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Salvage Cryosurgery in Prostate Cancer
Patient Selection a bone scan should be performed. Open or laparoscopic biopsy of the
Prostate-specific Antigen Levels pelvic lymph nodes may also be considered for high-risk patients.
The optimal time for intervention in a patient whose post-radiation
treatment increases PSA is unclear. A temporary rise in PSA levels after The lymph-node-positivity rate in patients from the salvage radical
brachytherapy commonly occurs around 20 months after treatment.
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prostatectomy series ranges from 11 to 40%. The role of the capromab
This ‘bounce phenomenon’ has also been described following pendetide scan in patients undergoing salvage cryosurgery has not
external-beam radiotherapy.
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No consensus exists among urologists been extensively studied, but may play a role in the patient with high-
or radiation oncologists as to when to ;, if it is determined that salvage volume disease or where the PSA doubling time is less than six months.
therapy is indicated, the clinician should consider variables such as Prostate size is less of a problem when considering salvage cryosurgery
pre-existing medical conditions and patient age and patient as the prostate of radiated patients loses volume after radiation therapy.
preference. If the PSA level rises above the nadir or the patient is A prior history of transurethral resection of the prostate (TURP) is a
deemed to have failed clinically based on any currently employed relative contraindication for salvage cryosurgery, especially if there is
evaluation tool (ASTRO, Phoenix, PSA doubling time/velocity), a a large TURP defect present, as these patients are at increased risk of
prostate biopsy should be performed if there are no contraindications urethral necrosis, leading to sloughing and urinary retention. The same
to further therapeutic intervention. The Partin table for predicting is true for the patient who has a history of a prior open prostatectomy
pathological stage does not apply to post-radiation therapy patients. for benign disease.
The patient with a PSA of 10ng/ml following radiation should not be
considered to have the same pathology as a non-radiated patient with Patient Selection Summary
a PSA of 10ng/ml. According to Spiess et al., a PSA level >10ng/ml at Currently, there are no clearly defined guidelines to aid in the proper
the time of diagnosis of local recurrence and a PSA doubling time ≤16 selection of patients for salvage cryosurgery. The optimal candidates for
months will predict a poor prognosis for salvage cryosurgery.
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If PSA the procedure are men who have pathological evidence of locally
doubling time is ≤6 months, there is a significantly higher risk of recurrent disease without clinical evidence of metastatic disease, a PSA
metastasis even if local disease is confirmed by biopsy.
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≤4ng/ml,
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a PSA doubling time somewhere greater than 12–16 months,
no evidence of SV invasion and a life expectancy >10 years.
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Prostate Biopsy
When a biopsy is performed, multiple cores should be obtained and the Technical Considerations and Modifications
pathologists should be informed that the patient has had previous Salvage cryosurgery can be performed in the patient with recurrent
radiation therapy, since there are definite pathological changes that can disease following external-beam radiotherapy as well as interstitial
occur post-radiation. Benign glands affected by radiation can mimic prostate brachytherapy, although the latter are clearly more difficult due
cancerous glands, and special staining with high-molecular-weight to the interference with the previously placed seeds. Previously placed
keratin may be necessary to make a correct diagnosis.
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Radiation radioactive seeds can be visualised quite well under TRUS and may
therapy may not eradicate cancer immediately, i.e. malignant glands cause some confusion as their sonographic appearance is similar to the
may remain as they slowly undergo apoptosis. Such severely affected that of the `tip of the cryoneedles, especially in the transverse view.
cancer cells may remain in the prostate for as long as 36 months after Placing the needles in the sagittal plane can overcome this difficulty,
radiation therapy. Therefore, a positive biopsy prior to 36 months as the length of the cryoneedles can be easily followed in this view. Due
after radiation treatment can be extremely difficult to interpret. to the previous radiation, the gland may be adherent to the anterior
Consequently, an experienced reading of the post-radiation biopsy rectal wall, diminishing the thickness of Denonvilliers’ fascia. This needs
specimen is essential. As with biopsies in the non-radiated patient, there to be assessed by TRUS prior to freezing so the surgeon can determine
are no definite guidelines specifying the number of cores that should be how to appropriately place the posterior cryoprobes and the
obtained. Recent literature has indicated that extended biopsy Denonvilliers’ thermocouple. If the space between the anterior rectal
strategies enhance the detection of cancer and that sextant biopsies are wall and posterior prostatic capsule is <5mm, it may not be possible to
no longer considered adequate.
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safely drive the temperatures down to -40°C, and freezing should be
terminated when the leading edge of the ice ball has extended just
In addition to the prostate biopsy, a biopsy of both seminal vesicles (SVs) beyond the capsule, even if the target temperature of -40°C is not
is recommended in this setting of potential radiation failure. Cancer- reached. Double freeze–thaw cycles have significantly better outcomes
invaded seminal vesicles may appear normal on imaging after radiation in terms of biochemical failure-free and local recurrence-free survival
therapy. The incidence of SV involvement in the patient with a rising PSA rates compared with one freeze–thaw cycle.
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When counselling patients
level after radiation with locally recurrent disease is much higher than in for any salvage procedure, the risks of urinary incontinence should be
the non-radiated patient. Pathological results from salvage radical discussed. The placement of a thermosensor to monitor the external
prostatectomy series reveal that the rate of SV involvement can be as sphincter’s temperature can reduce the potential of thermal injury to
high as 42%.
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Those patients with SV invasion will have a poorer this muscle. The thermosensor is introduced through the perineal skin
prognosis in general despite successful local treatment of the prostate and advanced until the impression of the tip of the thermocouple can be
gland. In the presence of SV involvement, prostate salvage cryosurgery seen in the sphincter. The placement can be documented by TRUS or
as monotherapy is not likely to be successful, and the use of cystoscopy. There is no evidence of benefit from hormone therapy prior
hormonal/chemotherapy approaches in these patients is likely to to salvage cryosurgery except for down-sizing purposes.
improve outcomes.
Treatment Outcomes
Metastatic Work-up Biochemical Outcomes
If a prostate biopsy reveals recurrent cancer in the gland, a metastatic Over the past few decades, several institutions have published their
evaluation including nodal imaging of the abdomen and pelvis as well as salvage cryosurgery results. Many of the published series from the
EUROPEAN UROLOGICAL REVIEW 21
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