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306Local recurrence of prostate cancer after external beam radiation: Early experience of salvage therapy using high intensity focused ultrasound
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C R Y O S U R G E R Y AS A SALVAGE T R E A T M E N T F O R L O C A L L Y R E C U R R E N T PROSTATE C A N C E R F O L L O W I N G RADIOTHERAPY: EARLY SINGLE INSTITUTE EXPERIENCE
L O C A L R E C U R R E N C E OF PROSTATE C A N C E R A F T E R E X T E R N A L BEAM RADIATION: EARLY EXPERIENCE OF SALVAGE T H E R A P Y USING H I G H INTENSITY FOCUSED ULTRASOUND
Ahmed St, Lindsey B., Davies J.
Poissonnier L. 1, Gelet A. 1, Chapelon J.Y?, Bouvier R. 3, Colombel M.1, Curiel L. 2, Vallancien G. 4
Royal Surrey County Hospital, Urology, Gnildford, United Kingdom INTRODUCTION & OBJECTIVES: Increasing numbers of patients are choosing minimally invasive therapies for early prostate cancer such as external beam radiotherapy to evade complications associated with major surgery. Recurrent prostate cancer after radiotherapy is of a higher grade and more advanced stage than the primary cancer in the majority of cases. Early detection of recurrence will render some of the patients suitable candidates for salvage treatment. Salvage pmstatectomy was the main treatment option for those patients; however, it is a technically difficult operation and with high complication rate. Cryosurgery has become an attractive minimally invasive option to treat early prostate cancer. The purpose of this study is to evaluate the safety and efficacy of salvage cryosurgery for locally recurrent prostate cancer following radiation therapy. MATERIAL & METHODS: 43 consecutive patients who underwent salvage prostate cryoablation with a minimum of 6 months follow-up were reviewed. Mean follow-up was 24.3 months (ranged from 6 to 54). All patients had biopsy proven recurrence and were restaged with MRI and bone scan. The cryosurgery was performed under general anaesthetic utilising double or triple freeze/thaw cycles, urethral warming catheter and thermocouple probes in all cases. 3 factors were used to define risk groups: PSA more than 10; Gleason score more than 6 and clinical stage more than T2a. Patients who have 2 or more factors were high-risk (n=28); patients with one factor were considered medium-risk (n-10) and any patient with no factor was low-risk (n=5). RESULTS: There were no operative or cancer related mortalities. At 3 months, 72% of patients (31/43) achieved nadir PSA level of less than 0.5 ng/ml. At the last follow-up, 7 of the 28 high-risk; 9 of the 10 medium-risk and 4 of the 5 lowrisk patients were biochemically disease-free (serum PSA of less than 0.5 ng/ml). Complications included: incontinence in 11%; impotence 94% and none had rectovesical fistula or prolonged perineal pain. CONCLUSIONS: The early results are encouraging. Cryosurgery appears to be an effective therapeutic option for radiation-failure prostate cancer although longer followup is required before final conclusions are made. High-risk patient were the least favourable group, hence, patient selection is essential. The recent advancements in technique and technology have increased the safety of salvage cryotherapy, although impotence rate remains high.
1Edouard Herriot Hospital, Urology, Lyon, France, 2Research Unit U556, Therapeutic Ultrasound, Lyon, France, 3Edouard Herriot Hospital, Anatomopathology, Lyon, France, 4Institut Mutualiste de Montsouris, Urology, Paris, France I N T R O D U C T I O N & OBJECTIVES: To evaluate the efficacy and safety of a salvage therapy using transrectal High Intensity Focused Ultrasound (HIFU) for locally recurrent prostate cancer, after External Beam Radiation Therapy (EBRT). M A T E R I A L & METHODS: All patients were treated with the Ablatherm®HIFU device (EDAP SA, France) under general or spinal anaesthesia. Specific parameters were progressively defined in order to avoid any rectal damage. Patients follow-up included sextant biopsies and PSA level measurements. Failure was defined as any positive biopsy occurrence or 3 consecutive rises in the PSA equals or exceeds 1 ng/ml. RESULTS: 106 patients were included in this series. The main baseline characteristics before HIFU were: mean age 68 ±6 years, mean prostate volume 19.9 ~10.6 cc, mean PSA level 7.85 :t-8.54 ng/ml, and all had positive biopsies, with pre-HIFU Gleason score at 2-6 in 41 patients, 7 in 22 patients, and 8-10 in the remaining 43 patients. The mean patients follow-up was 15.7 months (range: 3 to 99 months). After HIFU treatment, 84% of the patients presented negative biopsies, and 57% had a nadir PSA level < 0.5 ng/ml , this nadir level being obtained within 3 months. The disease free rate at 40 months was 40.5% (Gleason 2-6 : 57%, Gleason 7-10 : 31%). The adverse events related to HIFU included recto-urethral fistula in 5%, grade II or III incontinence in 22%, and bladder neck stenosis in 17%. No rectal injury occurred since the use of specific parameters. CONCLUSIONS: HIFU appears as a promising treatment option with a curative chance for the patients with local recurrence after EBRT. The HIFU related morbidity was lower than the morbidity reported after other types of salvage therapy, leading to a favourable risk-benefit ratio.
307 IS DRE ESSENTIAL FOR THE FOLLOW-UP OF PROSTATE CANCER PATIENTS? AN AUDIT OF 194 PATIENTS
308 ACTIVE M O N I T O R I N G REMAINS A USEFUL M A N A G E M E N T OPTION IN PROSTATE C A N C E R Smith R.. Khoubehi B., Undre S., Patel A.
Ragavan N., Sangar V., Gupta S., Herdmann J., Matanhelia S., Watson M., Blades R. St Mary's Hospital, Urology, London, United Kingdom Royal Preston Hospital, Dept. of Urology, Preston, United Kingdom INTRODUCTION & OBJECTIVES: Prostate cancer is the 2 na most common cancer amongst males in UK. In a few years time it is predicted to become the commonest cancer. This would increase patients being followed-up in the urology outpatients. Nurse specialists in UK are progressively taking up follow-up of these patients. However concerns regarding their ability to perform DRE, are always raised. The aim of this study was to assess the role DRE plays in altering the management of patients being followed-up for prostate cancer in a general outpatient setting. MATERIAL & METHODS: All the prostate cancer patients being followed-up in the Urology outpatients were audited prospectively over 2 month period. The patients were seen by a medical personnel. The period of follow-up, initial stage of the disease, management modality, consecutive PSA values and consecutive DRE findings (if available) were recorded. All the patients had DRE done on at least one occasion. The change in the management was defined as any alteration in the follow-up pattern; either as an advancement or postponement of a future appointment, the need for further investigation or treatment, the admission of a patient and the referral to a different specialist, for example an Oncologist or Palliative Care specialist. The attending physicians were requested to record whether there was any change in the management and which factors influenced the change. They were specifically requested to record whether DRE influenced a change. RESULTS: 194 patients on follow-up for treated prostrate cancer were included (mean age 74.8 years). All stages and treatments were included in this study (hormonal manipulation (n= 68), orchiectomy (n=8), radical radiotherapy with hormonal manipulation (n=lb), radical radiotherapy (n - 48), radical prostatectomy (n - 21), brachytherapy (n = 1) and active surveillance (n = 33)). The management changed in 47/194 (24%) patients. The factors that influenced the changes were PSA trend (n=27), LUTS (n=10), bone pain (n-4), change in DRE findings (n= 2) and other factors (abnormal renal function (n- 1), bleeding per rectum (n=l), pruritis (n =1) and erectile dysfunction (n= 1)). CONCLUSIONS: PSA trend is the most common factor influencing a change in management. DRE seems to play little role in the follow up of prostate cancer patients. Nurse Specialist clinic run parallel to consultant clinic with a protocol to perform DRE only as when necessary (e.g. increase in PSA, onset of new symptoms or worsening of existing symptoms) how been set up in the hospital.
I N T R O D U C T I O N & O B J E C T I V E S : Active surveillance or "Watchful waiting" is one of treatment options discussed with men with prostate cancer particularly for patients with an estimated life expectancy of less than 10 years. When such an approach is being considered, the patient and his urologist must weigh up the chances of progression (either local or metastatic) over the patient's lifetime against the morbidity associated with radical treatments, which may prove to be unnecessary. M A T E R I A L & METHODS: We have followed 34 patients with a clinical diagnosis of prostate cancer who had been referred to a dedicated, rapid access prostate clinic and who elected for active monitoring as their initial treatment. The mean age at diagnosis was 69 years (50 - 91) with a median presenting PSA of 7.6 ng/mI (1.5 - 179). A histological diagnosis was made in 29 men with a median Gleason sum score of 6 (3 - 9). Median follow-up was 29 months (1 - 120 months). RESULTS: 20 men (59%)had PSA values that remained static or had reduced. 4 men (12%) had a rising PSA but remained on surveiIlance. 5 men (15%) have undergone additional treaUnent: 1 man has started hormone suppression after 5 trouble-free years of surveillance; 3 have had external beam radiotherapy (all with current PSA <1 ng/ml) and 1 man had a radical prostatectomy (10 years after initial diagnosis, Gleason 3+4, all margins negative, PSA undetectable). There has been one death (a 91 year old who presented with a PSA of 179 and died without having been biopsied within 1 month of the consultation). 4 men (12%) were lost to follow-up. CONCLUSIONS: Watchful waiting remains a useful treatment option in selected cases. The majority of men in this series have a stable PSA and over two thirds have avoided treatment to date with no adverse consequences. This regime helps to reduce the costs of treatment (both in terms of the side effects and the financial cost of the treatment itself). Active monitoring may also be valuable as an initial strategy in men with low risk disease without obviously affecting the outcome if a change of treatment was recommended or chosen by the patient. It is important to counsel men undergoing surveillance of the importance of close follow-up, especially if the PSA is rising, so that alternative treatments can be discussed with patient if progression suspected.
European Urology Supplements 4 (2005) No. 3, pp. 79
306
C R Y O S U R G E R Y AS A SALVAGE T R E A T M E N T F O R L O C A L L Y R E C U R R E N T PROSTATE C A N C E R F O L L O W I N G RADIOTHERAPY: EARLY SINGLE INSTITUTE EXPERIENCE
L O C A L R E C U R R E N C E OF PROSTATE C A N C E R A F T E R E X T E R N A L BEAM RADIATION: EARLY EXPERIENCE OF SALVAGE T H E R A P Y USING H I G H INTENSITY FOCUSED ULTRASOUND
Ahmed St, Lindsey B., Davies J.
Poissonnier L. 1, Gelet A. 1, Chapelon J.Y?, Bouvier R. 3, Colombel M.1, Curiel L. 2, Vallancien G. 4
Royal Surrey County Hospital, Urology, Gnildford, United Kingdom INTRODUCTION & OBJECTIVES: Increasing numbers of patients are choosing minimally invasive therapies for early prostate cancer such as external beam radiotherapy to evade complications associated with major surgery. Recurrent prostate cancer after radiotherapy is of a higher grade and more advanced stage than the primary cancer in the majority of cases. Early detection of recurrence will render some of the patients suitable candidates for salvage treatment. Salvage pmstatectomy was the main treatment option for those patients; however, it is a technically difficult operation and with high complication rate. Cryosurgery has become an attractive minimally invasive option to treat early prostate cancer. The purpose of this study is to evaluate the safety and efficacy of salvage cryosurgery for locally recurrent prostate cancer following radiation therapy. MATERIAL & METHODS: 43 consecutive patients who underwent salvage prostate cryoablation with a minimum of 6 months follow-up were reviewed. Mean follow-up was 24.3 months (ranged from 6 to 54). All patients had biopsy proven recurrence and were restaged with MRI and bone scan. The cryosurgery was performed under general anaesthetic utilising double or triple freeze/thaw cycles, urethral warming catheter and thermocouple probes in all cases. 3 factors were used to define risk groups: PSA more than 10; Gleason score more than 6 and clinical stage more than T2a. Patients who have 2 or more factors were high-risk (n=28); patients with one factor were considered medium-risk (n-10) and any patient with no factor was low-risk (n=5). RESULTS: There were no operative or cancer related mortalities. At 3 months, 72% of patients (31/43) achieved nadir PSA level of less than 0.5 ng/ml. At the last follow-up, 7 of the 28 high-risk; 9 of the 10 medium-risk and 4 of the 5 lowrisk patients were biochemically disease-free (serum PSA of less than 0.5 ng/ml). Complications included: incontinence in 11%; impotence 94% and none had rectovesical fistula or prolonged perineal pain. CONCLUSIONS: The early results are encouraging. Cryosurgery appears to be an effective therapeutic option for radiation-failure prostate cancer although longer followup is required before final conclusions are made. High-risk patient were the least favourable group, hence, patient selection is essential. The recent advancements in technique and technology have increased the safety of salvage cryotherapy, although impotence rate remains high.
1Edouard Herriot Hospital, Urology, Lyon, France, 2Research Unit U556, Therapeutic Ultrasound, Lyon, France, 3Edouard Herriot Hospital, Anatomopathology, Lyon, France, 4Institut Mutualiste de Montsouris, Urology, Paris, France I N T R O D U C T I O N & OBJECTIVES: To evaluate the efficacy and safety of a salvage therapy using transrectal High Intensity Focused Ultrasound (HIFU) for locally recurrent prostate cancer, after External Beam Radiation Therapy (EBRT). M A T E R I A L & METHODS: All patients were treated with the Ablatherm®HIFU device (EDAP SA, France) under general or spinal anaesthesia. Specific parameters were progressively defined in order to avoid any rectal damage. Patients follow-up included sextant biopsies and PSA level measurements. Failure was defined as any positive biopsy occurrence or 3 consecutive rises in the PSA equals or exceeds 1 ng/ml. RESULTS: 106 patients were included in this series. The main baseline characteristics before HIFU were: mean age 68 ±6 years, mean prostate volume 19.9 ~10.6 cc, mean PSA level 7.85 :t-8.54 ng/ml, and all had positive biopsies, with pre-HIFU Gleason score at 2-6 in 41 patients, 7 in 22 patients, and 8-10 in the remaining 43 patients. The mean patients follow-up was 15.7 months (range: 3 to 99 months). After HIFU treatment, 84% of the patients presented negative biopsies, and 57% had a nadir PSA level < 0.5 ng/ml , this nadir level being obtained within 3 months. The disease free rate at 40 months was 40.5% (Gleason 2-6 : 57%, Gleason 7-10 : 31%). The adverse events related to HIFU included recto-urethral fistula in 5%, grade II or III incontinence in 22%, and bladder neck stenosis in 17%. No rectal injury occurred since the use of specific parameters. CONCLUSIONS: HIFU appears as a promising treatment option with a curative chance for the patients with local recurrence after EBRT. The HIFU related morbidity was lower than the morbidity reported after other types of salvage therapy, leading to a favourable risk-benefit ratio.
307 IS DRE ESSENTIAL FOR THE FOLLOW-UP OF PROSTATE CANCER PATIENTS? AN AUDIT OF 194 PATIENTS
308 ACTIVE M O N I T O R I N G REMAINS A USEFUL M A N A G E M E N T OPTION IN PROSTATE C A N C E R Smith R.. Khoubehi B., Undre S., Patel A.
Ragavan N., Sangar V., Gupta S., Herdmann J., Matanhelia S., Watson M., Blades R. St Mary's Hospital, Urology, London, United Kingdom Royal Preston Hospital, Dept. of Urology, Preston, United Kingdom INTRODUCTION & OBJECTIVES: Prostate cancer is the 2 na most common cancer amongst males in UK. In a few years time it is predicted to become the commonest cancer. This would increase patients being followed-up in the urology outpatients. Nurse specialists in UK are progressively taking up follow-up of these patients. However concerns regarding their ability to perform DRE, are always raised. The aim of this study was to assess the role DRE plays in altering the management of patients being followed-up for prostate cancer in a general outpatient setting. MATERIAL & METHODS: All the prostate cancer patients being followed-up in the Urology outpatients were audited prospectively over 2 month period. The patients were seen by a medical personnel. The period of follow-up, initial stage of the disease, management modality, consecutive PSA values and consecutive DRE findings (if available) were recorded. All the patients had DRE done on at least one occasion. The change in the management was defined as any alteration in the follow-up pattern; either as an advancement or postponement of a future appointment, the need for further investigation or treatment, the admission of a patient and the referral to a different specialist, for example an Oncologist or Palliative Care specialist. The attending physicians were requested to record whether there was any change in the management and which factors influenced the change. They were specifically requested to record whether DRE influenced a change. RESULTS: 194 patients on follow-up for treated prostrate cancer were included (mean age 74.8 years). All stages and treatments were included in this study (hormonal manipulation (n= 68), orchiectomy (n=8), radical radiotherapy with hormonal manipulation (n=lb), radical radiotherapy (n - 48), radical prostatectomy (n - 21), brachytherapy (n = 1) and active surveillance (n = 33)). The management changed in 47/194 (24%) patients. The factors that influenced the changes were PSA trend (n=27), LUTS (n=10), bone pain (n-4), change in DRE findings (n= 2) and other factors (abnormal renal function (n- 1), bleeding per rectum (n=l), pruritis (n =1) and erectile dysfunction (n= 1)). CONCLUSIONS: PSA trend is the most common factor influencing a change in management. DRE seems to play little role in the follow up of prostate cancer patients. Nurse Specialist clinic run parallel to consultant clinic with a protocol to perform DRE only as when necessary (e.g. increase in PSA, onset of new symptoms or worsening of existing symptoms) how been set up in the hospital.
I N T R O D U C T I O N & O B J E C T I V E S : Active surveillance or "Watchful waiting" is one of treatment options discussed with men with prostate cancer particularly for patients with an estimated life expectancy of less than 10 years. When such an approach is being considered, the patient and his urologist must weigh up the chances of progression (either local or metastatic) over the patient's lifetime against the morbidity associated with radical treatments, which may prove to be unnecessary. M A T E R I A L & METHODS: We have followed 34 patients with a clinical diagnosis of prostate cancer who had been referred to a dedicated, rapid access prostate clinic and who elected for active monitoring as their initial treatment. The mean age at diagnosis was 69 years (50 - 91) with a median presenting PSA of 7.6 ng/mI (1.5 - 179). A histological diagnosis was made in 29 men with a median Gleason sum score of 6 (3 - 9). Median follow-up was 29 months (1 - 120 months). RESULTS: 20 men (59%)had PSA values that remained static or had reduced. 4 men (12%) had a rising PSA but remained on surveiIlance. 5 men (15%) have undergone additional treaUnent: 1 man has started hormone suppression after 5 trouble-free years of surveillance; 3 have had external beam radiotherapy (all with current PSA <1 ng/ml) and 1 man had a radical prostatectomy (10 years after initial diagnosis, Gleason 3+4, all margins negative, PSA undetectable). There has been one death (a 91 year old who presented with a PSA of 179 and died without having been biopsied within 1 month of the consultation). 4 men (12%) were lost to follow-up. CONCLUSIONS: Watchful waiting remains a useful treatment option in selected cases. The majority of men in this series have a stable PSA and over two thirds have avoided treatment to date with no adverse consequences. This regime helps to reduce the costs of treatment (both in terms of the side effects and the financial cost of the treatment itself). Active monitoring may also be valuable as an initial strategy in men with low risk disease without obviously affecting the outcome if a change of treatment was recommended or chosen by the patient. It is important to counsel men undergoing surveillance of the importance of close follow-up, especially if the PSA is rising, so that alternative treatments can be discussed with patient if progression suspected.
European Urology Supplements 4 (2005) No. 3, pp. 79