Kim Mammen Abhinav Jaiswal Chris3an Medical College & Hospital Ludhiana India

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1 Kim Mammen Abhinav Jaiswal Chris3an Medical College & Hospital Ludhiana India

2 } In the case of prostate cancer, a new, more conserva3ve form of monitoring called Ac3ve Surveillance is emerging which might be an important method to help avoid early invasive treatment with some men with PSA levels under 10ng/ml. } ERSPC findings also confirm that approximately 30% of detected cancers actually have non- aggressive features and are indolent or slow growing.

3 } Screening has resulted in a marked increase in the number of newly diagnosed prostate cancers, while it is unclear whether the early detec3on of these tumours reduces the prostate cancer mortality. } Up to 80% of men with PSA screen- detected prostate cancer are over diagnosed, that is, their cancer would never have caused any symptoms. Over diagnosis would mauer less if treatment had no adverse effects. } It would be more acceptable to treat all cases, including those des3ned never to cause symptoms, if treatment was problem- free. However, while radical treatment for prostate cancer may or may not improve a man s longevity, it can certainly have a big impact on his lifestyle. Ideally, such interven3on should be restricted to those who need it.

4 } Ac3ve surveillance aims to individualize the management of early prostate cancer by selec3ng only those men with significant cancers for cura3ve treatment. } Pa3ents on ac3ve surveillance are closely monitored using serum PSA levels and repeat prostate biopsies. The choice between cura3ve treatment and con3nued observa3on is based on evidence of disease progression during this monitoring.

5 } Ac3ve surveillance must be dis3nguished from watchful wai3ng, which for decades has described a policy of observa3on with the use of pallia3ve treatment for symptoma3c progression. } Put another way in order to emphasize the differences between these two contras3ng approaches, whereas watchful wai3ng involves rela3vely lax observa3on with late, pallia3ve treatment for those who develop symptoms of progressive disease, ac3ve surveillance involves close monitoring with early, cura3ve treatment in those with evidence of biochemical or histological progression.

6 } PRIAS (Prostate cancer Research Interna3onal: Ac3ve Surveillance) presents a program in which selected men with early prostate cancer are managed by a protocolled follow- up strategy.

7 Inclusion Criteria: Histologically proven adenocarcinoma of the prostate Men should be fit for cura3ve treatment PSA- level at diagnosis 10 ng/ml PSA density (PSA D) less than 0.2 Clinical stage T1C or T2 Adequate biopsy sampling Gleason score 3+3=6 One or 2 biopsy cores invaded with prostate cancer Par3cipants must be willing to auend the follow- up visits Exclusion- criteria: Men who can not or do not want to be irradiated or operated A former therapy for prostate cancer

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10 } The new prostate- imaging technology that fuses MRI with real- 3me, three- dimensional ultrasound appears to offer a more exac3ng method to obtain biopsy specimens from suspicious areas within the organ. } The new technology may be most beneficial for pa3ents who fall into one of two categories: those who had prior nega3ve biopsies but have persistently elevated prostate- specific an3gen (PSA) levels "ac3ve surveillance" pa3ents those with low- risk prostate cancers who are being carefully monitored over 3me to see if their cancer progresses or becomes more aggressive. } Researchers found that targeted biopsy was five 3mes more likely to find cancer than non- targeted, systema3c biopsy.

11 } Targeted biopsy refers to direct 3ssue sampling of suspicious areas, as opposed to the older method of random, systema3c sampling in use since the 1980s. } The new method employs sophis3cated MRI (magne3c resonance imaging) technology, to visualize prostate cancer, and fusion of the MR images with real- 3me ultrasound. } The result is a 20- minute procedure, done in the clinic under local anaesthesia, much more accurate than the older method of prostate biopsy because of biopsy targe3ng.

12 } Benefit in pa3ent with ac3ve surveillance Confirm low volume low grade disease Follow lesions of over 3me } Improved risk stra3fica3on for prostate cancer using MR imaging } Focal Therapy Allows targe3ng, treatment and follow up of only the cancer and leaves the normal prostate and nerves untouched.

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14 } Many prostate tumours are detected at a very early stage when they are small and are confined to one region of the prostate gland. } These tumours cannot be felt in a digital rectal exam. They may be slow growing and pose liule immediate risk to a pa3ent's life. } However, because it can be difficult to predict which tumour will become life threatening, pa3ent or surgeon may want to eliminate a clinically localized early- stage tumor rather than pursue ac3ve surveillance.

15 } Focal therapy is a general term for a variety of non- invasive techniques for destroying small tumours inside the prostate leaving the gland intact and sparing most of its normal 3ssue. } In appropriate situa3ons, focal therapy can offer several advantages for men with early prostate cancer: Focal therapy can effec3vely destroy specific areas of cancer within the prostate while preserving normal prostate 3ssue and func3on. } Side effects of focal therapy including changes in urinary and sexual func3on are oken temporary and may be less severe than those associated with more- aggressive treatments.

16 } Because focal therapy causes minimal injury to the prostate gland, it does not preclude further treatment with radical prostatectomy, radia3on therapy, or addi3onal focal treatment to another part of the gland, if necessary. Cancer that returns aker radia3on therapy may be treated with focal therapy. } Focal therapy is oken performed on an outpa3ent basis or with a single overnight hospital stay.

17 } } Thermal focal therapies, use either heat or cold to destroy tumours. Focal Cryoabla3on - In focal cryoabla3on a needle- thin probe delivers a solu3on that surrounds the tumor and kills it by freezing it to a very low temperature. Because focal cryoabla3on targets only a small area within the prostate, it also has fewer side effects than other cryoabla3on techniques, which freeze the en3re prostate gland.

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19 High- Intensity Focused Ultrasound (HIFU) - HIFU uses the energy of sound waves, directed to the tumour with the help of MRI scans, to superheat and eliminate small tumours. HIFU is an aurac3ve focal therapy approach because it is rela3vely non- invasive. The effec3veness of this treatment is monitored in real 3me, using MRI to measure the temperature within the prostate during therapy.

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21 } } Nonthermal focal therapies, which use other methods to destroy tumours without harming the en3re prostate gland. Irreversible Electropora3on (IRE) - This nonthermal abla3on technique uses a device called the NanoKnife to pass an electrical current through the tumor. The electricity creates very 3ny openings (called pores) in tumor cells, leading to cell death. Ultrasound or CT is used to focus the current precisely on the tumor, sparing blood vessels and other 3ssues.

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23 Vascular Targeted Photodynamic Therapy (VTP) - A drug that destroys tumor cells and the blood vessels that support them is given intravenously and moves to the inside of the tumor. The drug is ac3vated by exposing it to light of a very specific colour (wavelength), which is delivered to the tumor site with specially designed fibres placed within the prostate. The photoac3ve substance can then directly target the vessel supplying tumor, closing it off and leading to the destruc3on of the tumor.

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25 } The prostate is anesthe3zed with local anaesthesia just as is done prior to a prostate biopsy. } The technique is performed under local anaesthesia in the MRI machine. } The region of interest harbouring the prostate cancer is iden3fied and a laser fibre is introduced directly into the prostate cancer under MRI guidance.

26 } MRI is highly temperature sensi3ve. Therefore, the temperature of the cri3cal structures adjacent to the prostate including the rectum, urinary sphincter, and erec3le nerves are monitored in real 3me so it is extremely rare to have any collateral damage to these structures. } The temperature of the abla3on site within the region of interest known to harbour prostate cancer is also monitored in real 3me to op3mize destruc3on of the indexed lesion of the cancer. } At the comple3on of the procedure, contrast is administered to show that the region of interest has been successfully ablated.

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28 Acknowledgements FS Katumalla U George S Rathore A Tuli N Shivanna A Parekh V Shah A Pharwaha William Masih

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