreas transplant (2), ileoanal pouch secondary to inflammatory bowel disease (IBD) (1), renal failure (1), and age (3).There were no intra- or postoperative complications. After a median follow-up of 18 months (1–40), none of the patients with multiple comorbidities had biochemical failures. Two patients from the salvage group experienced treatment failure requiring androgen deprivation therapy.Conclusions:This critical analysis of a single-surgeon experience at a large academic prostate cancer program revealed that the contemporary role of cryosurgery is, in select patients with comorbidities, preventing surgical and/or radiation therapy. Additionally, cryosurgery has a role in treating radiation failures. Further studies are necessary to investigate focal cryotherapy as an option for primary treatment, but our preliminary results are promising, without any biochemical failures in our focal therapy cohort.
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