Brachytherapy Vs. Cryoablation In The Treatment Of Prostate Cancer

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Cancer / Oncology
Article Date: 07 Aug 2008 - 3:00 PDT

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UroToday.com - Both cryoablation and brachytherapy are well studied alternatives to radical prostatectomy. The techniques are similar in the application of the needles to deliver the treatment, planning software and algorithms to achieve the best coverage, are delivered as outpatient treatment, and efficacy. The techniques differ in that cryoablation can be utilized for radiation failures and can be repeated.

There is a significant body of literature on brachytherapy and the controversies are centered around the isotope used and the dosimetry. While there may be some theoretical advantages to Pd103 in high risk tumors, there is no significant clinical data showing an advantage over I125. Generally Pd103 is used in combination with external beam and I125 in monotherapy. Treatment planning can be performed prior to implant (Preplan) or during the implant (intraoperative planning). The advantage of the preplan is that the number of seeds ordered is exact, but it requires a separate visit for the planimetry and is less flexible if changes need to be made during the implant. Intraoperative planning may result in ordering more seeds than required, but results show a significant improvement in both D90 and V100 compared to preplanning.

Cryoablation has had a controversial history which has improved with the third generation delivery devices. The needles are smaller and are able to deliver a more precise ice ball than the prior technologies. The addition of thermocouples for monitoring temperature and the urethral cooling device have dramatically reduced some of the worst complications previously reported with cryoablation including incontinence, tissue sloughing, and fistulae. The outcome database for cryoablation is relatively small compared to brachytherapy, but appears equal in terms of cancer control at 5 years in some studies and inferior in others.1-3 Complications such as loss of sexual function and incontinence appear to be higher in patients undergoing cryoablation though the new trend towards focal therapy may reduce these complications.4-7

There are few studies directly comparing the 2 technologies, but QOL analysis by Hubosky et al showed that QOL following either therapy showed equivalent scores on both bowel and bladder function initially, but favored cryoablation at 18 months.3 Sexual dysfunction was significantly more common with cryoablation both immediately after treatment and in longer term follow up.

References: 1. Cohen JK, Miller RJ, Ahmed S, Lotz MJ, Baust J Ten-year biochemical disease control for patients with prostate cancer treated with cryosurgery as primary therapy. Urology 71:515-8, 2008
2. Long JP, Bahn D, Lee F, et al. Five-year retrospective, multi-institutional pooled analysis of cancer-related outcomes after cryosurgical ablation of the prostate. Urology. Mar 2001;57(3):518-23
3. Hubosky LB, Fabrizio MD, Schelhammer PF, Barone BB, Tepera CM, Given RW, Single center experience with third-generation cryosurgery for management of organ-confined prostate cancer: critical evaluation of short-term outcomes, complications, and patient quality of life J Endourology 21:1521-1531, 2007.
4. Robinson JW, Donnelly BJ, Saliken JC, et al. Quality of life and sexuality of men with prostate cancer 3 years after cryosurgery. Urology. Aug 2002;60(2 Suppl 1):12-8.
5. Cohen JK, Miller RJ, Rooker GM, Shuman BA. Cryosurgical ablation of the prostate: two-year prostate-specific antigen and biopsy results. Urology. Mar 1996;47(3):395-401
Ghafar MA, Johnson CW, De La Taille A, et al. Salvage cryotherapy using an argon based system for locally recurrent prostate cancer after radiation therapy: the Columbia experience. J Urol. Oct 2001;166(4):1333-7; discussion 1337-8.
6. Chin JL, Pautler SE, Mouraviev V, et al. Results of salvage cryoablation of the prostate after radiation: identifying predictors of treatment failure and complications. J Urol. Jun 2001;165(6 Pt 1):1937-41; discussion 1941-2
7. Pisters LL, von Eschenbach AC, Scott SM, et al. The efficacy and complications of salvage cryotherapy of the prostate. J Urol. Mar 1997;157

Presented by: Sam D. Graham, Jr., MD, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

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