August 30, 2010, 5:00 pm A Rush to Operating Rooms That Alters Men’s Lives
By DANA JENNINGS
Jeanette Ortiz-Burnett/The New York TimesAs I scuffed through the stations of the prostate-cancer cross these past two years, I sometimes wondered whether I wasn’t a dupe caught up in a Robin Cook medical thriller.
Sure, the biopsy (so I was told) showed that my prostate was cancerous. And after it was removed, the pathology report revealed that the cancer was unexpectedly aggressive, thrusting me from the relative comforts of Stage 1 to the deep woods of Stage 3.
But at least on the surface, the cancer itself never did any damage. It was the treatments that razed me — the surgery, radiation and hormones producing a catalog of miseries that included impotence, incontinence and hot flashes. And a small voice kept whispering: What if this is all a lie? A dark conspiracy of the global medical-industrial complex?
And now comes “Invasion of the Prostate Snatchers,” by Ralph H. Blum and Dr. Mark Scholz, effectively confirming my whimsical paranoia.
Mr. Blum, a cultural anthropologist and writer, has lived with prostate cancer for 20 years without radical treatment, and Dr. Scholz is an oncologist who has treated the disease exclusively since 1995.
Their book, written tag-team style, is a provocative and frank look at the bewildering world of prostate cancer, from the current state of the multibillion-dollar industry to the range of available treatments.
About 200,000 cases of prostate cancer are diagnosed each year in the United States, and the authors say nearly all of them are overtreated. Most men, they persuasively argue, would be better served having their cancer managed as a chronic condition.
Why? Because most prostate cancers are lackadaisical — the fourth-class mail of their kind. The authors say “active surveillance” is an effective initial treatment for most men.
They add that only about 1 in 7 men with newly diagnosed prostate cancer are at risk for a serious form of the disease. “Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”
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.Yet radical prostatectomy is still the treatment recommended most often, even though a recent study in The New England Journal of Medicine suggested that it extended the lives of just 1 patient in 48.
And surgery, of course, is most often recommended by surgeons and urologists — who are also surgeons. Mr. Blum writes: “As one seasoned observer of the prostate cancer industry told me, ‘Your prostate is worth what Ted Turner would call serious cash money.’ ” As for patients, their rational thinking has been short-circuited by the word “cancer.” Scared, frantic and vulnerable — relying on a doctor’s insight — they are ripe to being sold on surgery as their best option. Just get it out.
Every urologist I met with after my diagnosis recommended surgery, even though it was believed then that I had a low-risk Stage 1 cancer. The best advice came from my personal urologist, who declined to do my operation because it was beyond him: “Avoid the community hospital guys who do a volume business in prostates.”
I did, but I’m still maimed. In my experience, doctors play down punishing side effects like incontinence, impotence and shrinking of the penis. Those are just words when you hear them, but beyond language when you go through them.
Despite the impression the authors give, though, judging the velocity or voraciousness of a prostate cancer can still be imprecise. I know this firsthand.
After my biopsy, it appeared that I had a Stage 1 cancer, a doddering old nag that the authors would have designated for active surveillance. As it turned out, I had an especially pure Stage 3 cancer, a real top-fuel eliminator in terms of velocity (and hunger).
I’m a wild card, the 1 man in 48 saved by surgery. Without it, my doctors wouldn’t have learned the cancer was so advanced, and wouldn’t have given me the hormones and radiation that helped keep me alive.
So yes, prostate cancer is a dark and mysterious country, and Mr. Blum and Dr. Scholz are good, levelheaded guides through these thickets. And in telling men to slow up and take a deep breath after they learn they have prostate cancer, they provide an invaluable service. I wish I had had this book back in 2008.
But all of this raises one last stark question: Was my life worth the 47 other prostatectomies that probably didn’t have to be performed?
I don’t know. I’m a man, not a statistic.
THE FOLLOWING ARE DR. SUAREZ' COMMENTS ON THE ABOVE ARTICLE:
There are so many valid points in this article and in this book. However, there is no mention of the alternative to surgical removal of the prostate. I am specifically referring to a technology known as High Intensity Focused Ultrasound (HIFU). The manufacturer of the technology is USHIFU, it is called the Sonoblate-500 and is based in Charlotte, N. C. This is a non invasive treatment for prostate cancer that has been approved in Europe and throughout the world since 1998. It is in final phase of investigation clinical trials by the FDA, and should be approved in the U.S. in the next 18-24 months. It provides an efficacy and cure rate similar to surgery and/or radiation, but it has less risks of complications such as referred in the article: impotence and urinary incontinence. It utilizes ultrasound energy that has no toxicity, and provides a precise treatment without scatter or displacement of the treatment to surrounding tissue. Therefore, less risk of collateral damage.
The U.S. is typically the last country to adopt new technology and new medical treatments. Mostly due to the rigors of FDA clinical evaluation, and this is a good thing. No one wants to be rendered a treatment that has not undergone proper evaluation for patient safety, efficacy and clinical outcomes. Once HIFU is approved, it will be the only prostate cancer therapy that would have undergone FDA approval. As all other therapies have had "grand fathered approval" by virtue that they were procedures performed prior to revision of FDA guidelines in 1976.
HIFU is an excellent alternative that merits consideration by men diagnosed with localized prostate cancer. It is available, and being performed by hundreds of American board certified urologist in countries where it is approved. In certain cases it is covered by insurance. The technology is based on similar delivery of energy used to break up kidney stones. It is called piezoelectric energy in the form of extracorporeal shock wave lithotripsy (ESWL). Before ESWL, patients underwent major surgery to remove kidney stones. With ESWL, they are now treated in an out patient setting with non invasive technology.
The advances in computer technology and imaging capabilities continue to transform the practice of medicine at fast and rapid speed. Some of these technologies may be considered disruptive by older , and less adopting physicians. But this the natural and normal course of evolution of medical care. I am convinced that HIFU will be the state of the art treatment of choice in the future.
For additional information, please visit website: www.hifumedicalexpert.com or www.ushifu.com.
George M. Suarez, M.D.
Medical Director,
The Miami Urology Center of Excellence
9195 Sunset Drive
Miami, Florida, 33173
Tel:305-595-0199. 1-877-949-5325
www.hifumedical.expert.com
Tuesday, August 31, 2010
PROSTATE CANCER SCREENING FOR OBESE MEN
Prostate Cancer Screening Should Be Adjusted For Overweight, Obese Men. Fact: Overweight and obese men may have diminished prostate cancer detection.
September is prostate cancer awareness month. The following was provided by the American Urologic Association, and is placed here for educational purposes.
MedWire (8/27, Guy) reported, "Overweight and obese men may have diminished prostate cancer detection owing to low prostate-specific antigen (PSA) levels," University of Texas researchers found after evaluating data on 3,697 individuals. More specifically, "potential explanations for the association between overweight/obesity and PSA is a possible hemodilution effect caused by greater blood volume, or the suppression of PSA production caused by lower testosterone levels and higher estrogen levels," according to the paper in Urology. Thus, the study authors "recommend adjusting prostate cancer screening to allow for the impact of body mass index (BMI)."
September is prostate cancer awareness month. The following was provided by the American Urologic Association, and is placed here for educational purposes.
MedWire (8/27, Guy) reported, "Overweight and obese men may have diminished prostate cancer detection owing to low prostate-specific antigen (PSA) levels," University of Texas researchers found after evaluating data on 3,697 individuals. More specifically, "potential explanations for the association between overweight/obesity and PSA is a possible hemodilution effect caused by greater blood volume, or the suppression of PSA production caused by lower testosterone levels and higher estrogen levels," according to the paper in Urology. Thus, the study authors "recommend adjusting prostate cancer screening to allow for the impact of body mass index (BMI)."
Monday, August 30, 2010
HIFU Shows Promise as a Prostate Cancer Therapy
HIFU Shows Promise As a Prostate Cancer Therapy
AMSTERDAM—High-intensity focused ultrasound (HIFU) shows promise as a treatment for early-stage prostate cancer, according to interim study results presented here at the 7th Meeting of the European Association of Urology's Section of Oncological Urology.
The study included 20 men with stage T1c-T2b, N0, and M0 unilateral prostate cancer. All subjects had a PSA of 15 ng/mL or lower, a Gleason score of 7 or less, and a prostate size of 40 cc or less. Six months after treatment with HIFU, 95% of men were able to achieve erections and had pad-free urinary continence. Also six months post-procedure, 55% of men had wet ejaculations and no patient had rectal toxicity. One man refused a biopsy at six months. Of the 19 men who underwent biopsy, two (10.5%) had cancer recurrence. One patient was switched to active surveillance and the other underwent another HIFU treatment. Six months later, magnetic resonance imaging and biopsy revealed no evidence of disease.
“By treating the disease using focal therapy we avoid the morbidity associated with radical therapy, while restoring men to a position in which they can have access to active surveillance,” said lead investigator Mark Emberton, MD, Consultant Urologist at University College London Hospital in London. “It's controversial, but it's definitely exciting—focal therapy is currently the only strategy on the table that might lead to significant and important reductions in treatment-related harms.”
AMSTERDAM—High-intensity focused ultrasound (HIFU) shows promise as a treatment for early-stage prostate cancer, according to interim study results presented here at the 7th Meeting of the European Association of Urology's Section of Oncological Urology.
The study included 20 men with stage T1c-T2b, N0, and M0 unilateral prostate cancer. All subjects had a PSA of 15 ng/mL or lower, a Gleason score of 7 or less, and a prostate size of 40 cc or less. Six months after treatment with HIFU, 95% of men were able to achieve erections and had pad-free urinary continence. Also six months post-procedure, 55% of men had wet ejaculations and no patient had rectal toxicity. One man refused a biopsy at six months. Of the 19 men who underwent biopsy, two (10.5%) had cancer recurrence. One patient was switched to active surveillance and the other underwent another HIFU treatment. Six months later, magnetic resonance imaging and biopsy revealed no evidence of disease.
“By treating the disease using focal therapy we avoid the morbidity associated with radical therapy, while restoring men to a position in which they can have access to active surveillance,” said lead investigator Mark Emberton, MD, Consultant Urologist at University College London Hospital in London. “It's controversial, but it's definitely exciting—focal therapy is currently the only strategy on the table that might lead to significant and important reductions in treatment-related harms.”
Thursday, August 26, 2010
SUBACUTE PENILE NUMBNESS AFTER BRACHYTHERAPY FOR PROSTATE CANCER
Friday, 20 August 2010
Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.
Penile numbness is a rare complication of permanent prostate brachytherapy, and optimal clinical management remains unclear. We present such a case and discuss pathophysiology and clinical management strategies.
A 68-year-old male presented with a serum prostate-specific antigen level of 6.9 ng/mL, Gleason score of 7 (3+4), and clinical T1c adenocarcinoma of the prostate. After a permanent prostate brachytherapy implant with (125)I monotherapy to a dose of 145Gy, the patient developed complete penile numbness postoperatively on the third day.
The patient experienced complete restoration of penile sensation and function by postoperative day 9 with conservative management.
Subacute penile shaft numbness after brachytherapy is rare and is caused by dorsal penile nerve compression. Over the course of a week, the restoration of penile sensation is likely to occur with conservative management.
Written by:
Sharp HJ, Swanson DA, Patel H, Gorbatiy V, Frenzel JC, Frank SJ. Are you the author?
Reference: Brachytherapy. 2010 Aug 2. Epub ahead of print.
doi: 10.1016/j.brachy.2010.02.197
PubMed Abstract
PMID: 20685173
UroToday.com Prostate Cancer Section
#
Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.
Penile numbness is a rare complication of permanent prostate brachytherapy, and optimal clinical management remains unclear. We present such a case and discuss pathophysiology and clinical management strategies.
A 68-year-old male presented with a serum prostate-specific antigen level of 6.9 ng/mL, Gleason score of 7 (3+4), and clinical T1c adenocarcinoma of the prostate. After a permanent prostate brachytherapy implant with (125)I monotherapy to a dose of 145Gy, the patient developed complete penile numbness postoperatively on the third day.
The patient experienced complete restoration of penile sensation and function by postoperative day 9 with conservative management.
Subacute penile shaft numbness after brachytherapy is rare and is caused by dorsal penile nerve compression. Over the course of a week, the restoration of penile sensation is likely to occur with conservative management.
Written by:
Sharp HJ, Swanson DA, Patel H, Gorbatiy V, Frenzel JC, Frank SJ. Are you the author?
Reference: Brachytherapy. 2010 Aug 2. Epub ahead of print.
doi: 10.1016/j.brachy.2010.02.197
PubMed Abstract
PMID: 20685173
UroToday.com Prostate Cancer Section
#
Tuesday, August 24, 2010
HEALTHDAY NEWS
MONDAY, Aug. 23 (HealthDay News) -- The initial treatment given to prostate cancer patients has a major impact on short- and long-term costs of care, a new study has found.
For example, while some may opt for an initial treatment that is less expensive in the short-term, the long-term costs of that treatment may actually be higher, the study authors explained.
Treatments options for early-stage prostate cancer include surgery, radiation therapy, hormonal treatment, watchful waiting, or combinations of those methods. Decisions about which treatment to use are based on a variety of factors, including cost, according to background information in the study, published online Aug. 23 in the journal Cancer.
In the study, U.S. researchers analyzed data from 13,769 prostate cancer patients, aged 66 and older, who were diagnosed in 2000 and followed-up for a period of five years. The data came from the Surveillance, Epidemiology and End Results (SEER)-Medicare database.
The men were divided into groups based on the treatment they received during the first nine months after being diagnosed with prostate cancer: watchful waiting, radiation, hormonal therapy, hormonal therapy plus radiation, and surgery. The men in the surgery group may also have received hormones and/or radiation therapy.
For most of these cases, treatment costs were highest in the first year and then declined sharply and remained steady over the next several years. According to the report, watchful waiting had the lowest initial ($4,270) and five-year total costs ($9,130), and hormonal therapy had the second lowest initial cost but the highest five-year total cost ($26,896).
The highest initial treatment costs were observed among those receiving hormonal therapy plus radiation ($17,474), and those undergoing surgery ($15,197), the investigators noted.
Over five years, total costs for hormonal therapy plus radiation were $25,097, and $19,214 for surgery.
When the researchers took into account that costs of treatment in the last 12 months of life are different than other treatment years and excluded the costs for that year, they found that total costs were highest for hormonal therapy plus radiation ($23,488) and hormonal therapy only ($23,199).
"This demonstrates that treatments that may be less expensive in the short term may have higher long-term costs," study leader Claire Snyder, of the Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health in Baltimore, said in a journal news release.
More information
The U.S. National Cancer Institute has more about prostate cancer.
For example, while some may opt for an initial treatment that is less expensive in the short-term, the long-term costs of that treatment may actually be higher, the study authors explained.
Treatments options for early-stage prostate cancer include surgery, radiation therapy, hormonal treatment, watchful waiting, or combinations of those methods. Decisions about which treatment to use are based on a variety of factors, including cost, according to background information in the study, published online Aug. 23 in the journal Cancer.
In the study, U.S. researchers analyzed data from 13,769 prostate cancer patients, aged 66 and older, who were diagnosed in 2000 and followed-up for a period of five years. The data came from the Surveillance, Epidemiology and End Results (SEER)-Medicare database.
The men were divided into groups based on the treatment they received during the first nine months after being diagnosed with prostate cancer: watchful waiting, radiation, hormonal therapy, hormonal therapy plus radiation, and surgery. The men in the surgery group may also have received hormones and/or radiation therapy.
For most of these cases, treatment costs were highest in the first year and then declined sharply and remained steady over the next several years. According to the report, watchful waiting had the lowest initial ($4,270) and five-year total costs ($9,130), and hormonal therapy had the second lowest initial cost but the highest five-year total cost ($26,896).
The highest initial treatment costs were observed among those receiving hormonal therapy plus radiation ($17,474), and those undergoing surgery ($15,197), the investigators noted.
Over five years, total costs for hormonal therapy plus radiation were $25,097, and $19,214 for surgery.
When the researchers took into account that costs of treatment in the last 12 months of life are different than other treatment years and excluded the costs for that year, they found that total costs were highest for hormonal therapy plus radiation ($23,488) and hormonal therapy only ($23,199).
"This demonstrates that treatments that may be less expensive in the short term may have higher long-term costs," study leader Claire Snyder, of the Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health in Baltimore, said in a journal news release.
More information
The U.S. National Cancer Institute has more about prostate cancer.
Monday, August 23, 2010
ARE YOU CONSIDERING CRYOSURGERY?
Prostate Cancer Cryotherapy:
Common Side Effects
Prostate cancer cryotherapy (cryosurgery) freezes the entire prostate gland through a minimally invasive procedure involving ultrathin cryoneedles. Side effects usually occur due to damage of the surrounding tissue during the procedure. The severity and occurrence of side effects are largely affected by the relative health of a patient as well as whether cryosurgery is a primary or salvage treatment option. The advent of the minimally-invasive ultrathin cryoneedles and more precise imaging techniques has greatly decreased the occurrence of many side effects, with the exception of impotence.
After undergoing prostate cancer cryotherapy, some patients may experience the following side effects:
Swelling in the Genital Area after Cryosurgery
The entry of the needles through perineum (the skin and muscles between the scrotum and anus) causes irritation and inflammation. Many physicians will recommend using ice packs on the affected area or beginning a regimen of over-the-counter anti-inflammatory drug.
Scrotal Edema
A more severe complication, scrotal edema occurs when fluid collects in the scrotum. Proper evaluation most be performed by a doctor so that proper course of treatment may be chosen.
Irritation during Urination
Many men will experience itching or burning while urinating after undergoing prostate cryosurgery. Symptoms usually will dissipate in a few days. Some men will also experience urgency. Speak with your physician if symptoms worsen after a few days.
Hematuria: Blood in the Urine
Many men will experience blood in the urine (hematuria) after undergoing prostate cryotherapy. There are two types of hematuria, gross and microscopic. Gross hematuria is visible to the naked eye. If bleeding persists past a few days, please speak with your physician.
Urethral sloughing and Urinary Obstruction
The passage of dead tissue through the urethra, urethral sloughing occurs when the urethra is damaged during the cryotherapy. Fortunately, the use of a warming catheter has greatly decreased the occurrence of urethral sloughing. Severe cases of sloughing cause urinary obstruction and require medical treatment. Men who have undergone transurethral resection of the prostate (TURP) or another prostate cancer treatment, such as external radiation therapy, are at higher risk for urethral sloughing.
Urethro-Rectal Fistula
One of the more serious and rarer side effects is urethro-rectal fistula. Urethro-recto fistula occurs when an unnatural channel forms between the urethra, which carries urine or ejaculate out of the body, and the rectum, which holds fecal matter prior to defecation. This channel allows materials from one part of the body to pass into another. The results can include diarrhea or urinary tract infections. New techniques in prostate cryosurgery have lead to decrease in fistula. The warming catheter and the ultrathin, precise cryoneedles have contributed to the decrease of the occurrence of fistula.
Other Side Effects
Other side effects include impotence and incontinence. Prostate cryotherapy entails relatively low rates of incontinence after the catheter is removed. To read more about incontinence, please click here. Cryotherapy is associated with higher rates of impotence, which is the ability of maintain an erection satisfactory for sexual intercourse. To read more about impotence, please click here.
Prostate Cryotherapy Side Effects
Impotence
Incontinence
Prostate Cancer Treatment Overview
Coping with Prostate Cancer
Are You at Risk for Prostate Cancer?
Prostate Cancer News
Glossary
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Common Side Effects
Prostate cancer cryotherapy (cryosurgery) freezes the entire prostate gland through a minimally invasive procedure involving ultrathin cryoneedles. Side effects usually occur due to damage of the surrounding tissue during the procedure. The severity and occurrence of side effects are largely affected by the relative health of a patient as well as whether cryosurgery is a primary or salvage treatment option. The advent of the minimally-invasive ultrathin cryoneedles and more precise imaging techniques has greatly decreased the occurrence of many side effects, with the exception of impotence.
After undergoing prostate cancer cryotherapy, some patients may experience the following side effects:
Swelling in the Genital Area after Cryosurgery
The entry of the needles through perineum (the skin and muscles between the scrotum and anus) causes irritation and inflammation. Many physicians will recommend using ice packs on the affected area or beginning a regimen of over-the-counter anti-inflammatory drug.
Scrotal Edema
A more severe complication, scrotal edema occurs when fluid collects in the scrotum. Proper evaluation most be performed by a doctor so that proper course of treatment may be chosen.
Irritation during Urination
Many men will experience itching or burning while urinating after undergoing prostate cryosurgery. Symptoms usually will dissipate in a few days. Some men will also experience urgency. Speak with your physician if symptoms worsen after a few days.
Hematuria: Blood in the Urine
Many men will experience blood in the urine (hematuria) after undergoing prostate cryotherapy. There are two types of hematuria, gross and microscopic. Gross hematuria is visible to the naked eye. If bleeding persists past a few days, please speak with your physician.
Urethral sloughing and Urinary Obstruction
The passage of dead tissue through the urethra, urethral sloughing occurs when the urethra is damaged during the cryotherapy. Fortunately, the use of a warming catheter has greatly decreased the occurrence of urethral sloughing. Severe cases of sloughing cause urinary obstruction and require medical treatment. Men who have undergone transurethral resection of the prostate (TURP) or another prostate cancer treatment, such as external radiation therapy, are at higher risk for urethral sloughing.
Urethro-Rectal Fistula
One of the more serious and rarer side effects is urethro-rectal fistula. Urethro-recto fistula occurs when an unnatural channel forms between the urethra, which carries urine or ejaculate out of the body, and the rectum, which holds fecal matter prior to defecation. This channel allows materials from one part of the body to pass into another. The results can include diarrhea or urinary tract infections. New techniques in prostate cryosurgery have lead to decrease in fistula. The warming catheter and the ultrathin, precise cryoneedles have contributed to the decrease of the occurrence of fistula.
Other Side Effects
Other side effects include impotence and incontinence. Prostate cryotherapy entails relatively low rates of incontinence after the catheter is removed. To read more about incontinence, please click here. Cryotherapy is associated with higher rates of impotence, which is the ability of maintain an erection satisfactory for sexual intercourse. To read more about impotence, please click here.
Prostate Cryotherapy Side Effects
Impotence
Incontinence
Prostate Cancer Treatment Overview
Coping with Prostate Cancer
Are You at Risk for Prostate Cancer?
Prostate Cancer News
Glossary
Home
Coping with Prostate Cancer Are You at Risk for Prostate Cancer? Prostate Cancer News Glossary
Home Contact Us Disclaimer Privacy Policy Resources Add URL Site Map
©2008
IS ROBOTIC SURGERY REALLY BETTER THAN THE OLD?
Is newer prostate surgery really better than the old
COMMENT: I had robotic prostate surgery at the end of 2009. I am unsatisfied with the results overall. The incontinence, ED, and worst of all my PSA has been rising gradually. If I had to do it over again this would definitely not the path I would have taken. My friend had the HIFU procedure out of the country and he is extremely satisfied. His sexual life is the same as before and PSA is back to normal.
Henry Woodridge
By Rachael Myers Lowe
NEW YORK | Mon Feb 22, 2010 4:30pm EST
NEW YORK (Reuters Health) - Robot-assisted laparoscopic, or "keyhole," surgery appears to be no better at reducing side effects than traditional "open" surgery to remove a cancerous prostate gland, according to new study from Memorial Sloan-Kettering Cancer Center in New York. Critics, however, claim the study relied on old data that doesn't reflect current practice.
Typically, in traditional open radical prostatectomy, a 6-inch long incision is made in the abdomen and the walnut-sized prostate gland and nearby lymph nodes are removed.
With the newer laparoscopic radical prostatectomy (LRP), several small incisions are made in the lower abdomen through which long-armed surgical instruments, including a camera, are inserted. While watching on a monitor, the surgeon manipulates the tools to cut away and extract the cancerous prostate and other tissue. Most laparoscopic surgeries performed today are robot-assisted.
While robot-assisted LRP usually leads to less blood loss and time spent in the hospital, the high cost of the equipment, its annual maintenance, and a long learning curve for surgeons has raised questions about its value, especially if patient outcomes are no better than the gold standard open surgery.
To investigate, Dr. William T. Lowrance and colleagues analyzed the outcomes for 5,923 men who had surgery to remove the prostate between 2003 and 2005. Overall, 4,858 men (82 percent) had the open procedure and 1,065 (18 percent) had the less-invasive LRP procedure. The claims data did not distinguish between LRP and robot-assisted LRP.
According to a report in The Journal of Urology, there were no differences between the older open procedure and the newer laparoscopic procedure in terms of deaths or medical or surgical complications 90 days after surgery, nor in use of additional cancer therapies in the year after surgery.
Yet, the researchers report that hospital advertising of LRP services was widespread and often overstated and implied benefits "not currently supported by existing evidence."
"It's perfectly reasonable for a man today to want a robot-assisted laparoscopic prostatectomy but patients need to have realistic expectations," which may be lacking, Lowrance told Reuters Health in an interview.
In a commentary published with the study, Dr. Yair Lotan, a cancer surgeon at the University of Texas Southwestern Medical Center in Dallas, wrote that the level of experience of the surgeon performing the procedure is more important for patient outcome than the type of procedure itself.
Lotan thinks patients "should be educated on likely outcomes of a procedure based on individual surgeon experience."
Dr. Jason Engel, Director of Urologic Robotic Surgery at George Washington University Hospital in Washington, D.C., agrees that surgeon experience is key to patient outcomes. He performs about 200 robot-assisted LRPs every year.
The Lowrance study, Engel told Reuters Health, is based on old data that does not reflect the level of surgeon expertise in robot-assisted LRP that is common today. In addition, the Medicare claims used in the study did not distinguish between patients who got the older LRP procedure and the new robot-assisted method.
"Nobody does the old LRP procedure any more," he said. "It's like comparing apples and oranges."
He acknowledged that some institutions over-sell the benefits of the robot-assisted LRP but he defended honest marketing campaigns.
"If I'm doing a great job, how am I going to get my name out there to let people realize there is this great product, when everyone knows to just go to an established institution, like Johns Hopkins, which specializes in the open RP (radical prostatectomy)," Engel said.
Engel also predicted that looking at data from surgeries performed more recently will likely show a difference in outcomes favoring robot-assisted LRP. The Lowrance study hinted at it, he noted, by finding no difference in outcomes at a time when surgeons were just starting to build experience.
"There's never been a head-to-head comparison between an experienced open surgeon and experienced robotic surgeon," Engel told Reuters Health.
Lotan believes the exponential growth of robot-assisted LRP services has been driven by a particularly American phenomenon - the perception that the newest high-tech procedures are the best even if supporting evidence is lacking.
Hospitals, noted Lotan, rarely recoup the millions of dollars spent on the robot equipment and its upkeep, but must have it to attract doctors and patients to their institutions.
Prostate cancer is the most commonly diagnosed cancer in American men. According to the American Cancer Society, more than 192,000 Americans are diagnosed with the disease annually; more than half are over the age 65.
SOURCE: The Journal of Urology, published online February 22, 2010.
Health
COMMENT: I had robotic prostate surgery at the end of 2009. I am unsatisfied with the results overall. The incontinence, ED, and worst of all my PSA has been rising gradually. If I had to do it over again this would definitely not the path I would have taken. My friend had the HIFU procedure out of the country and he is extremely satisfied. His sexual life is the same as before and PSA is back to normal.
Henry Woodridge
By Rachael Myers Lowe
NEW YORK | Mon Feb 22, 2010 4:30pm EST
NEW YORK (Reuters Health) - Robot-assisted laparoscopic, or "keyhole," surgery appears to be no better at reducing side effects than traditional "open" surgery to remove a cancerous prostate gland, according to new study from Memorial Sloan-Kettering Cancer Center in New York. Critics, however, claim the study relied on old data that doesn't reflect current practice.
Typically, in traditional open radical prostatectomy, a 6-inch long incision is made in the abdomen and the walnut-sized prostate gland and nearby lymph nodes are removed.
With the newer laparoscopic radical prostatectomy (LRP), several small incisions are made in the lower abdomen through which long-armed surgical instruments, including a camera, are inserted. While watching on a monitor, the surgeon manipulates the tools to cut away and extract the cancerous prostate and other tissue. Most laparoscopic surgeries performed today are robot-assisted.
While robot-assisted LRP usually leads to less blood loss and time spent in the hospital, the high cost of the equipment, its annual maintenance, and a long learning curve for surgeons has raised questions about its value, especially if patient outcomes are no better than the gold standard open surgery.
To investigate, Dr. William T. Lowrance and colleagues analyzed the outcomes for 5,923 men who had surgery to remove the prostate between 2003 and 2005. Overall, 4,858 men (82 percent) had the open procedure and 1,065 (18 percent) had the less-invasive LRP procedure. The claims data did not distinguish between LRP and robot-assisted LRP.
According to a report in The Journal of Urology, there were no differences between the older open procedure and the newer laparoscopic procedure in terms of deaths or medical or surgical complications 90 days after surgery, nor in use of additional cancer therapies in the year after surgery.
Yet, the researchers report that hospital advertising of LRP services was widespread and often overstated and implied benefits "not currently supported by existing evidence."
"It's perfectly reasonable for a man today to want a robot-assisted laparoscopic prostatectomy but patients need to have realistic expectations," which may be lacking, Lowrance told Reuters Health in an interview.
In a commentary published with the study, Dr. Yair Lotan, a cancer surgeon at the University of Texas Southwestern Medical Center in Dallas, wrote that the level of experience of the surgeon performing the procedure is more important for patient outcome than the type of procedure itself.
Lotan thinks patients "should be educated on likely outcomes of a procedure based on individual surgeon experience."
Dr. Jason Engel, Director of Urologic Robotic Surgery at George Washington University Hospital in Washington, D.C., agrees that surgeon experience is key to patient outcomes. He performs about 200 robot-assisted LRPs every year.
The Lowrance study, Engel told Reuters Health, is based on old data that does not reflect the level of surgeon expertise in robot-assisted LRP that is common today. In addition, the Medicare claims used in the study did not distinguish between patients who got the older LRP procedure and the new robot-assisted method.
"Nobody does the old LRP procedure any more," he said. "It's like comparing apples and oranges."
He acknowledged that some institutions over-sell the benefits of the robot-assisted LRP but he defended honest marketing campaigns.
"If I'm doing a great job, how am I going to get my name out there to let people realize there is this great product, when everyone knows to just go to an established institution, like Johns Hopkins, which specializes in the open RP (radical prostatectomy)," Engel said.
Engel also predicted that looking at data from surgeries performed more recently will likely show a difference in outcomes favoring robot-assisted LRP. The Lowrance study hinted at it, he noted, by finding no difference in outcomes at a time when surgeons were just starting to build experience.
"There's never been a head-to-head comparison between an experienced open surgeon and experienced robotic surgeon," Engel told Reuters Health.
Lotan believes the exponential growth of robot-assisted LRP services has been driven by a particularly American phenomenon - the perception that the newest high-tech procedures are the best even if supporting evidence is lacking.
Hospitals, noted Lotan, rarely recoup the millions of dollars spent on the robot equipment and its upkeep, but must have it to attract doctors and patients to their institutions.
Prostate cancer is the most commonly diagnosed cancer in American men. According to the American Cancer Society, more than 192,000 Americans are diagnosed with the disease annually; more than half are over the age 65.
SOURCE: The Journal of Urology, published online February 22, 2010.
Health
ROBOTIC SURGERY?
Is Robotic Prostate Surgery Really Better?
By TARA PARKER-POPE
In today’s New York Times, health reporter Gina Kolata explores the marketing and the science behind robot-assisted prostate cancer surgery.
Last year, 73,000 American men — 86 percent of the 85,000 who had prostate cancer surgery — had robot-assisted operations. Ms. Kolata writes:
It is not known whether robot-assisted prostate surgery gives better, worse or equivalent long-term cancer control than the traditional methods … Meanwhile, marketing has moved into the breach, with hospitals and surgeons advertising their services with claims that make critics raise their eyebrows.
By TARA PARKER-POPE
In today’s New York Times, health reporter Gina Kolata explores the marketing and the science behind robot-assisted prostate cancer surgery.
Last year, 73,000 American men — 86 percent of the 85,000 who had prostate cancer surgery — had robot-assisted operations. Ms. Kolata writes:
It is not known whether robot-assisted prostate surgery gives better, worse or equivalent long-term cancer control than the traditional methods … Meanwhile, marketing has moved into the breach, with hospitals and surgeons advertising their services with claims that make critics raise their eyebrows.
MEN WITH A FAMILY HISTORY OF PROSTATE CANCER...
The Los Angeles Times (8/19, Maugh) "Booster Shots" blog reported, "Men with a family history of prostate cancer are thought to be more likely to develop the disease themselves, so it is recommended they get screened for the disease more often." Accordingly, the "frequent screenings make it more likely a prostate tumor will be found -- including tumors that are not dangerous." But, does this mean "those men with a father or brother with the disease more likely to have a tumor diagnosis because of genetics -- or because they are more likely to be screened?" A new paper in the Journal of the National Cancer Institute "suggested that the answer was: a little bit of both."
Before reaching that conclusion, investigators "analyzed data from 22,511 brothers of 13,975 prostate cancer patients and found that the incidence of the disease was higher among brothers of prostate cancer patients than men of the same age in the general population,"HealthDay (8/10, Preidt) reported. "Disease incidence was highest among men who had two brothers with prostate cancer." Investigators also concluded that the "increased diagnostic activity among men with a family history of prostate cancer, which we observed, will inflate family history as a risk factor for prostate cancer in populations of men who commonly receive PSA
George M. Suarez, M.D.
Before reaching that conclusion, investigators "analyzed data from 22,511 brothers of 13,975 prostate cancer patients and found that the incidence of the disease was higher among brothers of prostate cancer patients than men of the same age in the general population,"HealthDay (8/10, Preidt) reported. "Disease incidence was highest among men who had two brothers with prostate cancer." Investigators also concluded that the "increased diagnostic activity among men with a family history of prostate cancer, which we observed, will inflate family history as a risk factor for prostate cancer in populations of men who commonly receive PSA
George M. Suarez, M.D.
PROTOCOL FOR PREVENTING RECTAL INJURY IN ABLATIVE THERAPY FOR PROSTATE CANCER
PROTOCOL FOR PREVENTING RECTAL INJURY IN ABLATIVE THERAPY FOR PROSTATE CANCER
The following article was in the recent AUA newsletter. Although rectal injury is extremely rare in the HIFU patient. This article certainly merits for us to consider adopting a post HIFU protocol when treating previous failed radiation therapy patients. This protocol should also be adopted for all patient that have had a prior failed treatment such as prior HIFU, Brachytherapy, IMRT, RRP and Cryotherapy.
Correlation Exists Between Acute, Late Urinary, And Rectal Injuries In Prostate Cancer Patients Treated With RT.
MedWire (8/19, Guy) reported, "A significant correlation exists between acute and late urinary and rectal injuries in prostate cancer patients treated with radiotherapy (RT)." In fact, the "occurrence of an acute urinary or rectal event was associated with an approximately three-times higher risk for a late event in patients treated with RT alone or with RT after prostatectomy," according to an Italian study detailed in the International Journal of Radiation Oncology Biology Physics.
I would offer the following post HIFU protocol for prevention of fistula:
•Withhold voiding trial until minimum 2 weeks post HIFU.
•Maintain patient on prophylactic antibiotics while S.P. Catheter is in place.
•Place patients on anticholinergics for the first 10 - 12 days. ie: Vesicare 10 mg. Q day.
•Place patient on high residue diet for 2 - 4 weeks, or until voiding. This will need to be detailed and provided to patients. Their idea of high residue diet may not be the correct one.
•Add Metamucil daily/prn as a bulk forming laxative to combat potential constipation from anticholinergics. As well as a synergy to high residue diet.
•Urine culture and sensitivity several days before removing S.P. catheter to confirm no infection.
•Hold off removing S.P. Catheter if the culture is positive and/or resistant to antibiotic patient is taking.
•Confirm ability to void by filling the bladder via S.P. tube, measure volume infused, and then measure volume voided. Do not remove the S.P. tube if greater than 20% residual urine.
•Post-void residual determination by ultrasound or bladder scan at 48 hours after S.P. tube is removed. Confirm no residual of significant volume.
•Weekly nurse call to patient for the first 3-4 weeks on bi-monthly for the first 3 months, followed by monthly for the next 3 months.
•Absolutely "nothing per rectum" for 6 months.
•Absolutely no instrumentation unless under direct vision, and with appropriate antibiotic prophylactic ie: Gentamicin or Rocephin I.M.
•Emergency medic alert card with contact numbers to be mandatory carried at all times. Consider a wrist bracelet with contact information and telephone contacts. Provide back up emergency contact telephone in the event P.I. can not be reached.
•Patients should be urged to curtail any heavy excessive exercise or work.
•They should also be urged to not travel beyond the U.S. for the first six months.
George M. Suarez, M.D.
The following article was in the recent AUA newsletter. Although rectal injury is extremely rare in the HIFU patient. This article certainly merits for us to consider adopting a post HIFU protocol when treating previous failed radiation therapy patients. This protocol should also be adopted for all patient that have had a prior failed treatment such as prior HIFU, Brachytherapy, IMRT, RRP and Cryotherapy.
Correlation Exists Between Acute, Late Urinary, And Rectal Injuries In Prostate Cancer Patients Treated With RT.
MedWire (8/19, Guy) reported, "A significant correlation exists between acute and late urinary and rectal injuries in prostate cancer patients treated with radiotherapy (RT)." In fact, the "occurrence of an acute urinary or rectal event was associated with an approximately three-times higher risk for a late event in patients treated with RT alone or with RT after prostatectomy," according to an Italian study detailed in the International Journal of Radiation Oncology Biology Physics.
I would offer the following post HIFU protocol for prevention of fistula:
•Withhold voiding trial until minimum 2 weeks post HIFU.
•Maintain patient on prophylactic antibiotics while S.P. Catheter is in place.
•Place patients on anticholinergics for the first 10 - 12 days. ie: Vesicare 10 mg. Q day.
•Place patient on high residue diet for 2 - 4 weeks, or until voiding. This will need to be detailed and provided to patients. Their idea of high residue diet may not be the correct one.
•Add Metamucil daily/prn as a bulk forming laxative to combat potential constipation from anticholinergics. As well as a synergy to high residue diet.
•Urine culture and sensitivity several days before removing S.P. catheter to confirm no infection.
•Hold off removing S.P. Catheter if the culture is positive and/or resistant to antibiotic patient is taking.
•Confirm ability to void by filling the bladder via S.P. tube, measure volume infused, and then measure volume voided. Do not remove the S.P. tube if greater than 20% residual urine.
•Post-void residual determination by ultrasound or bladder scan at 48 hours after S.P. tube is removed. Confirm no residual of significant volume.
•Weekly nurse call to patient for the first 3-4 weeks on bi-monthly for the first 3 months, followed by monthly for the next 3 months.
•Absolutely "nothing per rectum" for 6 months.
•Absolutely no instrumentation unless under direct vision, and with appropriate antibiotic prophylactic ie: Gentamicin or Rocephin I.M.
•Emergency medic alert card with contact numbers to be mandatory carried at all times. Consider a wrist bracelet with contact information and telephone contacts. Provide back up emergency contact telephone in the event P.I. can not be reached.
•Patients should be urged to curtail any heavy excessive exercise or work.
•They should also be urged to not travel beyond the U.S. for the first six months.
George M. Suarez, M.D.
INCREASED SCREENING AMONG MEN WITH FAMILY HISTORY OF PROSTATE CANCER PATIENTS DISCUSSED
The Los Angeles Times (8/19, Maugh) "Booster Shots" blog reported, "Men with a family history of prostate cancer are thought to be more likely to develop the disease themselves, so it is recommended they get screened for the disease more often." Accordingly, the "frequent screenings make it more likely a prostate tumor will be found -- including tumors that are not dangerous." But, does this mean "those men with a father or brother with the disease more likely to have a tumor diagnosis because of genetics -- or because they are more likely to be screened?" A new paper in the Journal of the National Cancer Institute "suggested that the answer was: a little bit of both."
Before reaching that conclusion, investigators "analyzed data from 22,511 brothers of 13,975 prostate cancer patients and found that the incidence of the disease was higher among brothers of prostate cancer patients than men of the same age in the general population,"HealthDay (8/10, Preidt) reported. "Disease incidence was highest among men who had two brothers with prostate cancer." Investigators also concluded that the "increased diagnostic activity among men with a family history of prostate cancer, which we observed, will inflate family history as a risk factor for prostate cancer in populations of men who commonly receive PSA
George M. Suarez, M.D
Before reaching that conclusion, investigators "analyzed data from 22,511 brothers of 13,975 prostate cancer patients and found that the incidence of the disease was higher among brothers of prostate cancer patients than men of the same age in the general population,"HealthDay (8/10, Preidt) reported. "Disease incidence was highest among men who had two brothers with prostate cancer." Investigators also concluded that the "increased diagnostic activity among men with a family history of prostate cancer, which we observed, will inflate family history as a risk factor for prostate cancer in populations of men who commonly receive PSA
George M. Suarez, M.D
VESICO-RECTAL FISTULA ASSOCIATED WITH HIFU
Vesico-rectal fistula associated with HIFU
Clinical Presentation
Vesico-rectal fistula are extremely rare with HIFU with a less than .5% repoeterted incidence.The presenting symptoms and signs of enterovesical fistulae occur primarily in the urinary tract. Symptoms include suprapubic pain, irritative voiding symptoms, and symptoms associated with chronic urinary tract infection (UTI). The hallmark of enterovesical fistulae may be described as “Gouverneur syndrome”, namely, suprapubic pain, frequency, dysuria, and tenesmus. Other signs include abnormal urinalysis findings, malodorous urine, pneumaturia, debris in the urine, hematuria, and UTIs.
The severity of the presentation also varies. Chronic UTI symptoms are common, and patients with enterovesical fistula frequently report numerous courses of antibiotics prior to referral to a urologist for evaluation. Urosepsis may be present and can be exacerbated in the setting of obstruction. It has been demonstrated in dog models that surgically created colovesical fistulae are tolerated well in the absence of obstruction.
Pneumaturia and fecaluria may be intermittent and must be carefully sought in the history. Pneumaturia occurs in approximately 50%-60% of patients with enterovesical fistula but alone is nondiagnostic, as it can be caused by gas-producing organisms (eg, Clostridium species, yeast) in the bladder, particularly in patients with diabetes mellitus (ie, fermentation of diabetic urine) or in those undergoing urinary tract instrumentation. Pneumaturia is more likely to occur in patients with diverticulitis or Crohn disease than in those with cancer. Fecaluria is pathognomonic of a fistula and occurs in approximately 40% of cases. Patients may describe passing vegetable matter in the urine. The flow through the fistula predominantly occurs from the bowel to the bladder. Patients very rarely pass urine from the rectum.
Symptoms of the underlying disease causing the fistula may be present. Abdominal pain is more common in patients with Crohn disease, but an abdominal mass is discovered in fewer than 30% of patients. In patients with Crohn disease who have a fistula, abdominal mass and abscess are more common.
General evaluation of vesico rectal fistula
Iatrogenic pathophysiology
Iatrogenic fistulae are usually induced by surgical procedures, primary or adjunctive radiotherapy, cryosurgery, HIFU and/or post procedural infection. Surgical procedures, including prostatectomies, particularly the post radiated salvage radical prostatectomy patient, as well in resections of benign or malignant rectal lesions, and laparoscopic inguinal hernia repair have been associated with fistula formation. Unrecognized rectal injury at the time of radical prostatectomy is an uncommon but well-documented etiology of recto urethral fistula.
Scatter or emission of treatment from external beam radiation, brachytherapy, HIFU or cryotherapy to bowel in the treatment field can eventually lead to fistula development. Radiation-associated fistulae usually develop years after radiation therapy for a gynecologic or urologic malignancy. The post HIFU fistula is more likely to develop in association with blind instrumentation or spontaneously at two to three months after the procedure. In the first three months after HIFU, there is recognized sloughing of the entire prostatic urethra. This is as a result of coagulative necrosis secondary to HIFU. During this period of time the prostatic tissue is ulcerated and friable. Making it extremely sensitive to blind instrumentation and at greater risk of injury to penetrating the surrounding tissue, and more so the rectum.
Fistulae develop spontaneously after perforation of the irradiated intestine, with the development of an abscess in the pelvis that subsequently drains into the adjacent bladder. Radiation-associated fistulae are usually complex and often involve more than one organ (eg, colon to bladder). Although rare, fistulae due to cytotoxic therapy have been reported in a patient undergoing a CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) regimen for non-Hodgkin lymphoma. Therefore, past medical history of such medications should be considered.
The incidence of radiation-induced fistula associated with urologic and gynecological (recto vaginal or vesicovaginal) cancers is approximately 0.5% to 1%. The overall risk of a fistula formation is the same as the risk of rectal injury following a radical prostatectomy or various forms of EBRT, and interstitial prostate brachytherapy. The patients at highest risk of a fistula associated with HIFU are those undergoing a salvage procedure.
Traumatic pathophysiology
Urethral disruption caused by blunt trauma or a penetrating injury can result in fistulae, but these fistulae are typically rectourethral in nature. That is why any need for instrumentation in the post HIFU patient should be done under direct vision. In the post surgical, or HIFU patient, the history of prior surgery alone should be sufficient to properly diagnose the etiology of the fistula. However, one should always keep in mind the possibility of associated pathology such as bowel malignancy, inflammatory bowel disease and bladder cancer as a contributing factor. Particularly if the fistula fails to heal spontaneously after attempts at conservative management have been exhausted.
DIAGNOSTIC TESTING
· Charcoal test: Oral activated charcoal can confirm the diagnosis of enterovesical fistula.
Several hours after ingestion, flecks of charcoal can be noted in the urine.
· Cystoscopy and possible biopsy.
· Endoscopic visualization has the highest yield for the identification of enterovesical fistula.
•Eighty to 100 percent of cases demonstrate bullous edema, erythema, or exudation of feculent material from the fistula site
•Generally, colonic fistulas occur on the left side and dome of the bladder, whereas small bowel fistulas occur on the dome and right side of the bladder.
•Biopsy of the fistula is indicated in cases where malignancy is suspected. · Colonscopy and barium enema.
· Although less common than diverticular disease, it is important to exclude primary intestinal malignancy as the cause for the fistula.
· CT or MRI of the pelvis.
· Air in the bladder in the absence of prior lower urinary instrumentation is highly suggestive of an enterovesical fistula.
VCUG
· May demonstrate the fistulous connection.
· In some cases, however, the fistula can act as a "flap valve" and contrast will not be seen entering the bowel.
HIFU FISTULA: INTRA AND PERI-OPERATIVE PREVENTION
· Standard DRE, followed by slow and careful insertion of a second finger. I do not use forceful dilation, but simple leave the two fingers in place until the rectum and sphincter accommodate to both fingers...and it does relax and accommodate with time. This cannot be forced or hurried.
· Abort the procedure if unable to accommodate the index and middle finger in the rectal vault or if excessive bleeding.
· Keep the index finger pushing down at the 6 o'clock position during gentle and slow introduction of the probe.
· I prefer using the latex allergy condom. They are more durable and less likely to break. Therefore, less risk of having to reinsert the probe again. Multiple reinsertions only add to potential trauma to the rectum.
· I prefer two (double) “O rings” at the proximal end of the condom. This will reduce the potential of breaking the condom seal and the risk of getting air in the condom---another risk of having to remove and reinsert the probe again.
· I prefer bring the temperature of the Sonochill down to as low as possible in order to decrease heating.
· I prefer to use the minimum needed amount of water in the condom. This decreases the amount of pressure on the gland during treatment. My theory on this is that the less volume of interface between the transducer and the gland, the greater the coefficient of absorption of energy capability in the tissue. This, versus a greater volume of interface, may result in greater compression of the gland and less absorption of energy in the compressed gland. This can potentiate scatter of energy in the wrong direction, such as the rectal wall., NVB, sphincter.
· The rectal wall must have a minimum of 4-5 mm. in thickness without compression and a similar thickness should be maintained at all times. Undue compression of the rectal wall increases the risk of rectal wall injury. This is tissue that previously been treated and is more likely to be fibrotic and less vascular. Thereby compromising the ability of healing.
· The recurrent treatment glands are typically small and can be treated in two zones. All treatment zones (4 and 3 cm. probes) should be performed with the "extra" icon on (3 on, 6 off cycle)
· If the gland is very small with a short AP distance, try to get most of the overlap in the anterior zone. Even if it means extending the treatment outside the capsule. The distance from the anatomic capsule to the "surgical capsule" when doing a RRP is the thickness of the vascular pedicle and peri-prostatic fatty tissue. It is several mm. in thickness, and unlikely hurt anything by slightly treating lateral in this region.
· I am a firm believer in maintaining RWD at the same level in the reference and real time images as much as possible. I prefer to add water when the distance in the real time images changes beyond one-tenth of a mm. For example, if the real time image drops from 1.5 cm to > 1.4, I will pause and add small amounts of water to return to the reference image distance of 1.5 cm. I believe these changes occur due to build up of steam and swelling within the gland. This however, is more common in the primary therapy tan recurrent cases. The pause time will also allow more cooling time.
· I also believe in pausing and stacking at 1/3 interval into each zone. This will assure that there has not been movement of the gland toward the base. This allows the operator to remove HIFU lesions that are now anterior and above the apex- the site of the most common strictures. It also allows adding or subtracting any necessary lesions at the level of the base. Which is where the gland retracts. Stopping and stacking at 1/3 interval will also add cooling tome to the procedure.
THE MOST COMMON CAUSES AND SITE FOR A FISTULA
FORMATION ASSOCIATED WITH HIFU
· The most common cause of a fistula in the HIFU patient occurs when treatment results in misdirected energy into the rectal wall and/or below Denonvillier's fascia.
· Misdirected energy can occur from pre-focal heating, or from energy bouncing off calcifications or radioactive seeds. Continuous observation during treatment and adjustments of rectal wall distance and energy are the best method of preventing this from happening.
· The recommended energy adjustment to rectal wall distance should be continuously monitored. Particularly at the first lesions at Apex wish marks the beginning of each treatment row. This is where there can be the most variation in rectal wall distance as the sequence of lesions alternates from side to side (M versus P). This is easily accomplished by moving the "mouse" over the energy icon to the right of the watt adjustment slide bar. The adjustment can be performed moving the energy marker, or by clicking on the F12 icon and using the up or down arrow.
· Treatment into the rectal wall or below Denonvilliar’s fascia most commonly occurs during treatment of the posterior zone. But can occur in any zone, and at anytime. It is most likely to occur at the most lateral borders of the prostate where the crescent shape of the gland is most evident as the gland "tents downward." Likewise toward the apex, where it begins to take an upward orientation or slopes up as it gets closer to the external sphincter.
· Prevention of treatment below Denonvilier's fascia at the lateral borders and toward the upward slope of the prostate can be achieved by adjusting the stepper and/or water in the condom accordingly.
· Be extremely careful to not exceed the 2 cm limit rectal wall distance when treating toward the most lateral sides of the prostate.
· Always allow a 1 - 1.5 mm safety margin between the lower limits of the treatment limits to Denonvillier's fascia. The HIFU lesion is "cigar shaped" at the tip. This will allow some degree of treatment to be extended downward.
· I personally do not feel it is necessary to compromise the energy level or "power down" when treating the posterior zone, and in fact this is the site most likely to have cancer whether primary or recurrent.
POST HIFU PROTOCOL FOR PREVENTION OF RECTAL FISTULA IN RECURRENT TREATMENT CASES
· Withhold voiding trial until 2 weeks post HIFU in recurrent treatment cases.
· Place patients on anticholinergics for the first 10 - 12 days. i.e.: Vesicare 10 mg. Q day.
· Place patient on high residue diet for 2 weeks, or until voiding. This will need to be detailed and provided to patients.
· Add Metamucil as a bulk forming laxative to combat potential constipation. As well as a synergy to high residue diet.
· Urine culture and sensitivity several days before removing S.P. catheter to confirm no infection.
· Hold off removing S.P. if the culture is positive and/or resistant to antibiotic patient is taking.
· Post-void residual determination by ultrasound or bladder scan at 48 hours after S.P. tube is removed.
· Weekly nurse call to patient for the first 3-4 weeks, bi-monthly for the first 3 months, followed by monthly for the next 3 months.
· Absolutely no instrumentation unless under direct vision, and with appropriate antibiotic prophylactic i.e.: Gentamicin or Rocephin I.M.
· Emergency medic alert card with contact numbers to be mandatory carried at all times.
· Patients should be urged to curtail any heavy excessive exercise or work.
· They should also be urged to not travel beyond the U.S. for the first six months.
MANAGEMENT OF POST HIFU FISTULA
· Always be on the lookout for early symptoms of the potential of a fistula in the post HIFU patient. Educate the patient to be alert of any of these symptoms.
· Early symptoms; New and acute onset of peri-rectal pain and/or sense of fullness. A sense constipation or desire to have a bowel movement but can't. Acute onset of watery diarrhea particularly associated with voiding. The presence of gas or fecal material per urethra. Fever, chills and general malaise.
· Immediate management: Place a Foley catheter or Suprapubic catheter. Either one should be done under direct vision. I prefer a Suprapubic catheter using a flexible cystoscope for guidance and confirmation. Obtain a urine culture, baseline CBC and blood culture if febrile. Place the patient on appropriate broad-spectrum antibiotics, anticholinergics and high residue diet. Obtain urine culture and sensitivity weekly. Restrict activities as much as possible to only necessary. If the Suprapubic remains in place for a prolonged period of time, change every three weeks.
· Consult a colo-rectal specialist. It is best to get him on board from the beginning in the event additional intervention such as a temporary diverting colostomy may be required. The post HIFU fistula is typically very small and will heal on it's own with the above measures. Be patient and consciously reassuring to patient and family.
· The post HIFU fistula will typically heal on it's own within 6 to 8 weeks. If clinical resolution of the fistula remain doubtful, a voiding cystourethrogram via the Suprapubic catheter and/or a CT Scan combination may be helpful in confirming closure.
George M. Suarez, M.D.
Co- Founder, Medical Director Emiritus
USHIFU. International HIFU
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Clinical Presentation
Vesico-rectal fistula are extremely rare with HIFU with a less than .5% repoeterted incidence.The presenting symptoms and signs of enterovesical fistulae occur primarily in the urinary tract. Symptoms include suprapubic pain, irritative voiding symptoms, and symptoms associated with chronic urinary tract infection (UTI). The hallmark of enterovesical fistulae may be described as “Gouverneur syndrome”, namely, suprapubic pain, frequency, dysuria, and tenesmus. Other signs include abnormal urinalysis findings, malodorous urine, pneumaturia, debris in the urine, hematuria, and UTIs.
The severity of the presentation also varies. Chronic UTI symptoms are common, and patients with enterovesical fistula frequently report numerous courses of antibiotics prior to referral to a urologist for evaluation. Urosepsis may be present and can be exacerbated in the setting of obstruction. It has been demonstrated in dog models that surgically created colovesical fistulae are tolerated well in the absence of obstruction.
Pneumaturia and fecaluria may be intermittent and must be carefully sought in the history. Pneumaturia occurs in approximately 50%-60% of patients with enterovesical fistula but alone is nondiagnostic, as it can be caused by gas-producing organisms (eg, Clostridium species, yeast) in the bladder, particularly in patients with diabetes mellitus (ie, fermentation of diabetic urine) or in those undergoing urinary tract instrumentation. Pneumaturia is more likely to occur in patients with diverticulitis or Crohn disease than in those with cancer. Fecaluria is pathognomonic of a fistula and occurs in approximately 40% of cases. Patients may describe passing vegetable matter in the urine. The flow through the fistula predominantly occurs from the bowel to the bladder. Patients very rarely pass urine from the rectum.
Symptoms of the underlying disease causing the fistula may be present. Abdominal pain is more common in patients with Crohn disease, but an abdominal mass is discovered in fewer than 30% of patients. In patients with Crohn disease who have a fistula, abdominal mass and abscess are more common.
General evaluation of vesico rectal fistula
Iatrogenic pathophysiology
Iatrogenic fistulae are usually induced by surgical procedures, primary or adjunctive radiotherapy, cryosurgery, HIFU and/or post procedural infection. Surgical procedures, including prostatectomies, particularly the post radiated salvage radical prostatectomy patient, as well in resections of benign or malignant rectal lesions, and laparoscopic inguinal hernia repair have been associated with fistula formation. Unrecognized rectal injury at the time of radical prostatectomy is an uncommon but well-documented etiology of recto urethral fistula.
Scatter or emission of treatment from external beam radiation, brachytherapy, HIFU or cryotherapy to bowel in the treatment field can eventually lead to fistula development. Radiation-associated fistulae usually develop years after radiation therapy for a gynecologic or urologic malignancy. The post HIFU fistula is more likely to develop in association with blind instrumentation or spontaneously at two to three months after the procedure. In the first three months after HIFU, there is recognized sloughing of the entire prostatic urethra. This is as a result of coagulative necrosis secondary to HIFU. During this period of time the prostatic tissue is ulcerated and friable. Making it extremely sensitive to blind instrumentation and at greater risk of injury to penetrating the surrounding tissue, and more so the rectum.
Fistulae develop spontaneously after perforation of the irradiated intestine, with the development of an abscess in the pelvis that subsequently drains into the adjacent bladder. Radiation-associated fistulae are usually complex and often involve more than one organ (eg, colon to bladder). Although rare, fistulae due to cytotoxic therapy have been reported in a patient undergoing a CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) regimen for non-Hodgkin lymphoma. Therefore, past medical history of such medications should be considered.
The incidence of radiation-induced fistula associated with urologic and gynecological (recto vaginal or vesicovaginal) cancers is approximately 0.5% to 1%. The overall risk of a fistula formation is the same as the risk of rectal injury following a radical prostatectomy or various forms of EBRT, and interstitial prostate brachytherapy. The patients at highest risk of a fistula associated with HIFU are those undergoing a salvage procedure.
Traumatic pathophysiology
Urethral disruption caused by blunt trauma or a penetrating injury can result in fistulae, but these fistulae are typically rectourethral in nature. That is why any need for instrumentation in the post HIFU patient should be done under direct vision. In the post surgical, or HIFU patient, the history of prior surgery alone should be sufficient to properly diagnose the etiology of the fistula. However, one should always keep in mind the possibility of associated pathology such as bowel malignancy, inflammatory bowel disease and bladder cancer as a contributing factor. Particularly if the fistula fails to heal spontaneously after attempts at conservative management have been exhausted.
DIAGNOSTIC TESTING
· Charcoal test: Oral activated charcoal can confirm the diagnosis of enterovesical fistula.
Several hours after ingestion, flecks of charcoal can be noted in the urine.
· Cystoscopy and possible biopsy.
· Endoscopic visualization has the highest yield for the identification of enterovesical fistula.
•Eighty to 100 percent of cases demonstrate bullous edema, erythema, or exudation of feculent material from the fistula site
•Generally, colonic fistulas occur on the left side and dome of the bladder, whereas small bowel fistulas occur on the dome and right side of the bladder.
•Biopsy of the fistula is indicated in cases where malignancy is suspected. · Colonscopy and barium enema.
· Although less common than diverticular disease, it is important to exclude primary intestinal malignancy as the cause for the fistula.
· CT or MRI of the pelvis.
· Air in the bladder in the absence of prior lower urinary instrumentation is highly suggestive of an enterovesical fistula.
VCUG
· May demonstrate the fistulous connection.
· In some cases, however, the fistula can act as a "flap valve" and contrast will not be seen entering the bowel.
HIFU FISTULA: INTRA AND PERI-OPERATIVE PREVENTION
· Standard DRE, followed by slow and careful insertion of a second finger. I do not use forceful dilation, but simple leave the two fingers in place until the rectum and sphincter accommodate to both fingers...and it does relax and accommodate with time. This cannot be forced or hurried.
· Abort the procedure if unable to accommodate the index and middle finger in the rectal vault or if excessive bleeding.
· Keep the index finger pushing down at the 6 o'clock position during gentle and slow introduction of the probe.
· I prefer using the latex allergy condom. They are more durable and less likely to break. Therefore, less risk of having to reinsert the probe again. Multiple reinsertions only add to potential trauma to the rectum.
· I prefer two (double) “O rings” at the proximal end of the condom. This will reduce the potential of breaking the condom seal and the risk of getting air in the condom---another risk of having to remove and reinsert the probe again.
· I prefer bring the temperature of the Sonochill down to as low as possible in order to decrease heating.
· I prefer to use the minimum needed amount of water in the condom. This decreases the amount of pressure on the gland during treatment. My theory on this is that the less volume of interface between the transducer and the gland, the greater the coefficient of absorption of energy capability in the tissue. This, versus a greater volume of interface, may result in greater compression of the gland and less absorption of energy in the compressed gland. This can potentiate scatter of energy in the wrong direction, such as the rectal wall., NVB, sphincter.
· The rectal wall must have a minimum of 4-5 mm. in thickness without compression and a similar thickness should be maintained at all times. Undue compression of the rectal wall increases the risk of rectal wall injury. This is tissue that previously been treated and is more likely to be fibrotic and less vascular. Thereby compromising the ability of healing.
· The recurrent treatment glands are typically small and can be treated in two zones. All treatment zones (4 and 3 cm. probes) should be performed with the "extra" icon on (3 on, 6 off cycle)
· If the gland is very small with a short AP distance, try to get most of the overlap in the anterior zone. Even if it means extending the treatment outside the capsule. The distance from the anatomic capsule to the "surgical capsule" when doing a RRP is the thickness of the vascular pedicle and peri-prostatic fatty tissue. It is several mm. in thickness, and unlikely hurt anything by slightly treating lateral in this region.
· I am a firm believer in maintaining RWD at the same level in the reference and real time images as much as possible. I prefer to add water when the distance in the real time images changes beyond one-tenth of a mm. For example, if the real time image drops from 1.5 cm to > 1.4, I will pause and add small amounts of water to return to the reference image distance of 1.5 cm. I believe these changes occur due to build up of steam and swelling within the gland. This however, is more common in the primary therapy tan recurrent cases. The pause time will also allow more cooling time.
· I also believe in pausing and stacking at 1/3 interval into each zone. This will assure that there has not been movement of the gland toward the base. This allows the operator to remove HIFU lesions that are now anterior and above the apex- the site of the most common strictures. It also allows adding or subtracting any necessary lesions at the level of the base. Which is where the gland retracts. Stopping and stacking at 1/3 interval will also add cooling tome to the procedure.
THE MOST COMMON CAUSES AND SITE FOR A FISTULA
FORMATION ASSOCIATED WITH HIFU
· The most common cause of a fistula in the HIFU patient occurs when treatment results in misdirected energy into the rectal wall and/or below Denonvillier's fascia.
· Misdirected energy can occur from pre-focal heating, or from energy bouncing off calcifications or radioactive seeds. Continuous observation during treatment and adjustments of rectal wall distance and energy are the best method of preventing this from happening.
· The recommended energy adjustment to rectal wall distance should be continuously monitored. Particularly at the first lesions at Apex wish marks the beginning of each treatment row. This is where there can be the most variation in rectal wall distance as the sequence of lesions alternates from side to side (M versus P). This is easily accomplished by moving the "mouse" over the energy icon to the right of the watt adjustment slide bar. The adjustment can be performed moving the energy marker, or by clicking on the F12 icon and using the up or down arrow.
· Treatment into the rectal wall or below Denonvilliar’s fascia most commonly occurs during treatment of the posterior zone. But can occur in any zone, and at anytime. It is most likely to occur at the most lateral borders of the prostate where the crescent shape of the gland is most evident as the gland "tents downward." Likewise toward the apex, where it begins to take an upward orientation or slopes up as it gets closer to the external sphincter.
· Prevention of treatment below Denonvilier's fascia at the lateral borders and toward the upward slope of the prostate can be achieved by adjusting the stepper and/or water in the condom accordingly.
· Be extremely careful to not exceed the 2 cm limit rectal wall distance when treating toward the most lateral sides of the prostate.
· Always allow a 1 - 1.5 mm safety margin between the lower limits of the treatment limits to Denonvillier's fascia. The HIFU lesion is "cigar shaped" at the tip. This will allow some degree of treatment to be extended downward.
· I personally do not feel it is necessary to compromise the energy level or "power down" when treating the posterior zone, and in fact this is the site most likely to have cancer whether primary or recurrent.
POST HIFU PROTOCOL FOR PREVENTION OF RECTAL FISTULA IN RECURRENT TREATMENT CASES
· Withhold voiding trial until 2 weeks post HIFU in recurrent treatment cases.
· Place patients on anticholinergics for the first 10 - 12 days. i.e.: Vesicare 10 mg. Q day.
· Place patient on high residue diet for 2 weeks, or until voiding. This will need to be detailed and provided to patients.
· Add Metamucil as a bulk forming laxative to combat potential constipation. As well as a synergy to high residue diet.
· Urine culture and sensitivity several days before removing S.P. catheter to confirm no infection.
· Hold off removing S.P. if the culture is positive and/or resistant to antibiotic patient is taking.
· Post-void residual determination by ultrasound or bladder scan at 48 hours after S.P. tube is removed.
· Weekly nurse call to patient for the first 3-4 weeks, bi-monthly for the first 3 months, followed by monthly for the next 3 months.
· Absolutely no instrumentation unless under direct vision, and with appropriate antibiotic prophylactic i.e.: Gentamicin or Rocephin I.M.
· Emergency medic alert card with contact numbers to be mandatory carried at all times.
· Patients should be urged to curtail any heavy excessive exercise or work.
· They should also be urged to not travel beyond the U.S. for the first six months.
MANAGEMENT OF POST HIFU FISTULA
· Always be on the lookout for early symptoms of the potential of a fistula in the post HIFU patient. Educate the patient to be alert of any of these symptoms.
· Early symptoms; New and acute onset of peri-rectal pain and/or sense of fullness. A sense constipation or desire to have a bowel movement but can't. Acute onset of watery diarrhea particularly associated with voiding. The presence of gas or fecal material per urethra. Fever, chills and general malaise.
· Immediate management: Place a Foley catheter or Suprapubic catheter. Either one should be done under direct vision. I prefer a Suprapubic catheter using a flexible cystoscope for guidance and confirmation. Obtain a urine culture, baseline CBC and blood culture if febrile. Place the patient on appropriate broad-spectrum antibiotics, anticholinergics and high residue diet. Obtain urine culture and sensitivity weekly. Restrict activities as much as possible to only necessary. If the Suprapubic remains in place for a prolonged period of time, change every three weeks.
· Consult a colo-rectal specialist. It is best to get him on board from the beginning in the event additional intervention such as a temporary diverting colostomy may be required. The post HIFU fistula is typically very small and will heal on it's own with the above measures. Be patient and consciously reassuring to patient and family.
· The post HIFU fistula will typically heal on it's own within 6 to 8 weeks. If clinical resolution of the fistula remain doubtful, a voiding cystourethrogram via the Suprapubic catheter and/or a CT Scan combination may be helpful in confirming closure.
George M. Suarez, M.D.
Co- Founder, Medical Director Emiritus
USHIFU. International HIFU
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Friday, August 20, 2010
TESTING OF BROTHER'S MAY BOOST FAMILY'S PROSTATE CANCER RATES
Testing of Brothers May Boost Family's Prostate Cancer Rates
Increased diagnostic activity may lead to siblings finding more early stage disease, study suggests
Lifestyle
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THURSDAY, Aug. 19 (HealthDay News) -- Men who have a brother with prostate cancer are more likely than other men to be diagnosed with the disease, but the reason may have more to do with greater surveillance than genetics, a new study suggests.
Swedish researchers analyzed data from 22,511 brothers of 13,975 prostate cancer patients and found that the incidence of the disease was higher among brothers of prostate cancer patients than men of the same age in the general population. Disease incidence was highest among men who had two brothers with prostate cancer.
However, the study found that early-stage disease was the type most often diagnosed in brothers of prostate cancer patients. This stage of prostate cancer is typically detected through a prostate specific antigen (PSA) test and may or may not be clinically relevant, the study authors explained in the report published online Aug. 19 in the Journal of the National Cancer Institute.
The researchers also found that the incidence of prostate cancer among brothers of prostate cancer patients was highest during the first year after the first brother's diagnosis.
"The increased diagnostic activity among men with a family history of prostate cancer, which we observed, will inflate family history as a risk factor for prostate cancer in populations of men who commonly receive PSA testing," concluded Dr. Ola Bratt, of the urology department at the Helsinborg Hospital in Sweden, and colleagues.
The study results could offer guidance to doctors, the authors suggested.
"When counseling men about their risk of hereditary predisposition to prostate cancer, one should consider the possibility that a familial aggregation of prostate cancer may be at least partially caused by increased diagnostic activity," Bratt and colleagues wrote.
More information
The American Cancer Society has more about prostate cancer.
-- Robert Preidt
SOURCE: Journal of the National Cancer Institute, news release,
Increased diagnostic activity may lead to siblings finding more early stage disease, study suggests
Lifestyle
Maserati’s $136,000 Auto Purrs; Silky Moves: Jason H. Harper
Goodbye, Government Motors
Robert Oatley: Wizard of Oz
What Do New Meadowlands Stadium, Nascar, and the USTA Have in Common?
Leader on Bush Tax Cuts Wins Allies to Save Them
Story Tools
e-mail this story
print this story
order a reprint
THURSDAY, Aug. 19 (HealthDay News) -- Men who have a brother with prostate cancer are more likely than other men to be diagnosed with the disease, but the reason may have more to do with greater surveillance than genetics, a new study suggests.
Swedish researchers analyzed data from 22,511 brothers of 13,975 prostate cancer patients and found that the incidence of the disease was higher among brothers of prostate cancer patients than men of the same age in the general population. Disease incidence was highest among men who had two brothers with prostate cancer.
However, the study found that early-stage disease was the type most often diagnosed in brothers of prostate cancer patients. This stage of prostate cancer is typically detected through a prostate specific antigen (PSA) test and may or may not be clinically relevant, the study authors explained in the report published online Aug. 19 in the Journal of the National Cancer Institute.
The researchers also found that the incidence of prostate cancer among brothers of prostate cancer patients was highest during the first year after the first brother's diagnosis.
"The increased diagnostic activity among men with a family history of prostate cancer, which we observed, will inflate family history as a risk factor for prostate cancer in populations of men who commonly receive PSA testing," concluded Dr. Ola Bratt, of the urology department at the Helsinborg Hospital in Sweden, and colleagues.
The study results could offer guidance to doctors, the authors suggested.
"When counseling men about their risk of hereditary predisposition to prostate cancer, one should consider the possibility that a familial aggregation of prostate cancer may be at least partially caused by increased diagnostic activity," Bratt and colleagues wrote.
More information
The American Cancer Society has more about prostate cancer.
-- Robert Preidt
SOURCE: Journal of the National Cancer Institute, news release,
PSA SCREENING HALVES MORTALITY FROM PROSTATE CANCER
PSA Screening Halves Mortality From Prostate Cancer: Gothenburg Study
Zosia Chustecka
Authors and Disclosures
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Metastatic GIST: Diagnosis and treatment
Learn more about diagnosing and treating metastatic progressive gastrointestinal stromal tumors (GIST), as four experts present the case of a 55-year-old male patient.
See case study July 1, 2010 — New data from a Swedish study show that population screening with prostate-specific antigen (PSA) in men between 50 and 69 years of age reduced prostate cancer mortality by almost half during a follow-up period of 14 years. The finding was published online today in Lancet Oncology.
"In this trial, prostate cancer screening was well accepted by the general population and can result in a relevant reduction in cancer mortality, greater than that reported in screening for breast and colorectal cancer," conclude the researchers, headed by Jonas Hugosson, MD, from the Department of Urology at the University of Gothenburg, Sweden.
This is the best mortality result ever seen with PSA screening — even better than the positive results reported from a large European study last year, which found a 20% reduction in prostate cancer deaths after 9 years. Those results came from the European Randomised Trial of Screening for Prostate Cancer (ERSPC) and provided for the first time "proof of the benefits of PSA screening," according to the investigators.
These new findings from Gothenburg provide the second proof after the ERSPC that PSA screening can save lives, David Neal MD, from the Department of Oncology at the University of Cambridge, United Kingdom, commented to Medscape Medical News.
Not Generalizable to the United States
However, there are several important caveats to the Gothenburg study, Dr. Neal writes in an accompanying editorial. It was small (n = 20,000), and more than half of the men were already included in the ERSPC study (n = 162,387, including 11,852 from the Gothenburg study). However, the 2 trials produced different results, probably because of the longer follow-up and younger age at screening in the Gothenburg study, he suggests.
Dr. Neal also emphasizes the context of the new finding. It comes from "a country with low levels of opportunistic PSA testing," which is in direct contrast to the situation in the United States, where there is already widespread PSA testing.
Hence, the results might be generalizable to other countries that have not had prior extensive PSA testing, but not to countries such as the United States, which already have such testing widely available, he said.
This may explain the negative results from the large study from the United States, the Prostate Lung Colorectal and Ovarian (PLCO), which found no reduction in prostate cancer mortality from PSA screening during a follow-up of 11 years. Those results have been discussed in some detail, with a major concern being potential contamination in the control group; the investigators noted that PSA testing had been widespread even before the study began.
The PCLO study is "flawed and will probably never show meaningful results," Dr. Neal commented to Medscape Medical News. "Many of the men were already screened with a PSA test."
The contradictory results from PLCO and ERSPC, which were published together in the New England Journal of Medicine last year, have fueled heated debate and controversy over the benefits vs harms of PSA screening.
However, Dr. Neal told Medscape Medical News that there is growing agreement that PSA screening does save lives from prostate cancer — at a price.
"The consensus is that PSA testing is a 'proof of principle' with a marker that has some defects. We need better biomarkers," he said. In the editorial, he mentions insulin-like growth factor or kallikrein family members, as well as genetic testing.
The new finding from Gothenburg shows that "PSA testing reduces death from prostate cancer in some circumstances," Dr. Neal concludes.
However, it does not imply that PSA screening programs should now be introduced internationally, he adds.
"One important finding in this study is that diagnosis of prostate cancer did not automatically result in men taking up radical treatment," Dr. Neal commented. About 40% of men were placed on active surveillance protocols, and 28% remain on these protocols. Hence, many of the men were managed conservatively, but despite this, there was a survival benefit in the groups that was screened, he pointed out.
Gothenburg Study "Mirrors Population Screening"
The Gothenburg study began in 1994 and enrolled 20,000 men who lived in the city and were older than 50 years (age range, 50 - 64 years; median age, 56 years). They were randomly assigned to either the screening or control group and then invited for screening with the PSA test. The invitations stopped at a median age of 69 years (range, 67 - 71 years).
This design "gives more representative results than does randomisation after informed consent, and mirrors the situation when screening is introduced in the population," the authors explain.
This study shows that a PSA-based screening program is acceptable to men aged 50 years or older, with 76% of men attending at least once, they report.
With such a participation rate, this screening program reduced prostate-cancer specific mortality "by as much as half over 14 years' follow-up."
During the median 14-year follow-up, prostate cancer was diagnosed in 12.7% of men in the screening group and 8.2% in the control group (hazard ratio, 1.64; P < .0001). Most of the prostate cancer diagnosed in the screening group was early-stage disease, the researchers comment. More patients in the screening group had hormonal therapy, treatment with curative intent, and surveillance, they add. According to the Cause of Death committee review, there were 44 deaths from prostate cancer in the screening group and 78 in the control group (according to death certificates, these numbers were 45 and 77, respectively). "Half of the attendees who died from prostate cancer were diagnosed at their first screening visit," the researchers note. The rate ratio (RR) of dying from prostate cancer was 0.56 in the screening group compared with the control group (P = .002). The absolute cumulative-risk reduction (Kaplan-Meier estimates) of death from prostate cancer at 14 years was 0.40%, reduced from 0.90% in the control group to 0.50% in the screening group. Compares Favorably With Other Cancer Screening At 14 years of follow-up, the number who needed to be invited to screening (NNS) to prevent 1 prostate cancer death was 293, whereas the number needed to be diagnosed (corresponding to number needed to treat, NNT) was 12, the Swedish researchers report. These outcomes compare favourably with the well-established screening programs for breast and colorectal cancer. "These outcomes compare favourably with the well-established screening programs for breast and colorectal cancer," Dr. Neal comments in the editorial. In their article, the Swedish researchers cite several papers for comparable figures. Mammography for breast cancer screening has reported a NNS of 377 and an RR of 0.68 for women aged 60 to 69 years, and an NNS of 1339 and RR of 0.86 for women aged 50 to 59 years at 11 to 20 years of follow-up. A separate review reported an NNT for mammography of 10 over 10 years. Colorectal cancer screening by fecal occult blood test has reported an RR of 0.84 in 2 separate reviews (after 11.7 - 18.4 years and 7.8 - 13 years, respectively), and an NNS of 1173 after 10 years. Colorectal cancer screening by flexible sigmoidoscopy has reported an RR of 0.69 and an NNS of 489 at median follow-up of 11.2 years. However, as sigmoidoscopy removes any polyps that are found, it is associated with a reduced colorectal cancer incidence, and so an NNT cannot be calculated. Differences Between Gothenburg and Previous Studies The Swedish researchers discuss in some detail the discrepancy between their findings and those from the 2 large previous studies of PSA screening — the ERSPC and the PLCO — and offer potential explanations. "First, the men in our study were younger (median age 56 years at baseline) than in both previous publications (median age>60years)," they point out.
"Younger men are less likely than older men to have incurable prostate cancer at the first screening, and are therefore more likely to gain the full benefit of screening," they comment.
In addition, the PSA threshold for biopsy was lower in the Gothenburg study, and so there was a "much higher rate" of biopsy for men with a positive screening result, the Swedish researchers note. There were also differences in the screening intervals, and the 2 previous studies also included digital rectal examination as a screening tool, whereas the Gothenburg study did not.
Perhaps the most important difference was the length of follow-up — a median of 14 years after randomization in the Gothenburg study compared with 9 years for ERSPC and 11.5 years for PLCO.
Dr. Hugosson and colleagues comment that the results for the first 10 years of follow-up from the Gothenburg study are similar to those from ERSPC, suggesting that most of the benefit from screening occurs after 10 years. "This is to be expected from a disease with a long lead-time and a long natural course," they add.
The NNT of 12 in the Gothenburg study is substantially lower than the NNT of 48 in the ERSPC, which suggests that NNT is very dependent on the length of follow-up, and "it is not easy to predict at which follow-up period the NNT will stabilise," they note.
As the NNT in prostate cancer screening mainly reflects the risk for overdiagnosis, the Swedish researchers suggest that this risk "is probably not as high as some have feared, at least if screening is restricted to the age groups included in this study" (ie, ages 50 - 69 years).
Inviting men over the age of 70 for PSA screening seems questionable.
"Inviting men over the age of 70 for PSA screening seems questionable," the researchers comment. The benefit from prostate cancer screening takes a long time to achieve, they point out. Only marginal benefits are gained within the first 10 years, and the risk of overdiagnosis and overtreatment are still the major concerns in this field, so "one should be cautious to recommend that all elderly men have PSA screening."
Approached for independent comment, Philip Kantoff, MD, from the Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, told
Medscape Medical News
that the new study "does strongly support the position that PSA-based screening reduces prostate cancer specific mortality."
"It also supports the previous findings that prostate cancer mortality in a screened population is low in the first 10 years, and that overtreatment appears to be a significant problem," Dr. Kantoff said. "The issues of refining who should be screened and how frequently — but most importantly, who needs to be treated — needs to be determined," he added.
Dr. Hugosson has received lecture fees from GlaxoSmithKline and Abbott Pharmaceuticals, and coauthor Hans Lilja, MD, has received honoraria from GlaxoSmithKline and holds patents for free PSA and hK2 assays. The other coauthors have disclosed no relevant financial relationships. Dr. Neal is one of the principal investigators on ProtecT, a trial of treatment of localized prostate cancer funded by the National Institute of Health Research.
Lancet Oncol. Published online July 1, 2010.
[CLOSE WINDOW]Authors and DisclosuresJournalistZosia ChusteckaZosia Chustecka is news editor for Medscape Hematology-Oncology and prior news editor of jointandbone.org, a Web site acquired by WebMD. A veteran medical journalist based in London, UK, she has won a prize from the British Medical Journalists Association and is a pharmacology graduate. She has written for a wide variety of publications aimed at the medical and related health professions. She can be contacted at ZChustecka@webmd.net.
Zosia Chustecka has disclosed no relevant financial relationships.
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■Controversies in Prostate Cancer (Urology)
■Prostate Cancer - External Beam Radiotherapy (Urology)
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■Prostate Cancer Resource Center
Medscape Medical News © 2010 Medscape, LLC
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Zosia Chustecka
Authors and Disclosures
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Information from Industry
Metastatic GIST: Diagnosis and treatment
Learn more about diagnosing and treating metastatic progressive gastrointestinal stromal tumors (GIST), as four experts present the case of a 55-year-old male patient.
See case study July 1, 2010 — New data from a Swedish study show that population screening with prostate-specific antigen (PSA) in men between 50 and 69 years of age reduced prostate cancer mortality by almost half during a follow-up period of 14 years. The finding was published online today in Lancet Oncology.
"In this trial, prostate cancer screening was well accepted by the general population and can result in a relevant reduction in cancer mortality, greater than that reported in screening for breast and colorectal cancer," conclude the researchers, headed by Jonas Hugosson, MD, from the Department of Urology at the University of Gothenburg, Sweden.
This is the best mortality result ever seen with PSA screening — even better than the positive results reported from a large European study last year, which found a 20% reduction in prostate cancer deaths after 9 years. Those results came from the European Randomised Trial of Screening for Prostate Cancer (ERSPC) and provided for the first time "proof of the benefits of PSA screening," according to the investigators.
These new findings from Gothenburg provide the second proof after the ERSPC that PSA screening can save lives, David Neal MD, from the Department of Oncology at the University of Cambridge, United Kingdom, commented to Medscape Medical News.
Not Generalizable to the United States
However, there are several important caveats to the Gothenburg study, Dr. Neal writes in an accompanying editorial. It was small (n = 20,000), and more than half of the men were already included in the ERSPC study (n = 162,387, including 11,852 from the Gothenburg study). However, the 2 trials produced different results, probably because of the longer follow-up and younger age at screening in the Gothenburg study, he suggests.
Dr. Neal also emphasizes the context of the new finding. It comes from "a country with low levels of opportunistic PSA testing," which is in direct contrast to the situation in the United States, where there is already widespread PSA testing.
Hence, the results might be generalizable to other countries that have not had prior extensive PSA testing, but not to countries such as the United States, which already have such testing widely available, he said.
This may explain the negative results from the large study from the United States, the Prostate Lung Colorectal and Ovarian (PLCO), which found no reduction in prostate cancer mortality from PSA screening during a follow-up of 11 years. Those results have been discussed in some detail, with a major concern being potential contamination in the control group; the investigators noted that PSA testing had been widespread even before the study began.
The PCLO study is "flawed and will probably never show meaningful results," Dr. Neal commented to Medscape Medical News. "Many of the men were already screened with a PSA test."
The contradictory results from PLCO and ERSPC, which were published together in the New England Journal of Medicine last year, have fueled heated debate and controversy over the benefits vs harms of PSA screening.
However, Dr. Neal told Medscape Medical News that there is growing agreement that PSA screening does save lives from prostate cancer — at a price.
"The consensus is that PSA testing is a 'proof of principle' with a marker that has some defects. We need better biomarkers," he said. In the editorial, he mentions insulin-like growth factor or kallikrein family members, as well as genetic testing.
The new finding from Gothenburg shows that "PSA testing reduces death from prostate cancer in some circumstances," Dr. Neal concludes.
However, it does not imply that PSA screening programs should now be introduced internationally, he adds.
"One important finding in this study is that diagnosis of prostate cancer did not automatically result in men taking up radical treatment," Dr. Neal commented. About 40% of men were placed on active surveillance protocols, and 28% remain on these protocols. Hence, many of the men were managed conservatively, but despite this, there was a survival benefit in the groups that was screened, he pointed out.
Gothenburg Study "Mirrors Population Screening"
The Gothenburg study began in 1994 and enrolled 20,000 men who lived in the city and were older than 50 years (age range, 50 - 64 years; median age, 56 years). They were randomly assigned to either the screening or control group and then invited for screening with the PSA test. The invitations stopped at a median age of 69 years (range, 67 - 71 years).
This design "gives more representative results than does randomisation after informed consent, and mirrors the situation when screening is introduced in the population," the authors explain.
This study shows that a PSA-based screening program is acceptable to men aged 50 years or older, with 76% of men attending at least once, they report.
With such a participation rate, this screening program reduced prostate-cancer specific mortality "by as much as half over 14 years' follow-up."
During the median 14-year follow-up, prostate cancer was diagnosed in 12.7% of men in the screening group and 8.2% in the control group (hazard ratio, 1.64; P < .0001). Most of the prostate cancer diagnosed in the screening group was early-stage disease, the researchers comment. More patients in the screening group had hormonal therapy, treatment with curative intent, and surveillance, they add. According to the Cause of Death committee review, there were 44 deaths from prostate cancer in the screening group and 78 in the control group (according to death certificates, these numbers were 45 and 77, respectively). "Half of the attendees who died from prostate cancer were diagnosed at their first screening visit," the researchers note. The rate ratio (RR) of dying from prostate cancer was 0.56 in the screening group compared with the control group (P = .002). The absolute cumulative-risk reduction (Kaplan-Meier estimates) of death from prostate cancer at 14 years was 0.40%, reduced from 0.90% in the control group to 0.50% in the screening group. Compares Favorably With Other Cancer Screening At 14 years of follow-up, the number who needed to be invited to screening (NNS) to prevent 1 prostate cancer death was 293, whereas the number needed to be diagnosed (corresponding to number needed to treat, NNT) was 12, the Swedish researchers report. These outcomes compare favourably with the well-established screening programs for breast and colorectal cancer. "These outcomes compare favourably with the well-established screening programs for breast and colorectal cancer," Dr. Neal comments in the editorial. In their article, the Swedish researchers cite several papers for comparable figures. Mammography for breast cancer screening has reported a NNS of 377 and an RR of 0.68 for women aged 60 to 69 years, and an NNS of 1339 and RR of 0.86 for women aged 50 to 59 years at 11 to 20 years of follow-up. A separate review reported an NNT for mammography of 10 over 10 years. Colorectal cancer screening by fecal occult blood test has reported an RR of 0.84 in 2 separate reviews (after 11.7 - 18.4 years and 7.8 - 13 years, respectively), and an NNS of 1173 after 10 years. Colorectal cancer screening by flexible sigmoidoscopy has reported an RR of 0.69 and an NNS of 489 at median follow-up of 11.2 years. However, as sigmoidoscopy removes any polyps that are found, it is associated with a reduced colorectal cancer incidence, and so an NNT cannot be calculated. Differences Between Gothenburg and Previous Studies The Swedish researchers discuss in some detail the discrepancy between their findings and those from the 2 large previous studies of PSA screening — the ERSPC and the PLCO — and offer potential explanations. "First, the men in our study were younger (median age 56 years at baseline) than in both previous publications (median age>60years)," they point out.
"Younger men are less likely than older men to have incurable prostate cancer at the first screening, and are therefore more likely to gain the full benefit of screening," they comment.
In addition, the PSA threshold for biopsy was lower in the Gothenburg study, and so there was a "much higher rate" of biopsy for men with a positive screening result, the Swedish researchers note. There were also differences in the screening intervals, and the 2 previous studies also included digital rectal examination as a screening tool, whereas the Gothenburg study did not.
Perhaps the most important difference was the length of follow-up — a median of 14 years after randomization in the Gothenburg study compared with 9 years for ERSPC and 11.5 years for PLCO.
Dr. Hugosson and colleagues comment that the results for the first 10 years of follow-up from the Gothenburg study are similar to those from ERSPC, suggesting that most of the benefit from screening occurs after 10 years. "This is to be expected from a disease with a long lead-time and a long natural course," they add.
The NNT of 12 in the Gothenburg study is substantially lower than the NNT of 48 in the ERSPC, which suggests that NNT is very dependent on the length of follow-up, and "it is not easy to predict at which follow-up period the NNT will stabilise," they note.
As the NNT in prostate cancer screening mainly reflects the risk for overdiagnosis, the Swedish researchers suggest that this risk "is probably not as high as some have feared, at least if screening is restricted to the age groups included in this study" (ie, ages 50 - 69 years).
Inviting men over the age of 70 for PSA screening seems questionable.
"Inviting men over the age of 70 for PSA screening seems questionable," the researchers comment. The benefit from prostate cancer screening takes a long time to achieve, they point out. Only marginal benefits are gained within the first 10 years, and the risk of overdiagnosis and overtreatment are still the major concerns in this field, so "one should be cautious to recommend that all elderly men have PSA screening."
Approached for independent comment, Philip Kantoff, MD, from the Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, told
Medscape Medical News
that the new study "does strongly support the position that PSA-based screening reduces prostate cancer specific mortality."
"It also supports the previous findings that prostate cancer mortality in a screened population is low in the first 10 years, and that overtreatment appears to be a significant problem," Dr. Kantoff said. "The issues of refining who should be screened and how frequently — but most importantly, who needs to be treated — needs to be determined," he added.
Dr. Hugosson has received lecture fees from GlaxoSmithKline and Abbott Pharmaceuticals, and coauthor Hans Lilja, MD, has received honoraria from GlaxoSmithKline and holds patents for free PSA and hK2 assays. The other coauthors have disclosed no relevant financial relationships. Dr. Neal is one of the principal investigators on ProtecT, a trial of treatment of localized prostate cancer funded by the National Institute of Health Research.
Lancet Oncol. Published online July 1, 2010.
[CLOSE WINDOW]Authors and DisclosuresJournalistZosia ChusteckaZosia Chustecka is news editor for Medscape Hematology-Oncology and prior news editor of jointandbone.org, a Web site acquired by WebMD. A veteran medical journalist based in London, UK, she has won a prize from the British Medical Journalists Association and is a pharmacology graduate. She has written for a wide variety of publications aimed at the medical and related health professions. She can be contacted at ZChustecka@webmd.net.
Zosia Chustecka has disclosed no relevant financial relationships.
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PROSTATE BRACHYTHERAPY SEED MIGRATION
Prostate Brachytherapy Seed Migration To The Ischial Bone: 2 Case Reports
Akitomo Sugawara M.D.
Department of Radiology
Keio University School of Medicine
Tokyo Japan
Naoyuki Shigematsu M.D.
Department of Radiology
Keio University School of Medicine
Tokyo Japan
Mototsugu Oya M.D.
Department of Urology
Keio University School of Medicine
Tokyo Japan
Jun Nakashima M.D.
Department of Urology
Tokyo Medical University
Tokyo Japan
Etsuo Kunieda M.D.
Department of Radiation Oncology
Tokai University School of Medicine
Isehara Japan
Citation: A. Sugawara, N. Shigematsu, M. Oya, J. Nakashima & E. Kunieda : Prostate Brachytherapy Seed Migration To The Ischial Bone: 2 Case Reports. The Internet Journal of Urology. 2010 Volume 7 Number 2
Keywords: Brachytherapy | 125I | Migration | Prostate cancer | Seed
Abstract
We report two cases of seed migration to the ischial bone after prostate brachytherapy. A 78-year-old male and a 66-year-old male underwent transperineal interstitial permanent prostate brachytherapy with loose 125I seeds. Postimplant pelvic radiographs revealed a seed that was overlapped by the right ischial bone. Postimplant pelvic computed tomography revealed a seed that migrated to the right ischial bone. The two cases had no symptoms related to the migrated seed. This is the first report of seed migration to the ischial bone after transperineal interstitial permanent prostate brachytherapy. For these two cases, it is hypothesized that the seeds migrated to the ischial bone via the pelvic venous pathway, not via the systemic circulation.
Introduction
Seed migration is a recognized event in prostate brachytherapy. Rare cases of seed migration to coronary artery, the right ventricle, and the vertebral venous plexus have been reported [1-3]. However, no cases of seed migration to the ischial bone have been reported. Here, we report two cases of seed migration to the ischial bone.
Case reports
Case 1
A 78-year-old man with T2aN0M0 (AJCC TNM classification, 2002) prostate cancer with a Gleason score of 6 (3+3) and a prostate-specific antigen (PSA) level of 13.05 ng/mL underwent prostate brachytherapy with loose 125I seeds using a Mick applicator (Mick Radio-Nuclear Instruments, Bronx, NY). The prescribed dose was 145 Gy. The preimplant prostate volume by transrectal ultrasound (TRUS) was 24.5 cc. The 125I source strength was 12.07MBq per source. The number of seeds implanted was 80.
Immediately after seed implantation, a pelvic radiograph showed no migrated seeds. Eighteen days after seed implantation, a pelvic radiograph showed a seed that had migrated to the pelvic area and was overlapped by the right ischial bone (Fig. 1). Seven weeks after seed implantation, postimplant pelvic computed tomography (CT) showed a seed that migrated to the right ischial bone (Fig. 2).

Figure 1. Case 1: Pelvic radiograph showing a seed that has migrated to the pelvic area and is overlapped by the right ischial bone (arrow).

Figure 2. Case 1: Pelvic computed tomography scan showing seed migration to the right ischial bone (arrow).
Case 2
A 66-year-old man with T1cN0M0 prostate cancer with a Gleason score of 6 (3+3) and a PSA level of 4.79 ng/mL underwent prostate brachytherapy with loose 125I seeds. The preimplant prostate volume by TRUS was 26.3 cc. The 125I source strength was 12.07MBq per source. The number of seeds implanted was 79.
Immediately after seed implantation, a pelvic radiograph showed no migrated seeds. One day after seed implantation, a pelvic radiograph showed a seed that had migrated to the pelvic area and was overlapped by the right ischial bone (Fig. 3). Three months after seed implantation, postimplant pelvic CT showed a seed that migrated to the right ischial bone (Fig 4).
The two patients had no symptoms related to the migrated seed, and they were informed of the migration.
The two patients had no symptoms related to the migrated seed, and they were informed of the migration.

Figure 3. Case 2: Pelvic radiograph showing a seed that has migrated to the pelvic area and is overlapped by the right ischial bone (arrow).

Figure 4. Case 2: Pelvic computed tomography scan showing seed migration to the right ischial bone (arrow).
Discussion
The present cases represent the first reports of seed migration to the ischial bone. A possible mechanism of seed migration to the ischial bone is that seeds might enter the periprostatic vessels, and might migrate directly to the ischial bone via the pelvic venous plexus. This hypothesis is supported by the following report [4]. In 1940, Batson reported the interconnectivity of the periprostatic vessels with the pelvic venous plexus, pelvic bones, sacral canal, and vertebral venous plexus [4]. The Batson’s plexus is valveless, and many reversals of flow are said to occur with changes in venous pressure secondary to changes in body posture and Valsalva manoeuvres [4]. The rich venous plexus of Batson is implicated as the route of hematogenous dissemination of prostate adenocarcinoma to the pelvic bones, femur, spine, and ribs.
Conclusion
The present cases are the first reports of seed migration to the ischial bone. For these two cases, it is hypothesized that the seeds migrated to the ischial bone via the pelvic venous pathway, not via the systemic circulation.
Correspondence to
Akitomo Sugawara, M.D.
Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
e-mail: h4411@wave.plala.or.jp
References
1. Davis BJ, Bresnahan JF, Stafford SL, Karon BL, King BF, Wilson TM: Prostate brachytherapy seed migration to a coronary artery found during angiography. J Urol; 2002; 168:1103. (s)
2. Davis BJ, Pfeifer EA, Wilson TM, King BF, Eshleman JS, Pisansky TM: Prostate brachytherapy seed migration to the right ventricle found at autopsy following acute cardiac dysrhythmia. J Urol; 2000; 164:1661. (s)
3. Nakano M, Uno H, Gotoh T, Kubota Y, Ishihara S, Deguchi T, Hayashi S, Matsuo M, Tanaka O, Hoshi H: Migration of prostate brachytherapy seeds to the vertebral venous plexus. Brachytherapy; 2006; 5:127-130. (s)
4. Batson OV: The Function of the Vertebral Veins and Their Role in the Spread of Metastases. Ann Surg; 1940; 112:138-149. (s)
This article was last modified on Tue, 17 Aug 10 20:17:07 -0500
This page was generated on Fri, 20 Aug 10 11:54:33 -0500, and may be cached.
Akitomo Sugawara M.D.
Department of Radiology
Keio University School of Medicine
Tokyo Japan
Naoyuki Shigematsu M.D.
Department of Radiology
Keio University School of Medicine
Tokyo Japan
Mototsugu Oya M.D.
Department of Urology
Keio University School of Medicine
Tokyo Japan
Jun Nakashima M.D.
Department of Urology
Tokyo Medical University
Tokyo Japan
Etsuo Kunieda M.D.
Department of Radiation Oncology
Tokai University School of Medicine
Isehara Japan
Citation: A. Sugawara, N. Shigematsu, M. Oya, J. Nakashima & E. Kunieda : Prostate Brachytherapy Seed Migration To The Ischial Bone: 2 Case Reports. The Internet Journal of Urology. 2010 Volume 7 Number 2
Keywords: Brachytherapy | 125I | Migration | Prostate cancer | Seed
Abstract
We report two cases of seed migration to the ischial bone after prostate brachytherapy. A 78-year-old male and a 66-year-old male underwent transperineal interstitial permanent prostate brachytherapy with loose 125I seeds. Postimplant pelvic radiographs revealed a seed that was overlapped by the right ischial bone. Postimplant pelvic computed tomography revealed a seed that migrated to the right ischial bone. The two cases had no symptoms related to the migrated seed. This is the first report of seed migration to the ischial bone after transperineal interstitial permanent prostate brachytherapy. For these two cases, it is hypothesized that the seeds migrated to the ischial bone via the pelvic venous pathway, not via the systemic circulation.
Introduction
Seed migration is a recognized event in prostate brachytherapy. Rare cases of seed migration to coronary artery, the right ventricle, and the vertebral venous plexus have been reported [1-3]. However, no cases of seed migration to the ischial bone have been reported. Here, we report two cases of seed migration to the ischial bone.
Case reports
Case 1
A 78-year-old man with T2aN0M0 (AJCC TNM classification, 2002) prostate cancer with a Gleason score of 6 (3+3) and a prostate-specific antigen (PSA) level of 13.05 ng/mL underwent prostate brachytherapy with loose 125I seeds using a Mick applicator (Mick Radio-Nuclear Instruments, Bronx, NY). The prescribed dose was 145 Gy. The preimplant prostate volume by transrectal ultrasound (TRUS) was 24.5 cc. The 125I source strength was 12.07MBq per source. The number of seeds implanted was 80.
Immediately after seed implantation, a pelvic radiograph showed no migrated seeds. Eighteen days after seed implantation, a pelvic radiograph showed a seed that had migrated to the pelvic area and was overlapped by the right ischial bone (Fig. 1). Seven weeks after seed implantation, postimplant pelvic computed tomography (CT) showed a seed that migrated to the right ischial bone (Fig. 2).

Figure 1. Case 1: Pelvic radiograph showing a seed that has migrated to the pelvic area and is overlapped by the right ischial bone (arrow).

Figure 2. Case 1: Pelvic computed tomography scan showing seed migration to the right ischial bone (arrow).
Case 2
A 66-year-old man with T1cN0M0 prostate cancer with a Gleason score of 6 (3+3) and a PSA level of 4.79 ng/mL underwent prostate brachytherapy with loose 125I seeds. The preimplant prostate volume by TRUS was 26.3 cc. The 125I source strength was 12.07MBq per source. The number of seeds implanted was 79.
Immediately after seed implantation, a pelvic radiograph showed no migrated seeds. One day after seed implantation, a pelvic radiograph showed a seed that had migrated to the pelvic area and was overlapped by the right ischial bone (Fig. 3). Three months after seed implantation, postimplant pelvic CT showed a seed that migrated to the right ischial bone (Fig 4).
The two patients had no symptoms related to the migrated seed, and they were informed of the migration.
The two patients had no symptoms related to the migrated seed, and they were informed of the migration.

Figure 3. Case 2: Pelvic radiograph showing a seed that has migrated to the pelvic area and is overlapped by the right ischial bone (arrow).

Figure 4. Case 2: Pelvic computed tomography scan showing seed migration to the right ischial bone (arrow).
Discussion
The present cases represent the first reports of seed migration to the ischial bone. A possible mechanism of seed migration to the ischial bone is that seeds might enter the periprostatic vessels, and might migrate directly to the ischial bone via the pelvic venous plexus. This hypothesis is supported by the following report [4]. In 1940, Batson reported the interconnectivity of the periprostatic vessels with the pelvic venous plexus, pelvic bones, sacral canal, and vertebral venous plexus [4]. The Batson’s plexus is valveless, and many reversals of flow are said to occur with changes in venous pressure secondary to changes in body posture and Valsalva manoeuvres [4]. The rich venous plexus of Batson is implicated as the route of hematogenous dissemination of prostate adenocarcinoma to the pelvic bones, femur, spine, and ribs.
Conclusion
The present cases are the first reports of seed migration to the ischial bone. For these two cases, it is hypothesized that the seeds migrated to the ischial bone via the pelvic venous pathway, not via the systemic circulation.
Correspondence to
Akitomo Sugawara, M.D.
Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
e-mail: h4411@wave.plala.or.jp
References
1. Davis BJ, Bresnahan JF, Stafford SL, Karon BL, King BF, Wilson TM: Prostate brachytherapy seed migration to a coronary artery found during angiography. J Urol; 2002; 168:1103. (s)
2. Davis BJ, Pfeifer EA, Wilson TM, King BF, Eshleman JS, Pisansky TM: Prostate brachytherapy seed migration to the right ventricle found at autopsy following acute cardiac dysrhythmia. J Urol; 2000; 164:1661. (s)
3. Nakano M, Uno H, Gotoh T, Kubota Y, Ishihara S, Deguchi T, Hayashi S, Matsuo M, Tanaka O, Hoshi H: Migration of prostate brachytherapy seeds to the vertebral venous plexus. Brachytherapy; 2006; 5:127-130. (s)
4. Batson OV: The Function of the Vertebral Veins and Their Role in the Spread of Metastases. Ann Surg; 1940; 112:138-149. (s)
This article was last modified on Tue, 17 Aug 10 20:17:07 -0500
This page was generated on Fri, 20 Aug 10 11:54:33 -0500, and may be cached.
Thursday, August 19, 2010
RADIATION THERAPY FOR PROSTATE CANCER?
____________________________________________________________________________________________________________________________
Radiation therapy for prostate cancer.
Get the facts.
If you are considering radiation therapy for prostate cancer, including the highly marketed concept of radioactive seeds. Get the facts before making a decision.The fact is that radioactive seeds are nothing more than another form of radiation. It is not much different than External Beam Radiotherapy, Image guided Modulated Radiotherapy (IMRT) or Proton radiotherapy. With all forms of radiation comes the toxic side effects of radiation. Anyone considering radiation should look into High Intensity Focused Ultrasound (HIFU) . There no radiation and no surgery. HIFU is truly totally non- invasive outpatient procedure. For further information, visit: www.hifumedicalexpert.com. If you want to get the facts on the secondary effects from radiation exposure in the treatment of prostate cancer, click on the link below and read the comments that follow.
Please see the recent article in Urology Times in the link below commenting on clinical outcomes of radiation therapy being similar to HIFU in treating prostate cancer.
http://digital.healthcaregroup.advanstar.com/nxtbooks/advanstar/ut_201008/index.php?startid=24
"Although this is another important article in the fast gaining popularity of HIFU as a treatment option for localized prostate cancer, and the efficacy in clinical outcomes. The fact is that as a slow growing cancer, it seems to respond to almost any type of treatment when it is diagnosed early and has favorable PSA and Gleason score. However, Radiation has additional toxic side effects that are not often discussed with the patients. Yet, it remains the most common form of treatment for prostate cancer. Mostly because of men's fear of undergoing surgery and the collateral damage associated with it. Even with radiation there is still high degree of side effects. These include erectile dysfunction and urinary incontinence and high degree of irritable or "bother symptoms" (bladder and bowel). What is seldom mentioned is the increased risk of developing a secondary malignancy. Particularly bladder and rectal cancer, reported as high as 70 % greater than men treated with alternatives other than radiation. (1) Furthermore, a recent study from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database has revealed that PSA recurrence after radiotherapy occurred in 63 % of men with 93 % being treated with Androgen deprivation therapy for salvage of PSA failure. (2) The alternative to Androgen deprivation is to treat radiation failures with Salvage HIFU and saving patients from being placed on hormone therapy. That in the end Androgen deprivation is only palliative and never curative."
George M. Suarez, M.D.
Co- Founder,
Medical Director Emeritus, USHIFU
WWW.HIFUMEDICALEXPERT.COM
9195 Sunset Dr. Miami, Florida, 33173 Telephone: 305-595-0199
Toll Free: I- WHY-LEAK or 1-877-949-5325
References:
(1) Baxter NN, Tepper JE, Durham SB. et al, Increased risk of rectal cancer after radiation: a population-based study. Gastroenterology, 2005;128:819-824.
(2) Agarwal PK, Sadestsky N, Konety BR et al: and the CaPSURE group. Treatment failure after primary and salvage therapy for prostate cancer: Likelihood, patterns of care, and outcomes. Cancer 2008;112:307-14
Radiation therapy for prostate cancer.
Get the facts.
If you are considering radiation therapy for prostate cancer, including the highly marketed concept of radioactive seeds. Get the facts before making a decision.The fact is that radioactive seeds are nothing more than another form of radiation. It is not much different than External Beam Radiotherapy, Image guided Modulated Radiotherapy (IMRT) or Proton radiotherapy. With all forms of radiation comes the toxic side effects of radiation. Anyone considering radiation should look into High Intensity Focused Ultrasound (HIFU) . There no radiation and no surgery. HIFU is truly totally non- invasive outpatient procedure. For further information, visit: www.hifumedicalexpert.com. If you want to get the facts on the secondary effects from radiation exposure in the treatment of prostate cancer, click on the link below and read the comments that follow.
Please see the recent article in Urology Times in the link below commenting on clinical outcomes of radiation therapy being similar to HIFU in treating prostate cancer.
http://digital.healthcaregroup.advanstar.com/nxtbooks/advanstar/ut_201008/index.php?startid=24
"Although this is another important article in the fast gaining popularity of HIFU as a treatment option for localized prostate cancer, and the efficacy in clinical outcomes. The fact is that as a slow growing cancer, it seems to respond to almost any type of treatment when it is diagnosed early and has favorable PSA and Gleason score. However, Radiation has additional toxic side effects that are not often discussed with the patients. Yet, it remains the most common form of treatment for prostate cancer. Mostly because of men's fear of undergoing surgery and the collateral damage associated with it. Even with radiation there is still high degree of side effects. These include erectile dysfunction and urinary incontinence and high degree of irritable or "bother symptoms" (bladder and bowel). What is seldom mentioned is the increased risk of developing a secondary malignancy. Particularly bladder and rectal cancer, reported as high as 70 % greater than men treated with alternatives other than radiation. (1) Furthermore, a recent study from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database has revealed that PSA recurrence after radiotherapy occurred in 63 % of men with 93 % being treated with Androgen deprivation therapy for salvage of PSA failure. (2) The alternative to Androgen deprivation is to treat radiation failures with Salvage HIFU and saving patients from being placed on hormone therapy. That in the end Androgen deprivation is only palliative and never curative."
George M. Suarez, M.D.
Co- Founder,
Medical Director Emeritus, USHIFU
WWW.HIFUMEDICALEXPERT.COM
9195 Sunset Dr. Miami, Florida, 33173 Telephone: 305-595-0199
Toll Free: I- WHY-LEAK or 1-877-949-5325
References:
(1) Baxter NN, Tepper JE, Durham SB. et al, Increased risk of rectal cancer after radiation: a population-based study. Gastroenterology, 2005;128:819-824.
(2) Agarwal PK, Sadestsky N, Konety BR et al: and the CaPSURE group. Treatment failure after primary and salvage therapy for prostate cancer: Likelihood, patterns of care, and outcomes. Cancer 2008;112:307-14
RADIATION THERAPY FOR PROSTATE CANCER?
____________________________________________________________________________________________________________________________
Radiation therapy for prostate cancer.
Get the facts.
If you are considering radiation therapy for prostate cancer, including the highly marketed concept of radioactive seeds. Get the facts before making a decision.The fact is that radioactive seeds are nothing more than another form of radiation. It is not much different than External Beam Radiotherapy, Image guided Modulated Radiotherapy (IMRT) or Proton radiotherapy. With all forms of radiation comes the toxic side effects of radiation. Anyone considering radiation should look into High Intensity Focused Ultrasound (HIFU) . There no radiation and no surgery. HIFU is truly totally non- invasive outpatient procedure. For further information, visit: www.hifumedicalexpert.com. If you want to get the facts on the secondary effects from radiation exposure in the treatment of prostate cancer, click on the link below and read the comments that follow.
Please see the recent article in Urology Times in the link below commenting on clinical outcomes of radiation therapy being similar to HIFU in treating prostate cancer.
http://digital.healthcaregroup.advanstar.com/nxtbooks/advanstar/ut_201008/index.php?startid=24
"Although this is another important article in the fast gaining popularity of HIFU as a treatment option for localized prostate cancer, and the efficacy in clinical outcomes. The fact is that as a slow growing cancer, it seems to respond to almost any type of treatment when it is diagnosed early and has favorable PSA and Gleason score. However, Radiation has additional toxic side effects that are not often discussed with the patients. Yet, it remains the most common form of treatment for prostate cancer. Mostly because of men's fear of undergoing surgery and the collateral damage associated with it. Even with radiation there is still high degree of side effects. These include erectile dysfunction and urinary incontinence and high degree of irritable or "bother symptoms" (bladder and bowel). What is seldom mentioned is the increased risk of developing a secondary malignancy. Particularly bladder and rectal cancer, reported as high as 70 % greater than men treated with alternatives other than radiation. (1) Furthermore, a recent study from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database has revealed that PSA recurrence after radiotherapy occurred in 63 % of men with 93 % being treated with Androgen deprivation therapy for salvage of PSA failure. (2) The alternative to Androgen deprivation is to treat radiation failures with Salvage HIFU and saving patients from being placed on hormone therapy. That in the end Androgen deprivation is only palliative and never curative."
George M. Suarez, M.D.
Co- Founder,
Medical Director Emeritus, USHIFU
WWW.HIFUMEDICALEXPERT.COM
9195 Sunset Dr. Miami, Florida, 33173 Telephone: 305-595-0199
Toll Free: I- WHY-LEAK or 1-877-949-5325
References:
(1) Baxter NN, Tepper JE, Durham SB. et al, Increased risk of rectal cancer after radiation: a population-based study. Gastroenterology, 2005;128:819-824.
(2) Agarwal PK, Sadestsky N, Konety BR et al: and the CaPSURE group. Treatment failure after primary and salvage therapy for prostate cancer: Likelihood, patterns of care, and outcomes. Cancer 2008;112:307-14
Dr. George M. Suarez is the co-founder and Medical Director, Emeritus of USHIFU and International HIFU. Dr. Suarez has served on the Board of Directors of Focus Surgery, the manufacturer of the Sonoblate 500. As well as currently serves on the Board of Directors of USHIFU. He has performed more HIFU procedures than any single urologist in North America, and has trained the vast majority of urologists performing HIFU. He has been involved with teaching, training and educational materials of HIFU dating back for almost 10 years.
For additional information on HIFU and on Dr. George M. Suarez, please visit www.hifumedicalexpert.com
Radiation therapy for prostate cancer.
Get the facts.
If you are considering radiation therapy for prostate cancer, including the highly marketed concept of radioactive seeds. Get the facts before making a decision.The fact is that radioactive seeds are nothing more than another form of radiation. It is not much different than External Beam Radiotherapy, Image guided Modulated Radiotherapy (IMRT) or Proton radiotherapy. With all forms of radiation comes the toxic side effects of radiation. Anyone considering radiation should look into High Intensity Focused Ultrasound (HIFU) . There no radiation and no surgery. HIFU is truly totally non- invasive outpatient procedure. For further information, visit: www.hifumedicalexpert.com. If you want to get the facts on the secondary effects from radiation exposure in the treatment of prostate cancer, click on the link below and read the comments that follow.
Please see the recent article in Urology Times in the link below commenting on clinical outcomes of radiation therapy being similar to HIFU in treating prostate cancer.
http://digital.healthcaregroup.advanstar.com/nxtbooks/advanstar/ut_201008/index.php?startid=24
"Although this is another important article in the fast gaining popularity of HIFU as a treatment option for localized prostate cancer, and the efficacy in clinical outcomes. The fact is that as a slow growing cancer, it seems to respond to almost any type of treatment when it is diagnosed early and has favorable PSA and Gleason score. However, Radiation has additional toxic side effects that are not often discussed with the patients. Yet, it remains the most common form of treatment for prostate cancer. Mostly because of men's fear of undergoing surgery and the collateral damage associated with it. Even with radiation there is still high degree of side effects. These include erectile dysfunction and urinary incontinence and high degree of irritable or "bother symptoms" (bladder and bowel). What is seldom mentioned is the increased risk of developing a secondary malignancy. Particularly bladder and rectal cancer, reported as high as 70 % greater than men treated with alternatives other than radiation. (1) Furthermore, a recent study from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database has revealed that PSA recurrence after radiotherapy occurred in 63 % of men with 93 % being treated with Androgen deprivation therapy for salvage of PSA failure. (2) The alternative to Androgen deprivation is to treat radiation failures with Salvage HIFU and saving patients from being placed on hormone therapy. That in the end Androgen deprivation is only palliative and never curative."
George M. Suarez, M.D.
Co- Founder,
Medical Director Emeritus, USHIFU
WWW.HIFUMEDICALEXPERT.COM
9195 Sunset Dr. Miami, Florida, 33173 Telephone: 305-595-0199
Toll Free: I- WHY-LEAK or 1-877-949-5325
References:
(1) Baxter NN, Tepper JE, Durham SB. et al, Increased risk of rectal cancer after radiation: a population-based study. Gastroenterology, 2005;128:819-824.
(2) Agarwal PK, Sadestsky N, Konety BR et al: and the CaPSURE group. Treatment failure after primary and salvage therapy for prostate cancer: Likelihood, patterns of care, and outcomes. Cancer 2008;112:307-14
Dr. George M. Suarez is the co-founder and Medical Director, Emeritus of USHIFU and International HIFU. Dr. Suarez has served on the Board of Directors of Focus Surgery, the manufacturer of the Sonoblate 500. As well as currently serves on the Board of Directors of USHIFU. He has performed more HIFU procedures than any single urologist in North America, and has trained the vast majority of urologists performing HIFU. He has been involved with teaching, training and educational materials of HIFU dating back for almost 10 years.
For additional information on HIFU and on Dr. George M. Suarez, please visit www.hifumedicalexpert.com
BRACHYTHERAPY - THE SEEDS
VALDESE --
Prostate cancer is second only to skin cancer as the most common cancer diagnosed among American men. Only lung cancer causes more cancer deaths in men. The National Cancer Institute estimates that 32,050 men will die of prostate cancer this year.
The numbers may paint a gloomy picture, but the fact is prostate cancer is usually a slow growing cancer, and most men don’t develop the disease until they are 65 years old or older. The screening tools available today mean prostate cancer can be caught in its earliest stages when it’s more easily cured. If the diagnosis is prostate cancer, several treatment options are available to men, and they are offered at the Cancer Center at Blue Ridge HealthCare.
One treatment is interstitial seed implant also known as prostate brachytherapy or prostate seed implantation. Blue Ridge Urology’s Brian Bauer, MD, a urologist, and the Cancer Center’s Greg Jones, MD, a radiation oncologist, have performed this procedure together for more than 10 years at Valdese Hospital.
While cancer screenings and PSA (prostate-specific antigen) test mean more men are finding out earlier if there is a problem, Dr. Jones said it’s important to make sure the patient is the right fit for treatment.
“If a man is in his 70s, particularly 75, 80 or older, it’s unlikely that early stage prostate cancer will affect his quality of life or overall life expectancy,” Dr. Jones said. “It’s more likely something else will become a life threatening problem. He could live his life never knowing he had prostate cancer. When a man in that age group with multiple underlying medical conditions comes to me, I consider it my responsibility to help him understand he has a choice. He does not necessarily have to go through treatment. Sometimes men have hard time accepting that and want to be treated anyway.”
If Dr. Jones and Dr. Bauer agree that seed implantation is the best option, Dr. Jones and his staff will then develop a computerized treatment plan, decide on the radiation dose and conceptualize a 3-D model of the prostate to see exactly where the seeds need to be implanted. Once completed, the patient is scheduled for outpatient surgery.
The radioactive seeds are similar in size to a grain of rice and are inserted with needles. “If you take a mechanical pencil and extend the tip about a quarter of an inch, that will give you a good idea of what a radioactive seed looks like,” Dr. Bauer said.
The patient is under anesthesia for the procedure. Using ultrasound and fluoroscopy (real time X-ray guidance), the urologist inserts the needles to plant the seeds based on the recommendation of the radiation oncologist.
The radioactive seeds are able to deliver an extremely high dose of radiation directly into the prostate gland. “Typically we use 25 needles to implant about 100 seeds,” Dr. Bauer said. “The seeds stay forever but the radioactivity will decrease over time.”
Brachytherapy allows for a tightly defined radiation dose in very specific areas, Dr. Jones said. “There’s less likely to be any radiation damage to normal tissues,” he said. “But because the dose is very high, there is still risk of complications and side effects. Brachytherapy is a very, very good alternative for prostate cancer treatment.”
Symptoms from the irritation of the urinary tract can often present three to four weeks after surgery, but these generally disappear within several weeks. As with other forms of treatment for prostate cancer, a man may also experience sexual difficulties following brachytherapy.
Another treatment option is intensity modulated radiation therapy (IMRT) using a linear accelerator. “Some cases should not be considered for brachytherapy or surgery, but could utilize external beam radiation. All three are reasonable options,” Dr. Jones said. “There is no discernable difference in cure rates if cases are selected appropriately. Cure rates should be outstanding for early stage prostate cancer as long as the quality of care is good, and we can certainly assure our patients the quality of care here is excellent.”
Prostate cancer is second only to skin cancer as the most common cancer diagnosed among American men. Only lung cancer causes more cancer deaths in men. The National Cancer Institute estimates that 32,050 men will die of prostate cancer this year.
The numbers may paint a gloomy picture, but the fact is prostate cancer is usually a slow growing cancer, and most men don’t develop the disease until they are 65 years old or older. The screening tools available today mean prostate cancer can be caught in its earliest stages when it’s more easily cured. If the diagnosis is prostate cancer, several treatment options are available to men, and they are offered at the Cancer Center at Blue Ridge HealthCare.
One treatment is interstitial seed implant also known as prostate brachytherapy or prostate seed implantation. Blue Ridge Urology’s Brian Bauer, MD, a urologist, and the Cancer Center’s Greg Jones, MD, a radiation oncologist, have performed this procedure together for more than 10 years at Valdese Hospital.
While cancer screenings and PSA (prostate-specific antigen) test mean more men are finding out earlier if there is a problem, Dr. Jones said it’s important to make sure the patient is the right fit for treatment.
“If a man is in his 70s, particularly 75, 80 or older, it’s unlikely that early stage prostate cancer will affect his quality of life or overall life expectancy,” Dr. Jones said. “It’s more likely something else will become a life threatening problem. He could live his life never knowing he had prostate cancer. When a man in that age group with multiple underlying medical conditions comes to me, I consider it my responsibility to help him understand he has a choice. He does not necessarily have to go through treatment. Sometimes men have hard time accepting that and want to be treated anyway.”
If Dr. Jones and Dr. Bauer agree that seed implantation is the best option, Dr. Jones and his staff will then develop a computerized treatment plan, decide on the radiation dose and conceptualize a 3-D model of the prostate to see exactly where the seeds need to be implanted. Once completed, the patient is scheduled for outpatient surgery.
The radioactive seeds are similar in size to a grain of rice and are inserted with needles. “If you take a mechanical pencil and extend the tip about a quarter of an inch, that will give you a good idea of what a radioactive seed looks like,” Dr. Bauer said.
The patient is under anesthesia for the procedure. Using ultrasound and fluoroscopy (real time X-ray guidance), the urologist inserts the needles to plant the seeds based on the recommendation of the radiation oncologist.
The radioactive seeds are able to deliver an extremely high dose of radiation directly into the prostate gland. “Typically we use 25 needles to implant about 100 seeds,” Dr. Bauer said. “The seeds stay forever but the radioactivity will decrease over time.”
Brachytherapy allows for a tightly defined radiation dose in very specific areas, Dr. Jones said. “There’s less likely to be any radiation damage to normal tissues,” he said. “But because the dose is very high, there is still risk of complications and side effects. Brachytherapy is a very, very good alternative for prostate cancer treatment.”
Symptoms from the irritation of the urinary tract can often present three to four weeks after surgery, but these generally disappear within several weeks. As with other forms of treatment for prostate cancer, a man may also experience sexual difficulties following brachytherapy.
Another treatment option is intensity modulated radiation therapy (IMRT) using a linear accelerator. “Some cases should not be considered for brachytherapy or surgery, but could utilize external beam radiation. All three are reasonable options,” Dr. Jones said. “There is no discernable difference in cure rates if cases are selected appropriately. Cure rates should be outstanding for early stage prostate cancer as long as the quality of care is good, and we can certainly assure our patients the quality of care here is excellent.”
NEW BALLOON TRICK CAN SAVE PROSTATE CANCER PATIENTS FROM IMPOTENCE
New Balloon Trick Can Save Prostate Cancer Patients From Impotence
Inflated idea: A balloon implanted in the body and then blown up could help lessen the side effects of treatment for prostate cancer
Treatment for prostate cancer can cause debilitating side-effects, including incontinence, a loss of libido and impotence. Now, doctors have developed a technique for reducing the risk of this happening - using a small balloon.
The prostate is a walnut-sized gland which lies underneath the bladder, surrounding the urethra (the tube that carries urine from the bladder).
Prostate cancer is the most common cancer in men, accounting for one in four tumours. The disease mainly affects those over 50, and the risk rises with age.
reatment often involves radiotherapy to kill cancerous cells. During the procedure, high-energy X-ray beams are directed at the prostate. Unfortunately, radiotherapy can also damage healthy cells surrounding the gland.
In some cases, this damage is short-term - side-effects, including tiredness and diarrhoea, last only a few weeks or months. But in others the damage is more severe, leading to urinary incontinence, a loss of libido and in 30-to-50 per cent of patients an inability to maintain an erection.
Scientists believe the new treatment, known as the SpaceGuard Balloon, will reduce this risk.
It is designed to create space around the prostate, pushing healthy tissue out of the radiotherapy's line of fire.
The balloon is placed next to the prostate. It is then filled with fluid until about the size of a peach. This acts as a shield for the healthy tissue.
The device, on trial at the Virginia Commonwealth University School of Medicine in the U.S., and other centres, is implanted under a local anaesthetic.
First, a tiny incision is made in the skin,and the folded and deflated balloon is inserted. A syringe is then used to inflate the balloon using saline solution.
The procedure takes around 30 minutes and can be done on an outpatient basis. The implant, developed by Israel-based BioProtect, is designed to dissolve after three to six months, the usual length of radiotherapy treatment for prostate cancer.
Researchers believe it will improve the safety and effectiveness of the therapy. It may also mean that the radiation dose can be increased, while damage to healthy tissue is reduced.
Dr Raj Persad, a urologist at the Bristol Royal Infirmary and Southmead Hospital, says: 'This new technology will enable clinicians to locate more precisely the exact tissue to target.
'Apart from reducing side-effects, it may also lead to a reduction in the amount of overall radiation the body receives. I look forward to seeing the results of the study.'
A urine test could be more accurate at detecting prostate cancer than taking blood samples. The test looks for high levels of PCA3, a 'marker' found in the urine when a prostate tumour is developing. U .S. researchers found the test was more accurate at distinguishing cancerous growths from benign ones than the existing prostate-specific antigen, or PSA, test.
The PSA test involves taking a blood sample to look for raised levels of the antigen, which is sometimes produced in greater quantities when prostate cancer has set in. But PSA levels can vary considerably.
They can also increase due to other non-cancerous conditions, such as an enlarged prostate, or benign prostatic hyperplasia. (A common problem with age, this is where the gland 'grows', pressing on the urethra causing symptoms such as incontinence and increased need to urinate.)
The results of trials of the new urine test showed men with prostate cancer had higher scores of PCA3 than those who had either benign growths or prostatic intraepithelial neoplasia - this is a tiny lesion in the prostate which may be a precursor to prostate cancer; it can disappear, remain unchanged, or progress to the cancerous stage.
Researcher Dr Christopher Amling says: 'If other studies confirm the link between PCA3 levels and tumour volume, this may help discriminate between more and less aggressive cancers.
Inflated idea: A balloon implanted in the body and then blown up could help lessen the side effects of treatment for prostate cancer
Treatment for prostate cancer can cause debilitating side-effects, including incontinence, a loss of libido and impotence. Now, doctors have developed a technique for reducing the risk of this happening - using a small balloon.
The prostate is a walnut-sized gland which lies underneath the bladder, surrounding the urethra (the tube that carries urine from the bladder).
Prostate cancer is the most common cancer in men, accounting for one in four tumours. The disease mainly affects those over 50, and the risk rises with age.
reatment often involves radiotherapy to kill cancerous cells. During the procedure, high-energy X-ray beams are directed at the prostate. Unfortunately, radiotherapy can also damage healthy cells surrounding the gland.
In some cases, this damage is short-term - side-effects, including tiredness and diarrhoea, last only a few weeks or months. But in others the damage is more severe, leading to urinary incontinence, a loss of libido and in 30-to-50 per cent of patients an inability to maintain an erection.
Scientists believe the new treatment, known as the SpaceGuard Balloon, will reduce this risk.
It is designed to create space around the prostate, pushing healthy tissue out of the radiotherapy's line of fire.
The balloon is placed next to the prostate. It is then filled with fluid until about the size of a peach. This acts as a shield for the healthy tissue.
The device, on trial at the Virginia Commonwealth University School of Medicine in the U.S., and other centres, is implanted under a local anaesthetic.
First, a tiny incision is made in the skin,and the folded and deflated balloon is inserted. A syringe is then used to inflate the balloon using saline solution.
The procedure takes around 30 minutes and can be done on an outpatient basis. The implant, developed by Israel-based BioProtect, is designed to dissolve after three to six months, the usual length of radiotherapy treatment for prostate cancer.
Researchers believe it will improve the safety and effectiveness of the therapy. It may also mean that the radiation dose can be increased, while damage to healthy tissue is reduced.
Dr Raj Persad, a urologist at the Bristol Royal Infirmary and Southmead Hospital, says: 'This new technology will enable clinicians to locate more precisely the exact tissue to target.
'Apart from reducing side-effects, it may also lead to a reduction in the amount of overall radiation the body receives. I look forward to seeing the results of the study.'
A urine test could be more accurate at detecting prostate cancer than taking blood samples. The test looks for high levels of PCA3, a 'marker' found in the urine when a prostate tumour is developing. U .S. researchers found the test was more accurate at distinguishing cancerous growths from benign ones than the existing prostate-specific antigen, or PSA, test.
The PSA test involves taking a blood sample to look for raised levels of the antigen, which is sometimes produced in greater quantities when prostate cancer has set in. But PSA levels can vary considerably.
They can also increase due to other non-cancerous conditions, such as an enlarged prostate, or benign prostatic hyperplasia. (A common problem with age, this is where the gland 'grows', pressing on the urethra causing symptoms such as incontinence and increased need to urinate.)
The results of trials of the new urine test showed men with prostate cancer had higher scores of PCA3 than those who had either benign growths or prostatic intraepithelial neoplasia - this is a tiny lesion in the prostate which may be a precursor to prostate cancer; it can disappear, remain unchanged, or progress to the cancerous stage.
Researcher Dr Christopher Amling says: 'If other studies confirm the link between PCA3 levels and tumour volume, this may help discriminate between more and less aggressive cancers.
Tuesday, August 17, 2010
http://digital.healthcaregroup.advanstar.com/nxtbooks/advanstar/ut_201008/index.php?starid=24
"Although this is another important article in the fast gaining popularity of HIFU as a treatment option for localized prostate cancer, and the efficacy in clinical outcomes. The fact is that as a slow growing cancer, it seems to respond to almost any type of treatment when it is diagnosed early and has favorable PSA and Gleason score. However, Radiation has additional toxic side effects that are not often discussed with the patients. Yet, it remains the most common form of treatment for prostate cancer. Mostly because of men's fear of undergoing surgery and the collateral damage associated with it. Even with radiation there is still high degree of side effects. These include erectile dysfunction and urinary incontinence and high degree of irritable or "bother symptoms" (bladder and bowel). What is seldom mentioned is the increased risk of developing a secondary malignancy. Particularly bladder and rectal cancer, reported as high as 70 % greater than men treated with alternatives other than radiation. (1) Furthermore, a recent study from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database has revealed that PSA recurrence after radiotherapy occurred in 63 % of men with 93 % being treated with Androgen deprivation therapy for salvage of PSA failure. (2) The alternative to Androgen deprivation is to treat radiation failures with Salvage HIFU and saving patients from being placed on hormone therapy. That in the end is palliative and never curative."
George M. Suarez, M.D.
Co- Founder,
Medical Director Emeritus, USHIFU
"Although this is another important article in the fast gaining popularity of HIFU as a treatment option for localized prostate cancer, and the efficacy in clinical outcomes. The fact is that as a slow growing cancer, it seems to respond to almost any type of treatment when it is diagnosed early and has favorable PSA and Gleason score. However, Radiation has additional toxic side effects that are not often discussed with the patients. Yet, it remains the most common form of treatment for prostate cancer. Mostly because of men's fear of undergoing surgery and the collateral damage associated with it. Even with radiation there is still high degree of side effects. These include erectile dysfunction and urinary incontinence and high degree of irritable or "bother symptoms" (bladder and bowel). What is seldom mentioned is the increased risk of developing a secondary malignancy. Particularly bladder and rectal cancer, reported as high as 70 % greater than men treated with alternatives other than radiation. (1) Furthermore, a recent study from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database has revealed that PSA recurrence after radiotherapy occurred in 63 % of men with 93 % being treated with Androgen deprivation therapy for salvage of PSA failure. (2) The alternative to Androgen deprivation is to treat radiation failures with Salvage HIFU and saving patients from being placed on hormone therapy. That in the end is palliative and never curative."
George M. Suarez, M.D.
Co- Founder,
Medical Director Emeritus, USHIFU
8-17-2010 POST BY DR. SUAREZ
As the founder of USHIFU and International HIFU, I have seen the continued growth of the technology and the growth into countries across the world. The opening in Bermuda is a great addition to facilitate patients in the proximity of the Northeast Coast.
George M. Suarez, M.D.
www.hifumedicalexpert.com.
George M. Suarez, M.D.
www.hifumedicalexpert.com.
MY COMMENTS ON THE FOLLOWING ARTICLE FROM UROLOGY TIMES
Please click on the following link and go to page 24 and 25 - The title is: " HIFU SUCCESS IMPROVES WITH TECHNOLOGICAL ADVANCES"
http://digital.healthcaregroup.advanstar.com/nxtbooks/advanstar/ut_201008/index.php?starid=24
MY COMMENTS:
This is another important article in the fast gaining popularity of HIFU as a treatment option for localized prostate cancer. The fact is that as a slow growing cancer, it seems to respond to almost any type of treatment when it is diagnosed early and has favorable PSA and Gleason score. However, Radiation has additional toxic side effects that are not often discussed with the patients. Yet, it remains the most common form of treatment for prostate cancer. These include erectile dysfunction and urinary incontinence and high degree of irritable or "bother symptoms. (bladder and bowel)" What is seldom mentioned is the increased risk of developing a secondary malignancy. Particularly bladder and rectal cancer, reported as high as 70 % greater than men treated with alternatives other than radiation. (1) Furthermore, a recent study from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database has revealed that PSA recurrence after radiotherapy occurred in 63 % of men with 93 % being treated with Androgen deprivation therapy for salvage of PSA failure. (2) These outcomes also add to the ability to treat radiation failures with Salvage HIFU and saving patients from being placed on hormone therapy.
References:
(1) Baxter NN, Tepper JE, Durham SB. et al, Increased risk of rectal cancer after radiation: a population-based study. Gastroenterology, 2005;128:819-824.
(2) Agarwal PK, Sadestsky N, Konety BR et al: and the CaPSURE group. Treatment failure after primary and salvage therapy for prostate cancer: Likelihood, patterns of care, and outcomes. Cancer 2008;112:307-14.
George M. Suarez, M.D.
Co- Founder,
Medical Director Emeritus, USHIFU
http://digital.healthcaregroup.advanstar.com/nxtbooks/advanstar/ut_201008/index.php?starid=24
MY COMMENTS:
This is another important article in the fast gaining popularity of HIFU as a treatment option for localized prostate cancer. The fact is that as a slow growing cancer, it seems to respond to almost any type of treatment when it is diagnosed early and has favorable PSA and Gleason score. However, Radiation has additional toxic side effects that are not often discussed with the patients. Yet, it remains the most common form of treatment for prostate cancer. These include erectile dysfunction and urinary incontinence and high degree of irritable or "bother symptoms. (bladder and bowel)" What is seldom mentioned is the increased risk of developing a secondary malignancy. Particularly bladder and rectal cancer, reported as high as 70 % greater than men treated with alternatives other than radiation. (1) Furthermore, a recent study from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database has revealed that PSA recurrence after radiotherapy occurred in 63 % of men with 93 % being treated with Androgen deprivation therapy for salvage of PSA failure. (2) These outcomes also add to the ability to treat radiation failures with Salvage HIFU and saving patients from being placed on hormone therapy.
References:
(1) Baxter NN, Tepper JE, Durham SB. et al, Increased risk of rectal cancer after radiation: a population-based study. Gastroenterology, 2005;128:819-824.
(2) Agarwal PK, Sadestsky N, Konety BR et al: and the CaPSURE group. Treatment failure after primary and salvage therapy for prostate cancer: Likelihood, patterns of care, and outcomes. Cancer 2008;112:307-14.
George M. Suarez, M.D.
Co- Founder,
Medical Director Emeritus, USHIFU
Monday, August 16, 2010
LATEST NEWS FROM INDIA
India HIFU adopts revenue sharing model with healthcare providers to penetrate in South Asian market
Monday, August 16, 2010 08:00 IST
Nandita Vijay, Bangalore
India HIFU, the Indian arm of US-HIFU specializing in treatment of prostrate cancer with its ultrasound technology 'Sonablate', is aggressively targeting the South Asian market. The company has adopted a unique financing concept which ensures that hospitals need not make upfront investment in the technology installation but partner India HIFU on a revenue sharing model.
According to Mukesh Rana, country manager, India HIFU, the company foresees huge potential in the Indian healthcare market going by the rising incidence of prostrate cancer which is an age-related and genetic condition aggravated by fatty diets and poor exhibition of the disease symptoms but are detected only with a blood test for prostrate specific antigen (PSA) levels.
Also the financing model envisaged by India HIFU would be a win-win situation for both the technology and the healthcare provider. Further the concept would ease the burden of equipment maintenance for hospitals and in the process help them to concentrate on treatment modalities, he said.
In the last 18 months, the company has set up five installations across India, which includes two hospitals in New Delhi: Rajiv Gandhi Cancer Centre and Primus; one each in Mumbai at Jaslok and Hyderabad Parimala Hospital. Currently, India HIFU charges Rs 3.25 lakh for the procedure to patients, he added.
'Sonablate' is a high intensity focused ultrasound equipment that targets the cancer cells. The robotic ablation technology according to the company is an alternative modality to combat prostate cancer with significant lower side effects as compared to other traditional treatment protocols like prostatectomy and radiotherapy.
In India so far, around 100 patients have undergone treatment with Sonablate and there has been a positive response, he said.
The product was developed by Prof Naren Sanghvi president of the Focus Surgery, Indianapolis. Sonablate studies on patients globally has proved it as a solution for organ confined prostrate cancer therapy. In fact, in Japan alone the company has a 10-year follow-up study with Sonablate therapy.
The treatment offers high economies-of scale and its success rate is reported to be around 93 percent. The big advantage of the technology is the minimally invasive feature which is viewed as far safer and as effective compared to prostatectomy or radiotherapy. The only challenge is to ensure that early stage detection is made, explained Rana.
The company is looking at the Indian sub-continent going by its 18,000 prostrate cancer patient population and a similar number in other south Asian countries. The challenge before India HIFU now is to look for right partners across the region to augment its installation base.
India HIFU is the exclusive distributor of the Sonablate system in the country. The company is in-charge of marketing and setting up Sonablate HIFU Centers too in the run.
On the alternate treatment options with HUFU, Rana stated that advanced research on use of Sonablate for kidney and pancreatic cancers were on. It will take a while to introduce the therapy to patients.
Globally the only other company which offers a similar technology is the France-based Edap. But, for US HIFU its longer presence in the market has allowed it to garner a higher installation base, said Rana.
Monday, August 16, 2010 08:00 IST
Nandita Vijay, Bangalore
India HIFU, the Indian arm of US-HIFU specializing in treatment of prostrate cancer with its ultrasound technology 'Sonablate', is aggressively targeting the South Asian market. The company has adopted a unique financing concept which ensures that hospitals need not make upfront investment in the technology installation but partner India HIFU on a revenue sharing model.
According to Mukesh Rana, country manager, India HIFU, the company foresees huge potential in the Indian healthcare market going by the rising incidence of prostrate cancer which is an age-related and genetic condition aggravated by fatty diets and poor exhibition of the disease symptoms but are detected only with a blood test for prostrate specific antigen (PSA) levels.
Also the financing model envisaged by India HIFU would be a win-win situation for both the technology and the healthcare provider. Further the concept would ease the burden of equipment maintenance for hospitals and in the process help them to concentrate on treatment modalities, he said.
In the last 18 months, the company has set up five installations across India, which includes two hospitals in New Delhi: Rajiv Gandhi Cancer Centre and Primus; one each in Mumbai at Jaslok and Hyderabad Parimala Hospital. Currently, India HIFU charges Rs 3.25 lakh for the procedure to patients, he added.
'Sonablate' is a high intensity focused ultrasound equipment that targets the cancer cells. The robotic ablation technology according to the company is an alternative modality to combat prostate cancer with significant lower side effects as compared to other traditional treatment protocols like prostatectomy and radiotherapy.
In India so far, around 100 patients have undergone treatment with Sonablate and there has been a positive response, he said.
The product was developed by Prof Naren Sanghvi president of the Focus Surgery, Indianapolis. Sonablate studies on patients globally has proved it as a solution for organ confined prostrate cancer therapy. In fact, in Japan alone the company has a 10-year follow-up study with Sonablate therapy.
The treatment offers high economies-of scale and its success rate is reported to be around 93 percent. The big advantage of the technology is the minimally invasive feature which is viewed as far safer and as effective compared to prostatectomy or radiotherapy. The only challenge is to ensure that early stage detection is made, explained Rana.
The company is looking at the Indian sub-continent going by its 18,000 prostrate cancer patient population and a similar number in other south Asian countries. The challenge before India HIFU now is to look for right partners across the region to augment its installation base.
India HIFU is the exclusive distributor of the Sonablate system in the country. The company is in-charge of marketing and setting up Sonablate HIFU Centers too in the run.
On the alternate treatment options with HUFU, Rana stated that advanced research on use of Sonablate for kidney and pancreatic cancers were on. It will take a while to introduce the therapy to patients.
Globally the only other company which offers a similar technology is the France-based Edap. But, for US HIFU its longer presence in the market has allowed it to garner a higher installation base, said Rana.
FLORIDA RESIDENTS CALL 305 595-0199
Welcome Florida Residents!
HIFU, which is short for High Intensity Focused Ultrasound, is a therapy that destroys prostate tissue with rapid heat elevation, which essentially "cooks" the tissue. Ultrasound energy, or sound waves, is focused at a specific location and at that "focal point," the temperature raises to almost 90 degrees Celsius in a matter of seconds. Any tissue at the "focal point" is destroyed; however, any tissue outside of the focal point remains unharmed.
In most cases, HIFU is a 1-4 hour, one-time procedure performed on an out-patient basis under spinal anesthesia.
HIFU is non invasive, non surgical and radiation free. It can be repeated if necessary and can also be used as a salvage technique if other prostate cancer treatments fail. To find out if HIFU treatment is right for you, simply fill out this form and we will contact you as soon as possible.
HIFU, which is short for High Intensity Focused Ultrasound, is a therapy that destroys prostate tissue with rapid heat elevation, which essentially "cooks" the tissue. Ultrasound energy, or sound waves, is focused at a specific location and at that "focal point," the temperature raises to almost 90 degrees Celsius in a matter of seconds. Any tissue at the "focal point" is destroyed; however, any tissue outside of the focal point remains unharmed.
In most cases, HIFU is a 1-4 hour, one-time procedure performed on an out-patient basis under spinal anesthesia.
HIFU is non invasive, non surgical and radiation free. It can be repeated if necessary and can also be used as a salvage technique if other prostate cancer treatments fail. To find out if HIFU treatment is right for you, simply fill out this form and we will contact you as soon as possible.
FLORIDA RESIDENTS CALL 305 595-0199
Welcome Florida Residents!
HIFU, which is short for High Intensity Focused Ultrasound, is a therapy that destroys prostate tissue with rapid heat elevation, which essentially "cooks" the tissue. Ultrasound energy, or sound waves, is focused at a specific location and at that "focal point," the temperature raises to almost 90 degrees Celsius in a matter of seconds. Any tissue at the "focal point" is destroyed; however, any tissue outside of the focal point remains unharmed.
In most cases, HIFU is a 1-4 hour, one-time procedure performed on an out-patient basis under spinal anesthesia.
HIFU is non invasive, non surgical and radiation free. It can be repeated if necessary and can also be used as a salvage technique if other prostate cancer treatments fail. To find out if HIFU treatment is right for you, simply fill out this form and we will contact you as soon as possible.
HIFU, which is short for High Intensity Focused Ultrasound, is a therapy that destroys prostate tissue with rapid heat elevation, which essentially "cooks" the tissue. Ultrasound energy, or sound waves, is focused at a specific location and at that "focal point," the temperature raises to almost 90 degrees Celsius in a matter of seconds. Any tissue at the "focal point" is destroyed; however, any tissue outside of the focal point remains unharmed.
In most cases, HIFU is a 1-4 hour, one-time procedure performed on an out-patient basis under spinal anesthesia.
HIFU is non invasive, non surgical and radiation free. It can be repeated if necessary and can also be used as a salvage technique if other prostate cancer treatments fail. To find out if HIFU treatment is right for you, simply fill out this form and we will contact you as soon as possible.
INDIA HIFU NEWS 8-16-2010
India HIFU adopts revenue sharing model with healthcare providers to penetrate in South Asian market
Monday, August 16, 2010 08:00 IST
Nandita Vijay, Bangalore
India HIFU, the Indian arm of US-HIFU specializing in treatment of prostrate cancer with its ultrasound technology 'Sonablate', is aggressively targeting the South Asian market. The company has adopted a unique financing concept which ensures that hospitals need not make upfront investment in the technology installation but partner India HIFU on a revenue sharing model.
According to Mukesh Rana, country manager, India HIFU, the company foresees huge potential in the Indian healthcare market going by the rising incidence of prostrate cancer which is an age-related and genetic condition aggravated by fatty diets and poor exhibition of the disease symptoms but are detected only with a blood test for prostrate specific antigen (PSA) levels.
Also the financing model envisaged by India HIFU would be a win-win situation for both the technology and the healthcare provider. Further the concept would ease the burden of equipment maintenance for hospitals and in the process help them to concentrate on treatment modalities, he said.
In the last 18 months, the company has set up five installations across India, which includes two hospitals in New Delhi: Rajiv Gandhi Cancer Centre and Primus; one each in Mumbai at Jaslok and Hyderabad Parimala Hospital. Currently, India HIFU charges Rs 3.25 lakh for the procedure to patients, he added.
'Sonablate' is a high intensity focused ultrasound equipment that targets the cancer cells. The robotic ablation technology according to the company is an alternative modality to combat prostate cancer with significant lower side effects as compared to other traditional treatment protocols like prostatectomy and radiotherapy.
In India so far, around 100 patients have undergone treatment with Sonablate and there has been a positive response, he said.
The product was developed by Prof Naren Sanghvi president of the Focus Surgery, Indianapolis. Sonablate studies on patients globally has proved it as a solution for organ confined prostrate cancer therapy. In fact, in Japan alone the company has a 10-year follow-up study with Sonablate therapy.
The treatment offers high economies-of scale and its success rate is reported to be around 93 percent. The big advantage of the technology is the minimally invasive feature which is viewed as far safer and as effective compared to prostatectomy or radiotherapy. The only challenge is to ensure that early stage detection is made, explained Rana.
The company is looking at the Indian sub-continent going by its 18,000 prostrate cancer patient population and a similar number in other south Asian countries. The challenge before India HIFU now is to look for right partners across the region to augment its installation base.
India HIFU is the exclusive distributor of the Sonablate system in the country. The company is in-charge of marketing and setting up Sonablate HIFU Centers too in the run.
On the alternate treatment options with HUFU, Rana stated that advanced research on use of Sonablate for kidney and pancreatic cancers were on. It will take a while to introduce the therapy to patients.
Globally the only other company which offers a similar technology is the France-based Edap. But, for US HIFU its longer presence in the market has allowed it to garner a higher installation base, said Rana.
Monday, August 16, 2010 08:00 IST
Nandita Vijay, Bangalore
India HIFU, the Indian arm of US-HIFU specializing in treatment of prostrate cancer with its ultrasound technology 'Sonablate', is aggressively targeting the South Asian market. The company has adopted a unique financing concept which ensures that hospitals need not make upfront investment in the technology installation but partner India HIFU on a revenue sharing model.
According to Mukesh Rana, country manager, India HIFU, the company foresees huge potential in the Indian healthcare market going by the rising incidence of prostrate cancer which is an age-related and genetic condition aggravated by fatty diets and poor exhibition of the disease symptoms but are detected only with a blood test for prostrate specific antigen (PSA) levels.
Also the financing model envisaged by India HIFU would be a win-win situation for both the technology and the healthcare provider. Further the concept would ease the burden of equipment maintenance for hospitals and in the process help them to concentrate on treatment modalities, he said.
In the last 18 months, the company has set up five installations across India, which includes two hospitals in New Delhi: Rajiv Gandhi Cancer Centre and Primus; one each in Mumbai at Jaslok and Hyderabad Parimala Hospital. Currently, India HIFU charges Rs 3.25 lakh for the procedure to patients, he added.
'Sonablate' is a high intensity focused ultrasound equipment that targets the cancer cells. The robotic ablation technology according to the company is an alternative modality to combat prostate cancer with significant lower side effects as compared to other traditional treatment protocols like prostatectomy and radiotherapy.
In India so far, around 100 patients have undergone treatment with Sonablate and there has been a positive response, he said.
The product was developed by Prof Naren Sanghvi president of the Focus Surgery, Indianapolis. Sonablate studies on patients globally has proved it as a solution for organ confined prostrate cancer therapy. In fact, in Japan alone the company has a 10-year follow-up study with Sonablate therapy.
The treatment offers high economies-of scale and its success rate is reported to be around 93 percent. The big advantage of the technology is the minimally invasive feature which is viewed as far safer and as effective compared to prostatectomy or radiotherapy. The only challenge is to ensure that early stage detection is made, explained Rana.
The company is looking at the Indian sub-continent going by its 18,000 prostrate cancer patient population and a similar number in other south Asian countries. The challenge before India HIFU now is to look for right partners across the region to augment its installation base.
India HIFU is the exclusive distributor of the Sonablate system in the country. The company is in-charge of marketing and setting up Sonablate HIFU Centers too in the run.
On the alternate treatment options with HUFU, Rana stated that advanced research on use of Sonablate for kidney and pancreatic cancers were on. It will take a while to introduce the therapy to patients.
Globally the only other company which offers a similar technology is the France-based Edap. But, for US HIFU its longer presence in the market has allowed it to garner a higher installation base, said Rana.
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