Safety Update Gynecomastia and Breast Pain
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Transcript Safety Update Gynecomastia and Breast Pain
Prostate Cancer:
Causes, Diagnosis, and Treatment
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Bruce B. Garber, MD, FACS
Clinical Associate Professor,
Drexel University College of Medicine.
Urologist, Chestnut Hill Hospital
Philadelphia, PA
www.garber-online.com
215-247-3082
Introduction
The prostate:
-is a gland located below the bladder
-is only present in men
-surrounds the urethra
-can undergo benign or malignant change
-Urine flows from the bladder through the urethra,
which is surrounded by the prostate
-An enlarged prostate can cause difficulty passing urine
-The prostate is not in the rectum, but can be palpated during a
digital rectal exam
Incidence
-Lung, colon, breast, and prostate cancer are the most
common solid organ cancers
-Over 200,000 men are diagnosed with prostate
cancer each year in the U.S.
-African-American men have the highest incidence
Prostate Cancer: Causes
Risk Factors Currently Under Investigation:
Racial origin: African American > all other races
Dietary factors: fatty foods implicated
Genetic factors: familial prostate cancer; prostate cancer genes have
been discovered
Prostate Cancer: Diagnosis
Methods of Detection:
1. Prostate exam (digital rectal exam, DRE)
2. Prostate-specific antigen (PSA) blood test
(free, total, complexed, velocity)
If either is abnormal:
– Ultrasound-guided prostate needle biopsy
Gleason Pathologic Scoring System for Prostate Cancer
Gleason DF. In: Tannenbaum M, ed. Urologic Pathology: The Prostate. Philadelphia, Pa:
Lea & Febiger; 1977:171-197.
Prostate Cancer Staging Systems
Stages A, B, C, D
TNM system (stage T1C is most common)
Whitmore-Jewett
Classification Stage A
Microscopic cancer confined to
the prostate and too small to be
felt by digital rectal exam
A1 Cancer well differentiated
and confined to one site
A2 Cancer moderately or
poorly differentiated or
present in more than
one site
Whitmore-Jewett
Classification Stage B
Cancer large enough to be felt
on DRE
B1 Small nodule on one lobe
of prostate
B2 Large nodule, several small
nodules, or a nodule
containing poorly
differentiated cells
Whitmore-Jewett
Classification Stage C
A large cancer involving nearly
the entire gland
C1 Cancer may have spread
a small distance beyond
the gland
C2 Cancer has invaded the
neighboring tissue
Whitmore-Jewett
Classification Stage D
Widespread (metastatic) cancer
D1 Cancer in pelvic lymph
nodes
D2 Cancer in bone or other
organs
Prostate Cancer: Treatment Options
Non-curative therapies:
1. Androgen deprivation
-LHRH-agonists
-Bilateral orchiectomy
-Antiandrogens
2. Chemotherapy
3. Observation
Potentially curative therapies:
1. Radical prostatectomy
• Retropubic
• Perineal
• Laparoscopic/Robotic
2. Radiotherapy
• External beam radiation
• Brachytherapy (radioactive seed implant, high dose
brachytherapy)
3. Cryo (freezing)
Non-curative Hormonal Therapy:
Currently Available Agents
LHRH-agonists:
Zoladex® (goserelin acetate
implant)
Lupron Depot® (leuprolide
acetate for depot suspension)
Viadur™ (leuprolide acetate
implant)
Eligard®
Vantas®
Antiandrogens:
Casodex® (bicalutamide)
Eulexin® (flutamide)
Nilandron (nilutamide)
Lupron Depot® is a registered trademark of TAP Pharmaceuticals, Inc.
Copyright© 2001 Bayer Corporation. Viadur™ is a trademark of ALZA Corporation under license to Bayer Corporation.
Eulexin® is a registered trademark of Schering-Plough Pharmaceuticals.
Nilandron is a registered trademark of Aventis.
Therapies of Curative Intent:
Radical prostatectomy (total prostate removal)
– Retropubic (abdominal incision)
– Perineal (incision under scrotum)
– Laparoscopic/Robotic (multiple ports)
Radiotherapy
– External beam radiation (IMRT, IGRT)
– Brachytherapy (radioactive seed implant; high dose
brachytherapy)
Cryoablation (freezing)
Radical Prostatectomy
Advantages
Can remove all the cancer
Disadvantages
Major operation
Erectile dysfunction
Incontinence
Scar tissue
Rectal injury
Wound infection, blood clots,
heart attack, etc.
Often doesn’t remove all of the
cancer
External Beam Radiation (EBRT)
Advantages
Efficacy similar to
prostatectomy
Outpatient
Disadvantages
Erectile dysfunction
Chronic bowel and bladder
irritation (cystitis, proctitis)
Requires roughly 7 weeks of
daily treatment
Increased risk of rectal &
bladder cancer
Brachytherapy (radioactive seed implant)
Advantages
Efficacy similar to EBRT
or surgery
Outpatient; one treatment
Disadvantages
Chronic bowel & bladder
irritation
Erectile dysfunction
Seed migration
Can’t treat large prostates
Increased risk of rectal &
bladder cancer
Cryoablation of the Prostate
(Cryosurgery, Cryotherapy)
CRYO = GREEK WORD FOR COLD
ABLATION = DESTRUCTION
What is Cryoablation?
Cryoablation: cancer treatment by freezing to
-40º Centigrade
No surgical incision, minimal blood loss, no radiation
Immediate cancer cell death
Dead cells are slowly reabsorbed by the body
Outpatient procedure, with rapid return to normal activities
FDA-approved, covered by Medicare & most carriers
New technology: <2% of Urologists currently offering
Cryoablation
TARGETED CRYOABLATION OF THE
PROSTATE (TCAP)
Transrectal ultrasound guided
Transperineal placement of 6-8
cryo (freezing) probes
Transperineal placement of 5-6
temperature-sensing probes
Urethral warming device to
preserve urethra & limit side
effects
Technology
•Computer creates “map” of the prostate
•Provides real-time guidance
•Identifies and guides probe placement
•Temperatures shown in real time
•Argon gas freezes prostate rapidly with
excellent control
•Two freeze/thaw cycles immediately kill cancer
cells
•Total procedure time about 60-90 minutes
Current Technology:
6-8 Probe Argon Cryosurgery System, Total Gland Ablation
6-8 Cryo probes in prostate
5-6 Temperature monitoring
probes
Argon Gas = rapid response,
excellent freeze control
Helium Gas = rapid thawing
Prostate Cryoablation
Probes inserted in between scrotum & rectum
Transrectal ultrasound guides the procedure
Targeted Cryoablation of
the Prostate (TCAP)
Prostate frozen
Before
Probes Placed
Prostate Cryoablation Techniques
Total Gland Ablation
Nerve-Sparing
Focal
Total Prostate Cryoablation
Nerve-Sparing Prostate Cryoablation
Focal Prostate Cryoablation
Results of Whole Gland Primary Prostate Cryoablation
J. Urol 180: 554-558 (2008)
1,198 patients
5-year biochemical disease-free status:
ASTRO
Phoenix
-low risk pts.:
84.7%
91.1%
-moderate risk pts.:
73.4%
78.5%
-high risk pts.:
75.3%
62.2%
-all pts.:
77.1%
72.9%
Rectal fistula rate: 0.4%
Urinary incontinence rate: 4.8%
Erectile dysfunction common, but can be successfully treated in most men
ASTRO definition of biochemical failure: 3 consecutive increases in PSA
Phoenix definition of biochemical failure: nadir PSA level +2
Results of Salvage Prostate Cryoablation
J. Urol 180: 559-564 (2008)
279 patients
5-year biochemical disease-free status:
ASTRO
Phoenix
58.9%
54.5%
Rectal fistula rate: 1.2%
Urinary incontinence rate: 4.4%
Erectile dysfunction common, but can be successfully treated in most men
Cryoablation
Advantages
Outpatient
Minimally-invasive
Can treat radiation failures
Can be repeated
Better than radiation for high
grade cancer (Gleason 7-10)
Disadvantages
Erectile dysfunction
Urinary problems (short-term)
Shorter track record than surgery
or radiation
Summary: Prostate Cryoablation
A well-established treatment for localized prostate cancer
Covered by Medicare & most carriers
Minimally invasive: no surgical incision
Minimal blood loss--blood transfusion not needed
Better than radiation for high risk (e.g. high Gleason score) disease
Can treat cancer recurrence after radiation therapy
Does not increase risk of rectal or bladder cancer
Avoids radiation cystitis and proctitis
Avoids seed migration seen with brachytherapy
Can be combined with hormonal therapy
Outpatient procedure for most men
Unlike any other treatment, can be repeated if necessary
Rapid return to normal activities
More rapid recovery than after radical prostatectomy
Erectile dysfunction frequent but treatable