Transcript Safety Update Gynecomastia and Breast Pain

Prostate Cancer:
Causes, Diagnosis, and Treatment
Options
Bruce B. Garber, MD, FACS
Clinical Associate Professor
Drexel University College of Medicine
Graduate Hospital
Philadelphia, PA
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: US Mortality and Incidence, 1973–
1997
SEER Cancer Statistics Review 1973-1997. National Cancer Institute. Bethesda, MD.
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)
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
– Brachytherapy (radioactive seed implant)
 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 33%
 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
•Temperature 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 Total Prostate Cryoablation
 89% of 590 men followed for 7 years were disease-free based on PSA
levels, 87% were disease-free on repeat biopsy
 Rate of rectal injury: 0 - 0.5%
 Rate of urinary incontinence: <5%
 Erectile dysfunction common, but can be successfully treated in almost
all 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 (EBRT or seeds)
 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