Emerging Technologies in the Treatment of Prostate Cancer

1
Emerging Technologies in the Treatment of
Prostate Cancer
Presented by Richard R. Lotenfoe, M.D.,
F.A.C.S.Diplomat of the American Board of Urology
2
Case 1
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.

• 54 y/o Caucasian male, healthy
• No family history of prostate
• cancer
• No voiding symptoms
• Wants a second opinion
• Prostate biopsy done one year ago
• for PSA 5.6

Case 1
Case 2
LAP
RALP
HIFU
CRYO
3
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
March/April 2006 PSA 5.6 Prostate volume 38ml
Case 1
Case 2
LAP
RALP
HIFU
CRYO
4
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• Patient deferred treatment because he did not
  like the options presented to him
• One year later PSA 9.9, DRE 40 grams, no
  nodules.
• Patient now seeking a minimally invasive, potency
  sparing surgery
• Re-staging recommended 3D mapping biopsy

Case 1
Case 2
LAP
RALP
HIFU
CRYO
5
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1
Case 2
LAP
RALP
HIFU
CRYO
6
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Distribution of positive cores Gleason 8
Case 1
Case 2
LAP
R
L
RALP
HIFU
CRYO
7
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• 61 y/o Caucasian male, healthy
• PSA 5.2 previous PSAs normal
• No family history of prostate cancer
• No significant voiding symptoms
• DRE 30 grams, right lobe nodules
• Prostate biopsy recommended

Case 1
Case 2
LAP
RALP
HIFU
CRYO
8
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Only one out of 12 biopsies positive Patient
counseled, is interested in minimally invasive,
potency sparing treatment. Recommend 3D mapping
biopsy
Case 1
Case 2
LAP
RALP
HIFU
CRYO
9
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1
Case 2
LAP
RALP
HIFU
CRYO
10
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Distribution of positive cores 13 out of 47,
Gleason Score 6
Case 1
Case 2
R
L
LAP
RALP
HIFU
CRYO
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Review of cases-1
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1

• Case 1 illustrates patient progressing from
  unilateral disease to bilateral disease, but also
  upgrading from Gleason Score 6 to Gleason Score
  8. Disease is located centrally and anteriorly,
  explaining the negative DRE.

Case 2
LAP
RALP
HIFU
CRYO
12
Review of cases-2
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1

• Case 2 illustrates that even a double sextant
  biopsy can give a false sense of security. The
  disease involves the whole right lobe, and is not
  small volume as suggested by the double sextant
  biopsy.

Case 2
LAP
RALP
HIFU
CRYO
13
Options (Cases 12)
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1

• Classic options for these young, healthy patients
  with localized disease are
• Radical Prostatectomy open retropubic, or open
  perineal
• Radiation therapy External Beam, Conformal,
  IMRT, Proton Beam, Brachytherapy, combos
• Newer technologies

Case 2
LAP
RALP
HIFU
CRYO
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Laparoscopic Radical Prostatectomy (LRP)
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1

• First performed in 1992
• Steep learning curve due to switch from open to
  laparoscopic, 2 dimensional vision, reduced range
  of motion, impaired hand-eye coordination,
  minimal tactile feedback
• Learning period is 80-100 cases
• Advantage less traumatic to patient, faster
  recovery

Case 2
LRP
RALP
HIFU
CRYO
15
Robot-Assisted Laparoscopic Radical Prostatectomy
(RALP)
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1
Case 2
LAP
RALP
HIFU
CRYO
16
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• First performed in May 2000
• Can be learned easily by surgeons with minimal
  laparoscopic experience
• System of a surgeons console with remotely
  controlled telemanipulators
• Three dimensional HD imaging with x12
  magnification
• Endowrist technology which duplicates the
  dexterity of the surgeons forearm and wrist at
  the operative site

Case 1
Case 2
LAP
RALP
HIFU
CRYO
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Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• European Urology Italian publication in January
  2007 reviewing literature on RALP
• the learning curve is short 12-30 cases
• Longer operating times than open prostatectomy
• Lower rates of blood loss, blood transfusion,
  less pain, and earlier patient discharge
• Comparable positive surgical margin rates
• Data on continence rates and potency rates still
  not clear
• Disadvantage costs of machine, maintenance and
  equipment

Case 1
Case 2
LAP
RALP
HIFU
CRYO
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Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1
Case 2
LAP
RALP
HIFU
CRYO
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High Intensity Focused Ultrasound (HIFU)
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1
Case 2
LAP
RALP
HIFU
CRYO
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Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• Focused Ultrasound Energy
• High energy pressure inside the focal zone
  (3x3x10mm) results in permanent tissue damage
• Individual lesions are placed next to each other
  to provide a continuous zone of necrosis
• Focal therapy possible, repeatable procedure

Case 1
Case 2
LAP
RALP
HIFU
CRYO
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Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• Non-invasive, bloodless
• Outpatient, minimal post-op patient discomfort
• Semi-automated with continuously variable power
  adjustment
• Real time 3D imaging available throughout the
  procedure
• Color Doppler ultrasound is built into the
  machine for identification of the neurovascular
  bundles so that they can be avoided

Case 1
Case 2
LAP
RALP
HIFU
CRYO
22
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• Outcomes gt6000 procedures done over 6 years
• Progression-free survival 63-87, recently
  reported to be as high as 94 (May 2007)
• Complications urethral strictures, urinary
  incontinence, impotence, rectal fistula.
• Reported rates are still variable due to
  modifications in equipment and technique, but
  appear very favorable as compared to other
  modalities. Focal therapy so far with 100
  continence and 100 potency rates.

Case 1
Case 2
LAP
RALP
HIFU
CRYO
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Cryoablation
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1

• First generation no ultrasound guidance, no
  urethral warming resulted in high rate of
  complications use of liquid nitrogen caused
  poorly controlled freezing
• Second generation Ultrasound guidance and
  urethral warming
• Third generation the use of pressurized gasses
  allows the use of small bore cryoprobes as well
  as active thawing for increased control

Case 2
LAP
RALP
HIFU
CRYO
24
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• Percutaneous placement of cryoprobes into the
  prostate under ultrasound guidance
• Controlled freezing/thawing using Argon and
  Helium gas via a small bore hollow needle
• Urethral warming catheter prevents urethral
  sloughing
• Placement of a separation needle in the midline
  between the prostate and the rectum helps prevent
  rectal injury

Case 1
Case 2
LAP
RALP
HIFU
CRYO
25
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• Classic cryoablation associated with gt90
  impotency rate
• Focal Cryoablation aids in preserving potency,
  minimizes risks of incontinence
• Focal cryoablation effectively treats localized
  prostate cancer
• Note Cryoablation is a repeatable procedure

Case 1
Case 2
LAP
RALP
HIFU
CRYO
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Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• Salvage Cryoablation of the Prostate Follow-up
  and Analysis of predictive Factors for outcome
  Chee Kwan NG, et al J.Urol. Vol. 178, 1253-1257,
  October 2007
• Current Status of Local Salvage Therapies
  Following Radiation Failure for Prostate Cancer
  Naji J. Touma, et al J. Urol Vol. 173, 373-379,
  February 2005
• Treatment of organ Confined Prostate Cancer with
  Third Generation Cryosurgery Preliminary
  Multicenter Experience Ken-Ryu Han, et al J.
  Urol. Vol 170, 1126-1130, October 2003
• Focal Nerve Sparing Cryosurgery for Treatment
  of primary prostate cancer A New Approach to
  Preserving Potency Gary Onik, et al Urology,
  Vol. 60, Issue 1, July 2002, 109-114
• Salvage Cryotherapy Using an Argon Based System
  for Locally Recurrent Prostate Cancer after
  Radiation Therapy The Columbia Experience
  Mohamed A. Ghafar, et al J. Urol. Vol. 166,
  1333-1338, October 2001
• Increased Risk of Rectal Cancer after Prostate
  Radiation A Population Based Study N.N. Baxter,
  et al Gastroenterology, Vol. 128, 819-824, 2005
• Bladder Cancer Risk Following primary and
  Adjuvant External Beam Radiation for Prostate
  Cancer Kristin Chrouser, et al J. Urol. Vol.
  174, 107-111, July 2005 as well as Letter to the
  Editor David J. Brenner et al J. Urol. Vol.
  175, 788-792
• Urinary Fistulas Following External Radiation or
  Permanent Brachytherapy for the Treatment of
  Prostate Cancer Kristin Chrouser, et al J.
  Urol. Vol 173, 1953-1957, June 2005
• Early Hyperbaric Oxygen Therapy Improves Outcome
  for Radiation-Induced Hemorrhagic Cystitis K.T.
  Chong, et al Urology Vol. 65, 649-653, 2005
• Late Normal Tissue Sequelae in the Second Decade
  After High Dose Radiation Therapy with Combined
  Photons and Conformal Photons for locally
  Advanced prostate Cancer B.G. Gardner, et al J.
  Urol. Vol. 167, 123-126, January 2002

Sources
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Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1

• Failure Definition-Dependent Differences in
  Outcome Following Radiation for Localized
  Prostate Cancer Can One Size Fit All? D. Kuban,
  et al Int J Radiat Oncol Biol Phys, Vol. 61,
  409-414, 2005
• Outcome Analysis of High Intensity Focused
  Ultrasound for Clinically Localized Prostate
  Cancer in Japan Seven Year Follow-Up- Makato
  Suzuki, Toyoaki Uchida, et al Tokyo, Japan (Oral
  presentation)
• Visually Directed High Intensity Focused
  Ultrasound for Organ Confined Prostate Cancer A
  Proposed Standard for Conduct of Therapy Rowland
  O. Illing, et al 2006 BJU International, 98,
  1187-1192
• Treatment of Localized Prostate Cancer Using High
  Intensity Focused Ultrasound Toyoaki Uchida, et
  al 2006 BJU International, 97, 56-61
• Transrectal Focused Ultrasound Combined with
  Transurethral Resection of the Prostate for the
  Treatment of Localized prostate Cancer
  Feasibility Study Guy Vallancien et al J. Urol.
  Vol. 171, 2265-2267, June 2004
• Local Control of Prostate Cancer by Transrectal
  High Intensity Focused Ultrasound Therapy
  Preliminary Results A. Gelet et al J. Urol.
  Vol. 161, 156-162, January 1999
• Current Status of HIFU and Cryotherapy in
  Prostate Cancer A Review G. Aus, Eur Urol
  2006, Vol 50, 927-934
• Evidence from Robot-Assisted Laparoscopic Radical
  Prostatectomy A Systematic Review Vincenzo
  Ficarra, et al European Urology 51 (2007) 45-56
• High-Intensity Focused Ultrasound (HIFU) for
  Prostate Cancer François-Joseph Murat, et al
  Cancer Control, July 2007, Volume 14, No. 3.

Sources