Al Ekish Shadi, Nayeemuddin Mohammed, Maddox Michael, Pareek Gyan
Section of Minimally Invasive Urology, Warren Alpert Medical School of Brown University, 2 Dudley St, Ste 174, Providence, RI 02905, USA.
JSLS. 2013 Jul-Sep;17(3):423-8. doi: 10.4293/108680813X13693422518551.
Technological advancements have reduced the morbidity associated with cryosurgery, leading to an increased interest in this modality for the treatment of organ-confined prostate cancer. In this study, we critically examine the current role of cryoablation of the prostate to better understand how to counsel patients regarding this treatment option.
A database was compiled over a 3-year period (2008-2011) of 30 patients who underwent cryoablation for organ-confined prostate cancer. Indications for cryosurgery included primary treatment, focal treatment (institutional review board-approved prospective study), and salvage cryotherapy for radiation failure. The primary outcomes were biochemical response via prostate-specific antigen (PSA) measurement and morbidity associated with cryoablation. Cryotherapy failure was defined as an increasing postcryotherapy PSA level ≥ 2 ng/mL above the post-treatment nadir, a positive prostate biopsy, or radiographic evidence of metastatic disease.
Of the 30 patients who underwent cryoablation from 2008 to 2011, 26 patients had complete follow-up data for analysis. Of these patients, 17 (65.38%) had total gland cryotherapy, 5 (19.23%) had salvage cryotherapy for radiation failure, and 4 (15.38%) had focal cryotherapy. The mean patient age was 68 years (54-89); median preoperative PSA was 5.5 ng/mL (1.7-15.9); median prostate volume was 35 mL (15-54); mean Gleason score was 7; and the median PSA at study conclusion was 0.7 (0.02-3.4) ng/mL. Of the 17 patients who had total prostate cryotherapy, 11 (64.7%) had significant factors precluding primary treatment by a surgical and/or radiation approach, including neurological disorders (2), morbid obesity (1), rectal cancer treated with radiation (1), kidney/pancreas transplant (2), ileoanal pouch secondary to inflammatory bowel disease (IBD) (1), renal failure (1), and age (3). There were no intra- or postoperative complications. After a median follow-up of 18 months (1-40), none of the patients with multiple comorbidities had biochemical failures. Two patients from the salvage group experienced treatment failure requiring androgen deprivation therapy.
This critical analysis of a single-surgeon experience at a large academic prostate cancer program revealed that the contemporary role of cryosurgery is, in select patients with comorbidities, preventing surgical and/or radiation therapy. Additionally, cryosurgery has a role in treating radiation failures. Further studies are necessary to investigate focal cryotherapy as an option for primary treatment, but our preliminary results are promising, without any biochemical failures in our focal therapy cohort.
技术进步降低了与冷冻手术相关的发病率，这使得人们对这种治疗局限性前列腺癌的方式的兴趣日益增加。在本研究中，我们审慎地审视了前列腺冷冻消融术目前的作用，以便更好地理解如何就这种治疗选择向患者提供咨询。
收集了一个为期3年（2008 - 2011年）的数据库，其中包含30例接受局限性前列腺癌冷冻消融术的患者。冷冻手术的适应证包括初始治疗、局部治疗（经机构审查委员会批准的前瞻性研究）以及针对放疗失败的挽救性冷冻治疗。主要结局是通过前列腺特异性抗原（PSA）测量评估的生化反应以及与冷冻消融相关的发病率。冷冻治疗失败的定义为冷冻治疗后PSA水平升高至高于治疗后最低点≥2 ng/mL、前列腺穿刺活检阳性或有转移性疾病的影像学证据。
在2008年至2011年接受冷冻消融术的30例患者中，26例患者有完整的随访数据可供分析。在这些患者中，17例（65.38%）接受了全腺冷冻治疗，5例（19.23%）接受了针对放疗失败的挽救性冷冻治疗，4例（15.38%）接受了局部冷冻治疗。患者的平均年龄为68岁（54 - 89岁）；术前PSA中位数为5.5 ng/mL（1.7 - 15.9）；前列腺体积中位数为35 mL（15 - 54）；Gleason评分平均为7分；研究结束时PSA中位数为0.7（0.02 - 3.4）ng/mL。在17例接受全前列腺冷冻治疗的患者中，11例（64.7%）有显著因素妨碍通过手术和/或放疗进行初始治疗，包括神经疾病（2例）、病态肥胖（1例）、接受过放疗的直肠癌（1例）、肾/胰腺移植（2例）、炎症性肠病（IBD）导致的回肠肛管袋（1例）、肾衰竭（1例）以及年龄因素（3例）。术中及术后均无并发症。中位随访18个月（1 - 40个月）后，所有有多种合并症的患者均无生化失败。挽救性治疗组中有2例患者出现治疗失败，需要接受雄激素剥夺治疗。
对一个大型学术性前列腺癌项目中一位外科医生的经验进行的这项批判性分析表明，在某些合并症患者中，冷冻手术目前的作用是避免手术和/或放疗。此外，冷冻手术在治疗放疗失败方面也有作用。有必要进一步研究将局部冷冻治疗作为初始治疗的一种选择，但我们的初步结果很有前景，在我们的局部治疗队列中没有出现任何生化失败的情况。
