focal cryosurgery

[BaldiR]

Is focal cryosurgery a reasonable alternative given my situation?
I am 67 years old and in good health. After a PSA of 6.6 and a firmness observed in a DRE, my biopsy showed a high-grade prostatic intraepithelial neoplasia in the left apex; and a Adenocarcinoma, Gleason score 3+3 tumor size <.1 cm of length of core biopsy in the right apex. The other 10 samples were benign prostatic tissue.

The comment was
“The core biopsies showed a focus of atypical glands. They are small to medium in size and crowed. The nuclei are modestly enlared with occasional nucleoli. A small battery of immunohistochemical stains was performed to clarify the focus. The glands in question do show positive cytoplasmic staining for racemase. A basal cell layer is not evident with p63 or high molecular weight cytokeratin. We felt the changes were most consistent with adenocarcinoma but the pattern was slightly unusual overall.” A second opinion by Dr. Netto at Johns Hopkins agreed that this represented a small focus of adenocarcinoma and this tumor has features of pseudohyperplastic carcinoma”.

[HeinrikMD]

Hi,

What muddles the report is the word “focus” on adenocarcinoma, as it seems to imply that the disease is confined and may be treated in the same way as an in-situ high grade PIN. The fact that the Gleason is only 6 as well as the PSA, then raises the possibility of indolent disease and so an expectant watch and wait would be among  the options of what to do.
If you would are interested in getting definitive local therapy, it may be better to pursue surgery or radiation, as the experience with cryotherapy is still accumulating.  

[BaldiR]

Did you miss the description of
a Adenocarcinoma, Gleason score 3+3 tumor size <.1 cm of length of core biopsy in the right apex.
If so, does this change your opinion.
I appreciate your help.

[HeinrikMD]

Hi,

Focal therapy is an intriguing option. While it is reasonable that therapy on an area where cancer is believed to exist may improve outcomes (and for other cancers, this has been done, so selected women with breast cancer get equivalent outcomes without needing to remove the entire breast), the actual available data involves largely case series of patients who were never compared with other therapeutic options (hence the data is for frank cancer, not an atypical biopsy). Hence, the merit of the procedure is not really known.
The first thing you need to clarify is to discuss what the diagnosis really is. The report sounds like you don't have invasive cancer, only a high-grade PIN (prostatic intraepithelial neoplasia), so for these cases, prostatectomies or radiation is not really recommended. So there is no therapy that is going to cut or burn the area at risk. There is a promising drug therapy available, which involves a hormonal medication called toremifene.