Abstract
Introduction: Routine PSA screening for prostate cancer (PCa) has increased the detection of intermediate-risk, localized disease. Conventional treatments for localized PCa include surgery, brachytherapy, cryotherapy or external beam radiotherapy (EBRT). However, for intermediate risk patients, rates of recurrence are moderately high and a multi-modal treatment approach for these patients may be necessary. We treated patients with a combination of cryotherapy and low dose EBRT to assess the safety and feasibility of this combinatory approach as well as to evaluate early oncological outcomes. Case Presentation: Men with intermediate risk (PSA = 10-20 ng/ml and/or Gleason = 7 and/or clinical T2b) localized PCa were prospectively enrolled in this study. Patients underwent cryotherapy and then 39 Gy EBRT 4-6 weeks after surgery. After completing EBRT, the men were followed every 3 months for 2 years. Adverse events, PSA, urinary and erectile function were assessed during each follow-up. Three patients completed the study. Preoperative PSA ranged from 3.5 to 7.9 ng/ml. There were no intraoperative complications and the treatment was well tolerated. Following cryotherapy and EBRT, all patients were pad-free within 6 months and remained continent for the duration of the study. Bother index remained stable throughout the study for all patients. No urethral strictures or rectal toxicities were observed. PSA remained undetectable for all patients. Conclusions: In this prospective study, cryotherapy combined with low dose EBRT was a safe approach for the treatment of intermediate-risk, localized PCa. Early oncological outcomes appeared to be favorable with all patients having undetectable PSA during the 2-year follow-up period. Further studies are warranted to confirm these preliminary results.
Highlights
Routine PSA screening for prostate cancer (PCa) has increased the detection of intermediate-risk, localized disease
Patients presenting these tumors may be treated with a variety of interventions including radical prostatectomy, cryotherapy, external beam radiotherapy (EBRT), and brachytherapy [3,4,5]; biochemical failure for patients with intermediate-risk disease is documented in approximately 20% - 40% of cases [6,7,8]
The American Urological Association (AUA) clinical guidelines have suggested a multi-faceted treatment approach for localized PCa and encourage patients with localized disease to enroll in clinical trials investigating combinatorial treatment strategies [9]
Summary
Recurrence following cryotherapy is likely due to failure in the periprostatic (extracapsular) tissue failure may occur either in the central zone surrounding the urethra due to the protective effect of the warming catheter or the prostatic apex [18]. The treatment failure following EBRT is likely to arise from the prostate as a result of restricting the necessary amount of radiation required to eliminate the tumor while minimizing damage to surrounding tissues. Given that cryotherapy and radiation may be complementary in that each may account for the potential deficiencies of one another, it is of great interest to assess the efficacy of a combination cryotherapy-EBRT treatment for localized PCa. We conducted the first step of a phase I dose-escalation study combining cryotherapy with EBRT.
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