Salvage Cryosurgery in Prostate Cancer

US Oncological Review, 2008;4(1):42-5

Radiation is a common form of therapy for patients with newly diagnosed and localized prostate cancer. It has been estimated that nearly one-third of newly diagnosed prostate cancer patients will choose one form of radiation therapy as their primary treatment. Despite modifications of delivering radiation to the gland such as intensity modulation, 3D conformal, and computer-assisted brachytherapy, a significant number of these patients will have a rise in their serum prostate-specific antigen (PSA) value some time after radiation has been administered. Urologists are often called upon to manage patients with rising PSA values and radiation-recurrent cancer.

According to the recent literature, the frequency of biochemical failure with external-beam radiotherapy ranges from 20 to 66%.1–8 However, in the past many investigators used different definitions of biochemical failure. In 1997, the American Society for Therapeutic Radiology and Oncology (ASTRO) defined biochemical failure as three consecutive PSA level rises separated by three- to four-month intervals (ASTRO panel consensus statement). More recently, the Phoenix consensus definition, PSA nadir plus 2ng/ml or more, was introduced.9 Since rising PSA levels can occur with both local and metastatic disease, an elevation does not necessarily imply that the patient has local recurrence. In addition, a PSA level elevation may be due to benign causes. These factors make it difficult to clearly define a locally salvageable population. Only approximately one-third of patients with biochemical failure will have local recurrence.10 If local recurrence is detected early, salvage therapy is feasible. Recent advances in both technology and the technique of salvage cryosurgery have led to the ability to eradicate these tumors with a reduction in morbidity.

Scientific Background

Clinically based cryosurgical procedures grounded on well-recognized scientific principles support physician-managed destruction of radiation recurrent tumors of the prostate.11–13 When performed with multiprobe devices and advanced imaging techniques, cryosurgery has yielded predictable and effective results in the long-term treatment of prostate adenocarcinoma in the primary setting.14–16

Prostate geometry dictates cryoneedle/cryoprobe (CN/P) placement: CN/P are placed to support thermal homogeneity at approximately -40°C throughout the prostate. Following template-assisted, ultrasound-guided placement of CN/P, the physician directs freezing from anterior to posterior in the gland. This sequencing supports clear visualization and control of the ablative process under transrectal ultrasound (TRUS).

The main principle of prostate cryosurgery is a thermal therapy that extracts heat (thermal energy) from the targeted tissue, resulting in a series of destructive effects. It has long been recognized that the tissue response from cold injury, which can range from inflammation to total destruction, depends on the severity of freezing. The lesion created by freezing is characterized by coagulation necrosis in the central region with a surrounding, relatively thin, peripheral region in which cell death is apparent. Under ultrasound, the ice ball can be clearly seen as a large hypoechoic region. The outer edge of the ice, which is the warmest part of the ice, can be monitored as it appears as a hyperechoic rim.

Salvage Cryosurgery

Salvage cryosurgery for curative intent should be strongly considered in men who have failed radiation therapy. The most appropriate candidates have documented persistent organ-confined prostate cancer, a PSA <10ng/ml, and a negative metastatic evaluation.

References:
  1. Radge H, Elgamal A-A, Snow PB, et al., Ten-year disease free survival after transperineal sonography-guided Iodine-125 brachytherapy with or without 45-Gray external beam irradiation in the treatment of patients with clinically localized, low to high Gleason grade prostate carcinoma, Cancer, 1998;83:989–1001.
  2. Stock RG, Stone NN, DeWyngaert JK, et al., Prostate-specific antigen findings and biopsy results following interactive ultrasound guided transperineal brachytherapy for early stage prostate carcinoma, Cancer, 1996;77:2386–92.
  3. Zelefsky MJ, Leibel SA, Gaudin PB, et al. Dose escalation with three-dimensional conformal radiation therapy affects the outcome of prostate cancer, Int Radiat Oncol Biol Phys, 1998;41:491–500.
  4. Dinges S, Deger S, Koswig S, et al., High-dose rate interstitial with external beam irradiation for localized prostate cancerresults of a prospective trial, Radiother Oncol, 1998;48:197–202.
  5. Crook JM, Bunting PS, Percent free prostate-specific antigen after radiotherapy for prostate cancer, Urology, 1998;52:100–105.
  6. Babaiain RJ, Kojima M, Saitoh M, et al., Detection of residual prostate cancer after external radiotherapy, Cancer, 1996;75: 2153–8.
  7. Laverdiere J, Gomez JL, Cusan L, et al., Beneficial effect of combining hormonal therapy administered prior and following external beam radiation therapy for localized prostate cancer, Int J Radiat Oncol Biol Phys, 1997;37:247–52.
  8. Ljung G, Norberg M, Hansson H, et al., Transrectal ultrasonically-guided core biopsies in the assessment of local cure of Prostatic cancer after radical external beam radiotherapy, Acta Oncologica, 1995;34:945–52.
  9. Roach M 3rd, Hanks G, Thames H Jr, et al., Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-ASTRO Phoenix Consensus Conference, Int J Radiat Oncol Biol Phys, 2006;65:965.
  10. Crook J, Malone S, Perry G, et al., Post-radiotherapy prostate biopsies: what do they really mean? Results for 498 patients, Int J Radiat Oncol Biol Phys, 2000;48:355.
  11. Baust JG, Gage AA, The Molecular Basis of Cryosurgery, BJU Int, 2005;95:1187–91.
  12. Hoffmann NE, Bischof JC, The cryobiology of cryosurgical injury, Urology, 2002;60:40–49.
  13. Baust JG, Gage AA, Klossner D, et al., Critical Issues in the Successful Application of Cryosurgical Ablation of the Prostate, Technol Cancer Res Treatment, 2007;6:97–110.
  14. Long JP, Bahn D, Lee F, et al., Five-year retrospective, multiinstitutional pooled analysis of cancer-related outcomes after cryosurgical ablation of the prostate, Urology, 2001;57:518–23.
  15. Prepelica KL, Okeke Z, Murphy A, Katz AE, Cryosurgical ablation of the prostate: high risk patient outcomes, Cancer, 2005:103: 1625–30.
  16. Bahn DK, Lee F, Badalament R, et al., Targeted cryoablation of the prostate: seven-year outcomes in the primary treatment of prostate cancer, Urology, 2002:60:3–11.
  17. Stock RG, Stone NN, Cesaretti JA, Prostate-specific antigen bounce after prostate seed implantation for localized prostate cancer: descriptions and implications, Int J Radiat Oncol Biol Phys, 2003;56:448.
  18. Rosser CJ, Kuban DA, Levy LB, et al., Prostate specific antigen bounce phenomenon after external beam radiation for clinically localized prostate cancer, J Urol, 2002;168:2001.
  19. Spiess PE, et al., Presalvage prostate-specific antigen (PSA) and PSA doubling time as predictors of biochemical failure of salvage cryotherapy in patients with locally recurrent prostate cancer after radiotherapy, Cancer, 2006;107(2):275–80.
  20. Sartor CI, Strawderman MH, Lin XH, et al., Rate of PSA rise predicts metastatic versus local recurrence after definitive radiotherapy, Int J Radiat Oncol Biol Phys, 1997;38:941.
  21. Crook JM, Bahadur YA, Robertson SJ, et al., Evaluation of radiation effect, tumor differentiation, and prostate specific antigen staining in sequential prostate biopsies after external beam radiotherapy for patients with prostate carcinoma, Cancer, 1997;79:81.
  22. Eichler, et al., Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review, J Urol, 2006:175(5):1605–12.
  23. Gheiler EL, Tefilli MV, Tiguert R, et al., Predictors for maximal outcome in patients undergoing salvage surgery for radio-recurrent prostate cancer, Urology, 1998;51:789.
  24. Chin JL, Pautler SE, Mouraviev V, et al., Results of salvage cryoablation of the prostate after radiation: identifying predictors of treatment failure and complications, J Urol, 2001;165:1937.
  25. Pound CR, Partin AW, Epstein JI, et al., Prostate-specific antigen after anatomic radical retropubic prostatectomy. Patterns of recurrence and cancer control, Urol Clin North Am, 1997;24:395.
  26. Pisters LL, von Eschenbach AC, Scott SM, et al., The efficacy and complications of salvage cryotherapy of the prostate, J Urol, 1997;157:921.
  27. Bales GT, Williams MJ, Sinner M, et al., Short-term outcomes after cryosurgical ablation of the prostate in men with recurrent prostate carcinoma following radiation therapy, Urology, 1995;46:676.
  28. Cespedes RP, von Eschenbach LL, McGuire AC, Long-term follow-up of incontinence and obstruction after salvage cryosurgical ablation of the prostate: results in 143 patients, J Urol, 1997;157:237.
  29. Bahn DK, Lee F, Silverman P, et al., Salvage cryosurgery for recurrent prostate cancer after radiation therapy: a seven-year follow-up, Clin Prostate Cancer, 2003;2:111.
  30. de la Taille A, Hayek O, Benson MC, et al., Salvage cryotherapy for recurrent prostate cancer after radiation therapy: the Columbia experience, Urology, 2000;55:79.
  31. Ghafar MA, Johnson CW, De La Taille A, et al., Salvage cryotherapy using an argon based system for locally recurrent prostate cancer after radiation therapy, J Urol, 2001;166:1333.
  32. Chin JL, Pautler SE, Mouraviev, et al., Results of salvage cryoablation of the prostate after radiation: identifying predictors of treatment failure and complications, J Urol, 2001;165:1937.
  33. Cresswell J, Asterling S, Chaudhary M, et al., Third-generation cryotherapy for prostate cancer in the UK: a prospective study of the early outcomes in primary and recurrent disease, BJU Int, 2006;97:969.
  34. Han KR, Belldegrum AS., Third-generation cryosurgery for primary and recurrent prostate cancer, BJU Int, 2004;93:14.
  35. Donnelly BJ, Saliken JC, Ernst DS, et al., Role of transrectal ultrasound guided salvage cryosurgery for recurrent prostate carcinoma after radiotherapy, Prostate Cancer Prostatic Diseases, 2005;8:235–42.
  36. Robinson JW, Donnelly BJ, Coupland K, et al., Quality of life two years after salvage cryosurgery for the treatment of local recurrence of prostate cancer after radiotherapy, Urologic Oncology, 2006;24:472–86.
  37. Anastasiadis AG, Sachdev R, Salomon L, Katz AE, Comparison of health-related quality of life and prostate-associated symptoms after primary and salvage cryotherapy for prostate cancer, J Cancer Res Clin Oncol, 2003;129:676–82.
Customize This