CRYOABLATION OF THE PROSTATE FOR ADENOCARCINOMA: a personal overview.September 1997
The limits of staging prostate cancer before surgery could be a reason to use cryoablation therapy at least in those cases with high risk of local spread. The theoretical bases for such statement are examined: the physiopathology of cryosurgical damage, the modern cryosurgical and control apparata available, the necessity of a team work of radiologists, pathologists and urologists. Initial data support this approach, but longer-term follow-up is needed.-----------------------------------
Over the last few years urologists, in the U.S. in particular, have discussed, at times harshly, on the introduction of cryosurgery in addition or even as an alternative to radiotherapy and open surgery in the treatment of prostate cancer in open contrast with many urologists who have fought, at all costs, the idea of any such possibility.
As it often happens among men, conflicts of ethical, economic, cultural and generational nature have risen on both sides hiding behind apparently unquestionable scientific reasoning which, in fact, often have a partly emotional and personal derivation. All this is well known to those who have taken part in the controversy.
Now that, after some years of isolation, my friend Dr. Graham Watson and I are being joined by illustrious and enthusiastic cryosurgeons in Europe, and that cryosurgery is finally spreading over the Old Continent, I would like to make some personal considerations on the problems related to it, hoping it may become food for thought to both friends and foes of past, present and future.
I therefore thank Prof. Ivo Kraljic, and through him the entire Croatian urological community, for hosting me on the first issue of the new Acta Urologica Croatica, to express my thought on the subject.
The first remark that should be made is that, as we approach the third millennium, the scientific community unanimously agrees on which is the best cure for PCA in one case only, and that is when the neoplasm is organ-confined.
All urologists agree that those patients with locally restricted carcinoma who have a greater life-expectancy than what may be assumed from medical therapy, should undergo surgery in the form of radical prostatectomy. On the other hand, those patients who show such locally progressed pathology that can rarely recover through surgery should undergo total androgen ablation.
Unfortunately, however, we do not really know exactly what the life expectancy of a patient with confined desease is especially when treated with the new non surgical therapies. What is more, we have only one certain and unequivocal "staging method" available in order to choose the best candidates for surgery or medical therapy: the distinction betweeno these two categories is given by a 5-year follow-up of those patients who have already undergone surgery; which is, of course, a paradox. But it is sadly true that too often only after surgery we know who should have really undergone it.
This is further confirmed by the fact that, as is well known, a large number of cases who are believed to be locally confined after a pre-operative staging, turn out to be not confined upon a final histological examination. There are even cases in which the pathology had a progression even though both lymphonodes and specimen margins were negative at surgery; and their percentage is such that it cannot be disregarded.
We should therefore conclude that we do not have sufficient staging methods. But, do we make proper use of what we have at our disposal?
Like a pilot about to take-off, let us make our check- off list:
Now we are ready to take-off (surgery) and all we have to do is to explain to the passenger-patient where we want to take him and why.
In any case, we must always bear in mind the route through which we will lead our passengers (hopefully) safely to destination and, in spite of the great limits our knowledge still has, if the check-off list has been carried out properly, we can at least try to fly.
This kind of process will support theurapeutical advices. If a surgical solution is advised and accepted, an objective (and partly presumed-inferred) tridimensional map of the taken or risk-laden area will allow a more specific surgical strategy for each patient.
One may, at this point, object that, in the real world, there is no time for this kind of approach. However, cancer is a very "real" thing to the patient, and we should therefore make all possible efforts to find the best approach to each individual situation.
This methodology is particularly necessary in the case of cryosurgery. Cryosurgical techniques, in fact, may and therefore must be modelled to the individual anatomopathological behaviour more than in traditional surgery.
I believe that cryosurgery may be applied to the prostate in many of those cases in which traditional surgery cannot give absolute guarantees of total cancer removal.