theo m. de reijke md phd febu department of urology ... · prostate delineation few soft tissue...
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Role of surgery
Theo M. de Reijke MD PhD FEBU
Department of Urology
Academic Medical Center
Amsterdam
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
TRUSgrayscale ultrasounds
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Ultrasound imaging
Cancer ? Cancer F. Debruyne
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
TRUS: Pulse inversion
• Compared to Power Doppler
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Future?
CEUS Fixed bubble imaging
VEGF-R2 peptides
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Prostate DelineationProstate Delineation
Few soft tissue contrast at midprostate and apex
No tumor definition
Computed TomographyProstate
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Prostate Cancer StagingMRI
Capsular penetration = irregular capsular bulge
OR infiltration of periprostatic fat OR
neurovascular bundle asymmetry
T
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Prostate Cancer StagingBone Scintigraphy
High sensitivity for osteoblastic mets
Excellent high risk screening modality
Whole body scan +/- SPECT
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Prostate Cancer StagingMRI
Plain Film MRI
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Prostate Cancer - PET
• Prostate Cancer has low
metabolism so FDG-PET is not
very sensitive
• Primary activity obscured by
bladder
• Cannot distinguish BPH from
cancer in central gland
• May have some small role in
evaluation of metastatic disease
• Other isotopes under
investigation – 11C acetate
- 11C choline
Oyama et al J Nucl Med 43:181, 2002
Schmid et al Radiology 235:623, 2005
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
PET scan
• Low sensitivity in PC
– Glucose utilization is not enhanced
enough
• Interpretation is difficult
– Renal clearance: hampers interpretation of
loco-regional involvement
• Conclusion: limited role in staging
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Lymph Node staging
• Contemporary incidence of LN+:
25% 1-2%
• imaging studies are unreliable
– low resolution
– observer dependent
– false (+): x based on size (>1 cm)
– false (-): microcopic LN involvement
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Non-invasive lymph node staging
Harisinghani et al N Engl J Med 348:2491-2499, 2003
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
• Radical prostatectomy
– Open
– Laparoscopic
– Robot-assisted
• Temperature based treatments
• Focal treatment
Surgery and alternative treatments
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Surgical treatment of localized
prostate cancer
• Pre-operative staging
• Approaches
• Extent of surgery
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Surgical treatment of localized
prostate cancer
• Pre-operative imaging
• Approaches
• Extent of surgery
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Surgical treatment of localized
prostate cancer
• Optimal cancer control
• Minimal morbidity
• Best functional results
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Selection of treatment
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Approaches
• Open• Perineal (Young 1905)
• Retropubic (Millin 1945, Walsh 1983)
• Laparoscopic (Robotic) (Raboy 1997, Schuessler 1997)
• Transperitoneal
• Extraperitoneal
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Robotics in Laparoscopy
Surgeons Console
Immersive 3D Display
Close Up of surgical
field
No goggles / headset
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Robotics in Laparoscopy
Finger Ring Attachments
Allow Endoscopic surgery
to be performed using
same skills as Open
Surgery
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Robotics in Laparoscopy
EndoWrist Instruments
Allow complex
manipulative surgery
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Radical prostatectomy - Complications
Complications more frequent than
generally reported
N=101.606
RRP (n=93.986) RPP (n=7.718)
28.8% 25%
Lu-Yao et al Urology 54:301-307, 1999
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Laparoscopic prostatectomy
• Advantage• patient recovery
• better anastomosis/continence??
• Disadvantage• only in experienced hands, learning curve
• time consuming
• no tactile information on specimen
• similar cancer control??
• Beware of patient selection
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Lap vs open
Open
(219)
Lap early
(219)
Lap late
(219)
OR time 196 288 218
Blood loss 1,550 1,100 800
Compl rate 19,2% 13,7% 6,4%
Analgesia 50.8 mg 33.8 mg 30.1 mg
TUC time 12 7 7
Rassweiler et al J Urol 169:1689, 2003
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Oncological results
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Romero-Otero et el Urol Oncol 25:499-504, 2007
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Conclusions surgery
• In experienced hands all treatment
options comparable
• Long term follow up seems to result in
same oncological results
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Ficarra et al Eur Urol 55:1037-1063, 2009
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Tewari et al Eur Urol 62:1-15, 2012
Open: 167.184
Lap: 57,303
RALP: 62.389
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Radical prostatectomy
• Numbers are important
In men undergoing radical prostatectomy
the rates of postoperative and late urinary
complaints are significantly reduced if the
procedure is performed in a high volume
hospital and by a surgeon who performs a high
number of these procedures…
Begg et al N Engl J Med 346:1138-1144, 2002
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Ann Int Med 148:435-448
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Surgical treatment of localized
prostate cancer
• Pre-operative staging
• Approaches
• Extent of surgery
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Rationale for focal treatment for
prostate cancer
• Proven concept in other tumours (Breast,
Renal, Testis, Bladder etc.)
• Could possibly reduce morbidity
• Could improve Quality of Life
• Reduce costs??
• Same efficacy compared with traditional
treatment??
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Techniques for non-radiation focal
therapy are available
• Cryotherapy
• High Intensity Focused Ultrasound
• Radio Frequency Ablation
• Photodynamic therapy
• Electroporation
• Indigo laser
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Techniques for non-radiation focal
therapy are available
• Cryotherapy
• High Intensity Focused Ultrasound
• Radio Frequency Ablation
• Photodynamic therapy
• Electroporation
• Indigo laser
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Principles of Cryobiology
1. Intracellular ice
formation membrane
damage
2. Cell dehydration
3. Ischaemia
4. Immunology
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Focal cryotherapy
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Whole gland treatment vs focal therapy
COLD registry
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Results focal cryotherapyTechnique N-pts FUP
(mean)
bDFS no.
(%)
Bx proven
recurrence
Potent Continence
target 55 3.6 ys 52 (95)
ASTRO
4 (7%)
outfield
44 (85%) 54 (95%)
unilateral 31 70 mos 26/28 (93)
ASTRO
1/25(45)
outfield
13/27
(48%)
11/27
(40%)
with Tx
31 (100%)
unilateral 25 28 mos 21 (88) ≤50
PSA nadir
2 (8%)
outfleld
1 (4%) infield
17 (71%) 25 (100%)
unilateral 60 16.7 mos 42 (80%)
ASTRO
14 (23%) total 24/34
(71%)
53/55 (96%)
Unilateral 77 24 mos
(mean)
72.7%
Phoenix
3/10 infield
7/10 outfield
unilateral 73 3.7 yrs 70% PSA
reduction
12 outfield
1 infield
86% 100%
Onik et al Urology 70(suppl):16-21, 2007 Ellis et al Urology 70(suppl):9-15, 2007
Bahn et al J Endourol 20:688-692, 2006 Truesdale et al Cancer J 16:544-549, 2010
Lambert et al Urology 69:1117-1120, 2007 Bahn et al Eur Urol 2012 Epub ahead of publication
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Ward & Jones BJUint 2011
N=1160/5853 (19.8%)
Biochemical recurrence-free rate 75.7%
Incontinence: 1.6%
ED: 41.9%
Urinary retention: 1.1%
Fistula: 0.1%
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Techniques for non-radiation focal
therapy are available
• Cryotherapy
• High Intensity Focused Ultrasound
• Radio Frequency Ablation
• Photodynamic therapy
• Electroporation
• Indigo laser
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
High Intensity Focused Ultrasound
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
HIFU - Physical Principle
Each shot consists
of a burst of
ultrasound waves
with a duration of 5
seconds
The focal volume is
very small: 19-24
mm in length by 1.7
mm in diameter
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
bRFS
Adjuvant treatment-free survival
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
“The place of HIFU has still to be defined”
“It should be considered experimental and
should be performed in strictly controlled trials”
Role as salvage therapy??
HIFU in localized prostate cancer:
conclusions
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Ahmed et al Lancet Oncol 2012
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Ahmed et al Lancet Oncol 2012
N=42
45-80 years
Low to high risk (PSA ≤15, GS ≤4+3, ≤cT2)
HIFU to “all” lesions
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Ahmed et al Lancet Oncol 2012
Median IIEF-15 similar at baseline and 12 months
Median EPIC score similar at baseline and 12 months
IPSS no difference between baseline and 12 months
Positive Bx in 9/39 men at 6 months
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Techniques for non-radiation focal
therapy are available
• Cryotherapy
• High Intensity Focused Ultrasound
• Radio Frequency Ablation
• Photodynamic therapy
• Electroporation
• Indigo laser
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Onik et al Techn Cancer Res Treatm 6:295-300, 2007
Lepor Rev Urol 10:254-261, 2008
RFA
PDTElectroporation
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MR-temperature map Killing zone
c. J. Feller, Palm Springs USA
Focal therapy
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Lindner et al J Urol 182:1371-1377, 2009
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Challenges – FUP of focal treatment
• Prostate in situ
• Untreated side
• PSA kinetics? ASTRO/Phoenix?
• Imaging
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Definitions need to be uniform
• Focal
• Targeted
• Conformal
• Zonal
• Hemi-treatment
• Lumpectomy
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m
Focal therapy
Does an index tumour exist
and if yes,
can we identify it?
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D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m