Jeffrey K. Cohen

Clinical experience with open renal cryoablation

OBJECTIVES To evaluate the safety and efficacy of open renal cryoablation of small solid renal masses, since the delivery of freezing temperatures has been shown to effectively ablate solid neoplasms of the liver, uterus, and prostate. METHODS A total of 29 patients were treated with open renal cryoablation since December 1996 and followed up to evaluate the treatment safety and initial radiographic response. RESULTS The median preoperative lesion size was 2.2 cm, with 22 solid renal masses and 7 complex renal lesions. Five serious adverse events occurred in 5 patients, with only one event directly related to the procedure. One patient experienced a biopsy-proven local recurrence, and 91.3% of patients (median follow-up 16 months) demonstrated a complete radiographic response with only a residual scar or small, nonenhancing cyst. CONCLUSIONS Open renal cryoablation appears to be a safe technique for the in situ destruction of solid or complex renal masses. However, inadequate freezing of renal cell carcinoma may result in local disease persistence. The expected slow growth rate of small renal cancers necessitates prolonged radiologic follow-up. Continued clinical research is required before renal cryoablation can be considered an acceptable curative treatment for renal cancer.

Endoglin (CD105) and Vascular Endothelial Growth Factor as Prognostic Markers in Prostatic Adenocarcinoma

We studied endoglin and vascular endothelial growth factor (VEGF) expression as prognostic markers in prostatic adenocarcinoma in 50 radical prostatectomy specimens. Cases were further categorized by Gleason score as follows: 8 to 10, 9 cases; 7(4 + 3), 9 cases; 7 (3 + 4), 14 cases; 6, 13 cases; and 4 or 5, 5 cases. All cases were immunostained for endoglin, CD31, and VEGF. Positively stained microvessels were counted in densely vascular foci in a x 400 field. VEGF staining intensity was scored on a 2-tiered scale. Results were correlated with survival and other parameters. Endoglin demonstrated significantly more microvessels than did CD31 (mean +/- SD, 37 +/- 15 vs 22 +/- 17; P < .001). VEGF expression was low in 21 cases (42%) and high in 29 (58%). Endoglin correlated positively with Gleason score, lymph node metastases, tumor stage, and preoperative prostate-specific antigen level (P < .05) but not with CD31. VEGF correlated significantly with angiolymphatic invasion and Gleason score (P < .05). A high endoglin microvessel count and VEGF expression correlated with shorter survival. Endoglin is a more specific and sensitive marker for tumor angiogenesis than CD31 and may serve as a prognostic marker for prostatic adenocarcinoma.

Complications after radical retropubic prostatectomy in the medicare population

OBJECTIVES Radical prostatectomy is the standard of care for the treatment of clinically localized prostate cancer in the appropriate patient. However, the morbidity associated with this procedure remains controversial, since complications from centers of excellence are low but nationwide surveys have reported a much higher risk of complications. This study reports the complication rates after radical retropubic prostatectomy (RRP) for men in the Medicare population. METHODS All men in the Medicare population who underwent RRP in 1991 were identified. All inpatient, outpatient, and physician (Part B) Medicare claims for these men for 1991 to 1993 were then analyzed to determine outcomes. Procedures performed for complications resulting from RRP were recorded, as were the diagnosis codes that may have heralded a complication after RRP. RESULTS In 1991, 25,651 men in the Medicare population underwent RRP. The mean age of these men was 70.5 years. Procedures for the relief of bladder outlet obstruction or urethral strictures after RRP occurred in 19.5% of these men. A penile prosthesis was implanted in 718 men (2.8%) after prostatectomy, and 593 men (2.3%) had an artificial urinary sphincter placed after prostatectomy. A diagnosis of urinary incontinence was reported in 5573 men (21.7%) after radical prostatectomy, but only 2025 of these men (7.9%) continued to carry this diagnosis more than 1 year after prostatectomy. A diagnosis of erectile dysfunction was reported in 5510 men (21.5%) after radical prostatectomy, but only 3276 of these men (12.8%) continued to carry this diagnosis more than 1 year after surgery. CONCLUSIONS A review of a large, nationwide, heterogenous cohort of men revealed a morbidity rate that is slightly higher than that reported by major centers that perform large numbers of radical retropubic prostatectomies but is lower than complication rates obtained by patient surveys. The limitations of claim information in determining patient outcomes, however, must be considered when evaluating these data.

Ultrasound characteristics of renal cryosurgery.

The ability to visualize renal cryosurgery using ultrasound was tested in an animal model. Five dogs underwent open laparotomy and ultrasound-monitored cryosurgery of both kidneys. On each kidney two cryolesions were made. The borders of the frozen region were identified on ultrasound as a hyperechoic rim created by the interface between frozen and unfrozen tissue. The thawed cryolesion appeared hyperechoic compared with the unfrozen kidney. Excellent correlation between the ultrasound and autopsy measurements of the cryolesions was obtained. Knowing this, renal cryosurgery under ultrasound monitoring may be possible.

Percutaneous transperineal cryosurgical ablation of the prostate for the primary treatment of clinical stage C adenocarcinoma of the prostate

OBJECTIVES To assess short-term response rate and local tissue destructive capabilities of cryosurgical ablation of the prostate (CSAP) in patients with clinical Stage C adenocarcinoma of the prostate. METHODS A retrospective chart review of 62 patients (mean age, 66 years; range, 49 to 79 years) treated on an institutional review board approved protocol at Allegheny General Hospital between June 1990 and December 1993 was performed. Standard follow-up examination included serial prostate-specific antigens (PSAs), digital rectal examination, and extensive biopsies at 3 months after CSAP. RESULTS Average hospital stay was 2 days and morbidity was minimal. Biopsy findings showed no residual detectable prostatic tumor in 79% of patients 3 months after 1 CSAP treatment and in 94.8% 3 months after 1 or 2 treatments. Mean/median 3-month postoperative PSAs for patients with negative biopsy findings were 0.59 +/- 1.66 and 0.10 ng/mL, respectively, compared with 14.0 +/- 12.1 and 8.90 ng/mL preoperatively. CONCLUSIONS CSAP appears to produce controllable, reproducible local tissue destructive effects. Long-term (more than 5 years) crude and disease-free survival rates are not known for CSAP.

Urinary morbidity with a modified peripheral loading technique of transperineal 125i prostate implantation

PURPOSE Analysis of urinary morbidity within the first 12 months following a modified peripheral loading technique for permanent transperineal transrectal ultrasound (TRUS) guided (125)I prostate implantation and comparison of urinary morbidity with various clinical and implant parameters. MATERIALS AND METHODS Between October 1, 1996, and March 11, 1998, 87 patients with favorable, early stage prostate cancer were treated with permanent transperineal TRUS guided (125)I prostate implantation. A peripheral loading technique was utilized for source placement with 75-80% source distribution in the periphery and 20-25% source distribution centrally. A mean total activity of 38 mCi of (125)I was implanted (range, 19-66 mCi). The mean source activity was 0.43 mCi/source (range, 0.26-0.61 mCi/source) and the mean number of sources implanted was 88 (range, 56-134). The minimum prescribed dose to the prostate was 145 Gy. The median D(90), V(100), and V(150) were 152 Gy (range, 104-211 Gy), 92% (range, 71-99%), and 61% (range, 11-89%), respectively. The median follow-up time was 19 months (range, 12-29 months). Urinary morbidity was scored at 3 weeks and then at 3-month intervals for the first 2 years using a modified Radiation Therapy Oncology Group (RTOG) grading system (scale 0-5). RESULTS Most patients developed at least minor urinary symptoms with frequency or nocturia being the most common. Overall, 79% (69/87) of patients experienced urinary morbidity with 21% (18/87) reporting no symptoms. The incidence of overall Grade 1 urinary morbidity was 37% (32/87); Grade 2 morbidity was 37% (32/87); and Grade 3 morbidity was 6% (5/87). There was no Grade 4 or 5 morbidity. The incidence of Grade 0 frequency/nocturia was 36% (31/87); Grade 1 was 33% (29/87); Grade 2 was 30% (26/87); and Grade 3 was 1% (1/87). Grade 0 dysuria was seen in 56% (49/87) of patients; 32% (28/87) had Grade 1; 10% (9/87) Grade 2; and 1% (1/87) Grade 3 dysuria. Most urinary symptoms started a few weeks after implantation and began to subside by 6 months. At 12 months, 22% (19/87) of patients had persistent urinary symptoms (78% Grade 0, 15% Grade 1, 3% Grade 2, and 3% Grade 3). The mean urethral point dose was 174 Gy (range, 99-315 Gy). The mean number of sources implanted correlated significantly with the likelihood of developing acute urinary morbidity (p = 0.03). The total activity implanted also correlated with the morbidity outcome dysuria (p = 0.01) with a threshold seen at 37 mCi. Urethral point dose, source activity, intraoperative TRUS prostate volume, D(90), V(100), V(150), patient age, pretreatment PSA, Gleason score, and T stage did not correlate with morbidity. CONCLUSIONS Permanent transperineal TRUS guided (125)I prostate implantation using a modified peripheral loading technique is associated with mild urinary morbidity that resolves in 78% of patients by 12 months. Grade 3 urinary morbidity was encountered in only 6% (5/87) of patients. Urinary morbidity may be related to the total number of sources implanted and/or the total activity implanted. Overall urinary morbidity was not correlated with urethral point dose, source activity, intraoperative TRUS prostate volume, D(90), V(100), V(150), patient age, pretreatment PSA, Gleason score, and T stage. The low incidence of urinary morbidity may be a consequence of our modified peripheral loading technique and/or the selection of patients with good-to-excellent preimplant urological parameters. Longer follow-up is necessary to assess biochemical control rates and long-term morbidity.

Comparison of the hospital costs for radical prostatectomy and cryosurgical ablation of the prostate

OBJECTIVES To compare the hospital costs of radical prostatectomy (RP) and cryosurgical ablation of the prostate (CSAP). METHODS All patients who underwent either RP or CSAP at Allegheny General Hospital during an 18-month period beginning in January 1995 were included in this study. Hospital costs were generated for each case, and a chart review was undertaken for each patient. Costs were obtained from the hospital accounting office and divided into 11 categories, including total costs. Pretreatment grade, clinical stage, and prostate-specific antigen level were obtained from the patients chart. Noncost information such as length of stay, number of operating room units charged, and patient age were also obtained from the hospital record. RESULTS Sixty-seven men underwent RP and 114 men underwent CSAP during the study period. Average hospital costs were

A comparison of complications between ultrasound-guided prostate brachytherapy and open prostate brachytherapy

4150 for men undergoing CSAP and

Cryosurgical ablation of the prostate

5660 for men undergoing RP, a difference of 27.2% (P < 0.001). The difference in hospital costs was almost completely explained by the difference in room costs (

Molecular Chemical Imaging of Kidney Cancer Tumor Margins

682 for CSAP and