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Emerging Technologies in the Treatment of Prostate Cancer

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... Conformal, IMRT, Proton Beam, Brachytherapy, combo's. Newer technologies ... External Radiation or Permanent Brachytherapy for the Treatment of Prostate ... – PowerPoint PPT presentation

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Title: 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
11
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
14
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
17
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
18
Urology Health Solutions, IncRichard Lotenfoe,
M.D., F.A.C.S.
Case 1
Case 1
Case 2
LAP
RALP
HIFU
CRYO
19
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
20
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
21
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
23
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
26
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
27
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
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