AN ALTERNATIVE EXPERIENCE FOLLOWING FOCAL SALVAGE CRYOTHERAPY.
The purpose of this text is to provide an alternative view and perhaps more encouraging view of cryotherapy than the prior Yananow entitled "Stuff to take when experiencing cryosurgery: a patient, NOT a physician perspective". This prior titled brief may have been accurate, but I thought was frankly scary and could have discouraged prospective cryotherapy patients. I am not sure when the patient was treated, his physical condition, or how he was treated since each could have affected the results, leading to his long description.
Background. The cryotherapy treatment that I will discuss is related to the operation I received also at Ventura CA under direction of Dr. Duke Bahn in May 2015 for salvage or secondary prostate cancer. My original diagnosis was in July 2008 of Gleason 4+3=7 and the treatment I selected was proton beam therapy at Loma Linda Univ Medical Center, CA. I had no problem in the treatment. My PSA varied up and down over the years, but finally in May 2014 (after 5.5 years), the PCa was considered recurrent, with the PSA rising 4 consecutive times and equaling 2.55. After doing imaging at the Phoenix Molecular Imaging Center, Phoenix, AZ in Jul 2014 and under several consultations, concluded cryotherapy should be considered. In Sep 2014, Dr. Bahn conducted a color doppler ultrasound guided biopsy and the pathology showed Gleason 6 and 7 tumors in the prostate. In May 2015, I underwent the cryo with no significant issues. I was in reasonably good physical shape and ws 71 years old. The operation was for focal targeted therapy in the right side that was detected first by the Arizona imaging and through Bahn's color Doppler. The risks for salvage therapy is greater than primary therapy according to most reports, but the fact that the cryo was targeted and limited would have decreased the risks. Bahn's own chart shows a general success rate of 50-70% for salvage cryo. Under his direction, I seriously do not think there are significant dangers of most serious problem of fistulas (holes in the bladder to the rectum) developing which may require an external collection bag. These scary incidents mostly occurred in the early period of cryo before urethral warming procedures (now, about 1% chance). I elected to be under general anesthesia instead of spinal anesthesia and woke up about 3 hours after the operation which took only 1.5 hours. Since I was not within driving distance from Ventura, I was hospitalized one night after the cryo. Just to be safe, I scheduled being in a hotel two more nights and flying the third day later out from Los Angeles. If you travel a long distance, would suggest some additional time before traveling. The only irritating issue was the need to have the catheter in place and taping/untaping the 2 sizes of bags. I developed some tape burns which took about 3 more weeks to heal. I will provide further comment on the device details from the prior patient.
Ice Bag: I requested the ice bag previously furnished at the hospital, but frankly did not need and never used. There was some minor pain, not in the scrotum for about 5 days but readily alleviated by medication.
Elliptical donut pillow. I previously checked the availability of this item, but beware the shipping costs could exceed the cost of the item. I did not need when riding in a vehicle or on the air flight.
Urine collection system. The hospital provided one 500 ml and one 2000 ml bag. I requested and was provided another 500 ml bag. The irritating aspect was changing the 500 ml to the 2000 ml whenever I rested or went to sleep at night (the 500 ml would not drain properly since it was attached to the thigh). You need to reattach the tube to the bag every time - make sure you have paper towels, so don't leak urine all over the place. Also make sure that the 2000 ml bag is properly hooked to the bed frame or chair. If you toss and turn when sleeping - forget about turning or else you will tangle the tubing. If you need to change the catheter holder (special tape with a loop for the drain tube), buy it in Ventura before you leave as it may not be available in many hospital supply houses. In fact, I was able to buy only one available there. My scrotum and penis were not affected by the catheter - there was no swelling in either. Minor issue is that the penis end was little irritated, treated with A&D ointment. Despite Dr. Bahn suggesting that he could show me how to remove the catheter - I declined - I would suggest strongly you make an appointment before to the operation with your local urologist for removal. The catheter is known as a "Foley Catheter", having a narrow tube internally parallel to the drain tube Inside your bladder at the end of the tube is a balloon, minimizing the catheter from pulling out (see the internet). To remove the liquid and collapse the balloon, the urologist will use a hypodermic needle inserted into an opening at the base. After the urologist withdraws the liquid, he will slowly withdraw the catheter, which only pains for a second - don't let a nurse rip it out - will be more painful! Due to the pre-arranged doctor's appointment, I had the catheter removed 7 days after the operation (Bahn suggested 5 days). Yes, Dr. Bahn's advice is important - you must be able to urinate during the 5 days recovery and thereafter - if not, go to emergency - something is clogged up.
Travel. If you are hospitalized, you will need to have a spouse or friend pick you up in front of the hospital, although you will be able to walk. I had absolutely no problem riding in a car (and could drive, although discouraged) or on the plane, unlike the prior patient. Only irritant is that I had to go to the restroom at least every 2-3 hours to drain the bag. No special clothes were required for travel, except, of course wear long pants to conceal the bag. I could walk perfectly well and did not need any assistance or wheelchair for the flight. There was minor but tolerable pain felt in the urinary tract alleviated by pain medication for a total of 5 days days after the operation. You don't need an athletic supporter (at least in my case). The drawback was that the pain meds caused constipation which did not pass for another 3 days. Also, I would suggest before going into surgery you buy a six pack of light male pads - there was some minor leakage (through the end of the penis) for about 4 days after the operation.
Side effects. The only potential side effect of the treatment is that 2 months later, I seem to be having more feelings of urgency to urinate - not entirely sure that it is the result of the cryo or not. About every 3-4 days or so, I may have a minor leakage and am thinking about wearing pads again when there is a long interval before accessing a bathroom. Another "side effect" is that Dr. Bahn does not take Medicare or health insurance for his services. The hospital, attending surgeon, and anesthesiologist charges for the operation and are covered under normal Medicare and health insurance. I am scheduled for a 6-month follow up ultrasound - which I will have to pay also. Hope this information helps others.
I am providing an update of my prior submittal concerning cryotherapy. My experience was focused on cryotherapy, but actually it was more involved. As a result of my diagnosis of biochemical recurrence in May 2014 (exceeding PSA 2.0 + nadir) , I went through a 2-part secondary treatment. The probably PCa residual nodes were located in the prostate and one lymph node as a result of advanced imaging using C-11 carbon acetate PET/CT scan and F18 Na F PET/CT bone scan at Phoenix Molecular Imaging Center, Phoenix, AZ in Jul 2014. A biopsy conducted in Sep 2014 confirmed the 2 residual PCa nodes in the prostate, both on right side, Gleason 3+3 and Gleason 3+4. The lymph node was not biopsied, due to the advised difficulty of pinpointing that node, but based on the imaging could be inferred that it was also PCa. First order was to take care of that node. I could have undergone surgery to remove all the lymph nodes but chose radiation since less risky. I underwent IMRT radiation at 50 grays for 28 days from Mar 5 to Apr 17, 2015 on the left and right sides of the prostate where the lymph nodes are located. Concurrently did Lupron ADT for 6 months Mar 3 to Sep 2. Following the radiation, I went to undergo the cryotherapy on May 20, 2015, as previously described. I had a 6 month cryotherapy follow-up with Dr. Bahn on Nov 5, 2015 and the color Doppler revealed essentially a dead tissue on the right side where was treated and normal blood flow in the left side, both indicating no evidence of cancerous growth. I am continuing to monitor my PSA and testosterone at 3 month intervals to determine when the PSA values would be "normal" and not suppressed by ADT. Only now, of Jul 29, 2016, about 10 months since the effectiveness of Lupron wore off has my testosterone returned to "normal" at 513 (earlier pre-ADT values were between 582 and 684 in 2014). My PSA is now 0.03 measured under an "ultra" assay. Plan is now to continue monitoring - if the PSA rises to a level of 1.0, will again undergo another round of C-11 acetate imaging to determine PCa residual locations and if can be stopped using another round of targeted therapy. I am not in favor of systemic therapy (ADT), unless there is no other option. Hope this answers the mail!
Nothing significant to report since my last update of Aug 2016. I am continuing to monitor my PSA (ultra sensitive assay since 07/2016) every 3 months to determine if it will rise to a level of detectability using recent PET technology. My current PSA = 0.14 as of Aug 5, 2017. My plan is when it reaches PSA = 1.0, I intend to seek a second round of PET scans to determine the extent and location of residual prostate cancer lesions. This may provide information on how to eradicate the remaining lesions, if possible. The only medication I am on currently is Avodart (0.5 mg/ per day- since 07/2015) and metformin (500 mg/ 2x per day - since 02/2017), both under advice of Dr. Mark Scholz. These meds may also hold down the lesions for now.
I am currently considering a 3rd round of treatment for oligometastatic prostate cancer. I am uncertain whether this blog site contained what has happened. To summarize:
07.01.2008 Notified of Gleason 4+3=7, 2/8 cores cancerous at 50%, stage T2a
11.24.2008 Completed 45 treatments of proton beam therapy (Loma Linda, CA), at 81 grays
05.27.2014 Apparent recurrence, PSA=2.55 (5.5 yrs since treatment)
07.17.2014 Underwent C-11 Acetate PET/CT scan, Phoenix AZ, detected 2 lesions-1 in prostate, 1 outside lymph node, right
04.17.2015 Completed 28 treatments of IMRT, at 50.4 grays (for lymph node), Honolulu, HI
05.20.2015 Completed cryotherapy, targeted on right prostate, from Duke Bahn, Ventura, CA
05.17.2018 Apparent secondary recurrence, 5 consecutive PSA increases to PSA=0.45 (3 yrs since last treatment)
10.03.2018 Underwent Ga-68 PSAM PET/CT scan, UCLA, L.A.,CA. detected 1 lesion in groin lymph node. Considering additional treatment - may elect surgical removal of lymph at location
I have provided an earlier version of my cryotherapy associated with the first recurrence. I would like to share my subsequent experiences for patients for reasons of (1) keep monitoring your PSA because recurrences are common and every patient must seek imaging to identify where the aberrant lesions are located and possible remedies. (2) If available, seek the PSMA PET/CT scans usually in Ga-6 (ILLuccix) or F-18(Pylarify) agents. Conventional bone scans and FDG PET are insensitive and will not be any good for all except the massive lesions. See the historical versions below:
1st Recurrence. Determined on May 27, 2014 (about 5.5 years since PBT completion) when PSA = 2.55 (at Phoenix definition of radiation recurrence, nadir = 0.35) . Confirmed with advanced imaging C-11 Acetate PET/CT in Phoenix, which revealed 2 lesions, one on right iliac lymph node and one inside the prostate itself, on the right side. On Mar 3, 2015 I undertook a 3 month dose of Lupron to supplement a failed 6 month dose of Eligard previously taken on Nov 3, 2014, both intended to enhance the effects of a proposed radiation therapy. The remedial treatment as a combination: an IMRT radiation for 28 treatments (6 weeks) here in Honolulu, completed on Apr 17, 2015 on both sides of iliac lymph nodes and at Ventura. Subsequently, I completed cryotherapy (targeted freezing on the right side of the prostate) on May 20, 2015.
2nd Recurrence. Estimated on Aug 27, 2018 after 4 consecutive PSA rises over 1 year period at PSA = 0.59 (about 4.3 years since 1st recurrence). I undertook another advanced imaging, Ga-68 PSMA PET/CT at UCLA on Oct 3, 2018 which revealed another oligo-metastatic lesion (meaning < or = 5 lesions) in the right inguinal lymph node. On Dec 6, 2018 I undertook a 6-month dose of ADT (Lupron) to enhance the intended proposed radiation therapy. Undertook SBRT treatment at UCLA at 40 Grays, completed on Mar 1, 2019. Unfortunately, two years later, the radiation likely induced a case of lymphedema, swelling in the right leg, since the radiation was directed near the lymphatic system in that vicinity. I undertook several months of (12/20- 02/21) of acupuncture which provided some minor relief but continue to wear a pressure sock to this day.
3rd Recurrence. Estimated on Sep 14, 2023 after 4 near consecutive PSA rises in 1 year, at PSA = 1.95 (about 5 years since 2nd recurrence). I undertook Ga-68 PSMA PET/CT at InVision, Honolulu which revealed possible lesion in right obturator region. Signed up for LUNAR Phase 2 clinical trial at UCLA, under Dr. Amar Kishan, which would inject Lu-177 (Pluvicto), in 2 cycles separated by 8 weeks, combined with SBRT treatment to any oligo-metastatic lesion detected. Lu-177 injected on Dec 11, 2023 and Feb 8, 2024. Lesions (2) detected in Ga-68 PSMA PET/CT on Mar 5, 2024 at right exterior iliac lymph node and right obturator lymph node. Treated independently with SBRT 35 grays for each lesion, completed in Mar 20, 2024. PSA monitoring to continue every 3 months to one year.
Paul's e-mail address is: hpmizue AT gmail.com (replace "AT" with "@")
