Embolization - Prostate Cancer

 Prostate Cancer

  1. Introduction
  2. Clinical Presentation
  3. Diagnosis
  4. Treatment
  5. Prostatic Artery Chemoembolization
  6. Follow up Control
  7. Pre Quimioembolization Consultation
  8. What to do to be treated if I am a foreigner or if I live abroad?
  9. The Chemoembolization
  10. Several Steps of Chemoembolization
  11. The Post Chemoembolization
  12. FU Control
  13. Advantages of Chemoembolization
  14. Questions and Answers
  15. Testimonials
  16. Pregnancy after the Chemoembolization
  17. Free Comunications
  18. Published papers

 1-Introduction 

Prostatic cancer (PCa) is the most frequent cancer in Europe in men over 70 years-old and the most commonly diagnosed non-skin cancer in men in the United States. PCa follows lung cancer in annual fatality rate, with a lifelong risk for diagnosis of 15.9%(1,2). Over 200.000 new cases are diagnosed each year with approximately one in every six U.S. men affected by the disease. Histology studies from autopsy series show that about 33% of men between 40 and 60 years-old have prostate cancer (3). The incidence of PCa increases with age and reaches 75% in men older than 85 years (4).

 2- Clinical Presentation 

Prostate cancer may not have any clinical symptoms. Some cases may have urinary symptoms due to benign prostatic hyperplasia associated to prostate cancer. Elevated PSA may be the single suspicious sign of prostate cancer. PCA may occur in patients with PSA below 2.             

3- Diagnosis

Any patient with high PSA should have a parametric magnetic ressonance. If this examen shows signs of a possible prostate cancer, prostate biopsy needs to be performed.

4- Treatment  

Radical prostatectomy (RP) is a curative treatment for localized PCa. Other curative treatments are external beam radiotherapy (EBRT) and brachytherapy. Alternative options to RP include hormonal therapy, watchful waiting and active surveillance (5-7).

5- Prostatic Artery Chemoembolization 

For those patients who refuse any other treatment, prostatic artery chemoembolization is performed instead of the watchful waiting. For the purpose, under local anesthesia a catheter is placed percutaneously, under X-rays control, in the prostatic arteries. Following that, a cytostatic that is a cancer medication, is placed in the prostatic arteries. The procedure is finished by the embolization of those arteries by an embolic agent. Thus, the cytostatic medication will continue its action in the prostatic cancer.

 

  1. The excellent results of PAE and the high incidence of prostate cancer gave us the inspiration for a dream of treat the diseases by a similar non invasive procedure. Therefore on April 2013 we performed the 1st chemoembolization in prostate cancer. He was our friend 55 years age who refused prostatectomy the single treatment that was offered to him. The reasonable results led us to improve some technical expects of the procedure. Nowadays we do not have any doubt about the success of chemoembolization that will be similar to the PAE in BPH.
  2. The first patient was in acute urinary retention with bladder catheter for 3 months. In the previous years he had 3 surgeries, however he refused another one. He asked me to treat him by the same process I used to treat uterine fibroid in a friend of him.
  3. We started uterine fibroid embolization on June 2004. Five years later after having treated over 800 patients with excellent results and having Knowledge of the common major complications after surgery of BPH, we thought to start embolization of the prostatic arteries for benign prostatic hyperplasia.

    6- Pre Quimioembolization ConsultationThen

Before the outpatient clinic consultation the patients must have the PSA, creatinine, glicemia, colesterol, prostate volume by rectal ultrasound, PVR (Post Void Residual Volume) and the 2 filled questionaires concerning symptom (IPSS – International Prostate Score Symptom) quality of life (QoL) and erectile function (IIEF – International Index Erectile Function). You should give information concerning other diseases (AVC, infarction, diabetes) medicines taken to prostate and others. If you are a smoker, how many cigarrettes  a day. Upon receiving these data your will be informed if you ar or not a candidate.  After receiving these documents you will be informed if you have indication to be treated.  You will be studied by the Interventional Radiology team at an outpatient clinic at S. Louis Hospital in which the procedure, the results and risks are explained and a small brochure with all information is given to the patient. In order to evaluate the possibility of chemoembolization they need to have an Angiography by C.T. to study the pelvic vessels and a parametric Magnetic Resonance of the prostate. You should have biopsy of prostate report. You may be schedule for prostate treatment of you refuse any other treatment.

 

Angiography of the pelvic vessels by Magnetic Resonance

Angiography by CT

7- As we do not want interfere with other treatment by urologists, you will be accepted as our patient for chemoembolization only if you refuse any other treatment.

  • What to do to be treated if I am a foreigner or if I live abroad?   Dear,Thanks for the interest in Quimioembolization for prostate cancer, for better information consult the site www.martinspisco.hslouis.pt In order to evaluate if you are a good candidate for the procedure, please fill the attached questionnaire and send it back and answer the following answers.
  1.  Upon receiving all the above requests you will be informed if you have indication for the treatment. If you have indication and before embolization you need to get the following texts: Creatinine, ureia, glycemia, cholesterol, hemogram, urine II, ultrasound of bladder by rectum with evaluation of post-void bladder residuo and urinary flow rate.

                                             IPSS

                              SCORE- IIEF- 5

(International Index of Erectile Function)

This questionnaire is used to evaluate your sexual function in the last 6 months:

1. How safe were you to have an erection and maintain it?

1. Not sure at all

2. Not very sure

3. Moderately safe

4. Safe

5. Very safe

2. When you had erections as a result of sexual stimulation, how often was your penis rigid enough (hard) to allow penetration?

1. I have not been sexually stimulated

2. Almost never or never2. Rarely (much less than half the time)

3. Sometimes (about half the time)

4. Most of the time (much more than half the time)

5. Almost all the time or all the time

3. When you have tried to have sex, how often have you been able to stay erect after penetrating your partner? 

1. I did not try to have sex

2. Almost never or never

3. Rarely (much less than half the time)

4. Sometimes (about half the time)

5. Most of the time (much more than half the time)

6. Almost all the time or all the time

4. During your sexual intercourse, how difficult was it to stay erect until the end of these relationships?

1. I did not try to have sex

2. Extremely difficult

3. Very difficult

4. Difficult

5. A little difficult

6. Not difficult

5. When you tried to have sex, how often were you satisfied?

1. I did not try to have sex

2. Almost never or never

3. Rarely (much less than half the time)

4. Sometimes (about half the time)

5. Most of the time (much more than half the time)

6. Almost all the time or all the time

  1. The Chemoembolization

Just before, during and after the procedure the patients take an ansiolytic per mouth. Analgesic and anti-inflammatory are given trough an intravenous line. Local anesthesia is given in the inguinal zone, through which the femoral artery is punctured. A slender flexible plastic tube (catheter) is placed in that artery. Then, the prostatic arteries of the opposite side to the puncture site are catheterized with a microcatheter with 1 mm of diameter. Placement of the catheter into the small prostatic arteries is done under X-Ray control, citostatic drugs are injected in prostate artery. Polyvinyl alcohol particles (PVA) are used to block those arteries. This material is innocuous and doesn’t give any reaction. It will be absorbed in 6 months and has been used is US over 50 years for other kinds of embolization.

At the end, a final text is performed to check that most small prostatic arteries are blocked. Following that, the catheter is taken out and placed in the ipsilateral prostatic arteries and chemoembolization is performed as mentioned above. The procedure lasts about 1 hour.

Fig.4-   SCHEMATIC DRAWING OF THE PROCEDURE

10. Several Steps of Chemoembolization

Fig. 1 – Angiographic suite with the table where the patient will be laid down.

Fig. 2 – Patient laid down on table, covered except inguinal zones.

Fig. 3 – Local anesthesia in inguinal zone with small needle.

Fig. 4 – Catheter in femoral artery through an 1.5mm hole

Fig. 5 – Medical team-2 interventional radiologists and a radiographer. Under X-Ray control, the catheter is placed in each of the prostatic arteries. Angiography of the prostatic arteries is obtained by contrast medium injection thought the catheter. Citostatic will be injected in prostatic arteries thought the catheter.

Fig. 6 – Syringe with citostatic drugs and polyvinyl alcohol particles used to block the prostate arteries.

A – Catheter placed in right iliac artery

B – Catheter placed in right prostatic artery, before embolization the prostatic vessels are opacified

C – After embolization, only some vessels are shown because the others are blocked

D – Catheter placed in left iliac artery

E – Catheter placed in left prostatic artery, before embolization the prostatic vessels are opacified

F – After embolization, only some vessels are shown because the others are blocked

G –Pisco Prostate Catheter

 

  1. The Post Chemoembolization

Once the chemoembolization is finished the catheter is removed out and the 1.5 mm puncture site hole in the inguinal zone is compressed for 10 minutes and a badge is placed over the area. After placement of the bandage, the patient is taken to his room. Two hours after the embolization the patient can go to the toilette.

Fig. 1 – Compression over the 1.5 mm hole for 10 minutes after the catheter was taken out.

Fig. 2 – After compression no scar is shown.

Fig. 3 – Bandage placed over the small hole until next morning.

The patient may spend the night in the hospital and they will be released next morning, if they have hypertension, however most patients may go home 4- 6 hours after the procedure. Next day the patients don’t need to be in bed and they can return to their normal life, except driving for one day. At the release from the Hospital the patients will have the mobile phone number of the team that is available 24 hours a day.

12. FU Control

PSA is performed every month up to 6 months and then every 3 months up to 1 year and then every 6 months. Parametric magnetic ressonance (pm RM) is performed at 12 months and then yearly. Prostatic ultrasound is performed at 12 months and then yearly. Six months after Chemoembolization, PSA and parametric RM at 1 year will show clear evidence of improvement of the tumor. Otherwise, the patient will be adviced to chose an alternative therapy. This is the advantage of chemoembolization. If the patient has chosen an alternative therapy before chemoembolization, this procedure could not be performed.

13. Advantages of Chemoembolization

Chemoembolization of Prostate Cancer is a minimally invasive procedure, performed  under local anesthesia, without pain or only light pain, without blood loss, no need of blood transfusion, an outpatient procedure, only some hours of hospitalization, no need of bladder catheter, recover time of one day, minor complications, no urinary incontinence and no sexual dysfunction. In order to avoid complications and get good results it is important a careful selection of the patients. Therefore, those patients with advanced atherosclerosis are excluded.

The chemoembolization of prostate cancer is an optimal procedure in carefully selected of the patients and we presume that, in some time, it will be the future treatment for that disease.

Chemoembolization is different from other alternative treatments to PCA due to efficacy and efficiency, faster, painless and fast recovery, non invasive.

14. Questions and Answers

1- What is Chemoembolization?

The embolization of the hypogastric arteries has been attempted and described to treat conditions secondary to uncontrollable bleeding, prostatic or bladder oncological conditions or surgery. We ourselves have published in 1989 in the American journal “Radiology” its achievement in uncontrollable bleeding of the pelvis due to tumors. The supraselective arterial embolization for the treatment of urinary symptoms secondary to BPH was the technique used in a patient with persistent hematuria, described by DeMeritt in 2000. The embolization of prostatic arteries (EAP) in the Treatment of Benign Hyperplasia is an innovative technique, minimally invasive and reliefs symptoms. It is held at the St. Louis Hospital. It has a lower risk than surgery and good preliminary results. Its purpose is to interrupt the blood flow that supplies the prostate, solving the problem and preserving the prostate. No blood flow to the prostate causes its atrophy and symptoms improve or disappear.

The team of the Hospital Saint Louis Interventional Radiology, after making successful embolization in over eight hundred patients with uterine fibroids, is now performing embolization in benign prostatic hyperplasia. In our country, it is held at the Hospital Saint Louis, since March 2009 and over 1400 patients have already been treated.

Anywhere in the world, the embolization is carried out by an Interventional radiologist, a doctor who is specially trained to carry out this and other types of minimally invasive techniques, without any incision and leaving no scar. Chemoembolization is embolization of prostate arteries with cytostatics and particles performed for patients with prostate cancer.

2- How is Chemoembolization performed?

Under local anesthesia, and without loss of blood, a small hole of 1.5 mm diameter in the groin is made, through which a thin plastic tube, catheter, is introduced. By a sophisticated digital X-ray monitoring apparatus, the catheter is led into the prostatic arteries in which citostatic, plus embolizing small particles are then injected in the prostate arteries, closing the branches that supply this gland, but saving the internal pudendal artery, so that the patient can still keep erectile function.

Embolization is then repeated on the opposite prostatic artery, through the same hole and through the same catheter.

The technique usually lasts about 1 hour, while the patient is conscious and may even display the television monitor that shows the treatment in vivo. After the procedure, manual compression is carried out for about 5 minutes and a small compressive dressing is placed and maintained until the next morning. Two hours after embolization, the patient should be able to get up and urinate.

Hospitalization only lasts a few hours and almost all patients go home after dinner, if the blood pressure is normal or even if they live several hundred kilometers away from Lisbon. In this period, there will be a permanent contact with the medical team to assess complains or clarify any doubts.

3- How did the embolization start?

For years, I thought about the embolization as a treatment of benign prostatic hyperplasia.

In March 2009 I was contacted by a friend of 78 years with benign prostatic hyperplasia, bladder catheter for 6 months, and major depression. He refused surgery, as he had suffered a lot the three times he had submitted to it. After exclusion of malignancy and explanation of the technique and risks, he was treated successfully, with withdrawal four days later. He began to urinate without any difficulty, got out of depression and his sexual activity improved considerably. Six months later his girl friend was pregnant.

Given the success of this technique the absence of complications and the high incidence of prostate cancer, I began performing chemoembolization in patients refusing surgery or other alternative treatment on April 2013.

4- What tests need to be runned before chemoembolization?

Besides the prostate biopsy that you have done, you need to make a pelvic ultrasound via rectum to evaluate the prostate volume. The patient must also have PSA, flowmetry, post-voiding bladder residue and routine blood tests (blood count, cholesterol, triglycerides, creatinine, urea and total and free testosterone). Finall, you will have to perform a CT angiography to study the pelvic vessels. If the PSA is higher than 10 you need to do a bone scintigraphy. Finally you need to do a parametric Resonance Magnetic of the prostate.

5- What are the risks associated with Chemoembolization?

Embolization is a very safe technique, however, it may be associate with some risks, as any medical treatment, but they are rare. Currently, most patients do not feel any symptoms after embolization. Some may refer slight pain, heat or burning, which are easily controlled by appropriate medication. The embolization risks are much lower than surgery. In order to avoid risks, patients whose arteries are very atherosclerotic, revealed by the Angio TAC, are excluded. Complications are those of any catheterization, being the most frequent, the hematoma at the puncture site, urinary tract infection; easily prevented by taking antibiotics started before embolization), urine or sperm with blood and temporary purple colouring of the thigh and abdomen. However, these side effects disappear after a few days without treatment.

6- Will Chemoembolization be painfull?

Embolization does not cause any pain during or after the procedure.

7- How long does it take to recover from it?

The day after embolization, the patient should not stay in bed and can, in most cases, get back to his normal life. However, the patient shall not drive. The patient can resume his professional activity usually 2 days after treatment.

8- How are the results of chemoembolization evaluated?

There will be a great reduction of the PSA and prostatic ultrasound carried, a reduction in prostate volume of about 10% to 30% can be observed, disappearance of symptoms take place soon after embolization or at the latest after one week week. The parametric Resonance Magnetic will show no increase in size of the tumor, reduction in size or the tumor may not be shown.

9- Is my sexual potency affected?

Unlikely prostatectomy and TURP, in which some patients are left with sexual dysfunction, retrograde ejaculation, sexual function is not affected after chemoembolization.

None of the 1400 treated patients for BPH, had sexual function affected.

10- Can I be treated by Chemoembolization?

You can be treated only if you refuse any other treatment for prostate cancer and if your prostatic arteries are not involved by advanced atherosclerosis.

 

11- What to do to be treated?

If you live in Portugal must ask for an appointment at the Hospital Saint Louis. You should do prostate ultrasound with rectal probe, ultrasound of bladder, PSA, recent flow rate  and residue vesical post-micturition.

Before the appointment you must complete international surveys on symptoms, quality of life and sexual function.

The doctor will examine your case and the technique will be explained to you. It may be necessary to run more tests. After this consultation, you must do an Angio CT for evaluation of the pelvic vessels and possible treatment. However, this test has some limitations because some aspects of the vessel’s anatomy cannot be detected by CT and only during treatment. If you live abroad you need do the reconditions written before in ≠ 8.

15. Testimonials

J.C.- PAE – 1160

L.S.- EAP 955

On January 6, 2016, I arrived at St. Louis hospital at 7:00 am to have a prostate embolization, with the aggravation of having a carcinoma detected through a biopsy. Having gone through a painful ordeal of more than five years, having consulted four urologists, and any one of them advised me to do the traditional surgery, which I rejected.

Then I found it well to consult a naturopathic doctor, and to make treatment through natural products, I spent a lot of money and I got worse. Each time I found myself more desperate, to the point of being forced to urinate. I was lucky to talk to someone who had two family members who had done the embolization. And from that point on, he made an appointment with Mr. Professor Dr. João Martins Pisco and followed the entire recommendation made by him. It has been more than two years since the PSA values ​​fell to 1.35 and the carcinoma was no longer detected on the resonance.

For this reason, my good to the whole team of Mr. Professor. I have a normal life I do not take any medication and I feel good.

R. M. – EAP 1120- Subject: Thanks.

I hereby express my thanks to Dr. João Martins Pisco and his team for all the attention paid, dedication and applied science in the treatment of my prostate that on 03/11/2016 I was submitted for Embolization with the Nº 1120 . Recovery has been normal, just as urination and sexual appetite after the first month has returned to normal. Tests indicate a marked decrease in prostate volume. The PSA at the beginning of treatment was quite high (12,210) ng / ml. After the treatment has been lowering its value on 10/01/2018 = 0.315 ng / ml which gives me a feeling of marked improvements and well being. I also have to thank all his dedication over this period by calling by phone with instructions, upon receipt of examinations that I am sending, which I acknowledge. I end with votes for your prosperity in health and well being taking care of the health of others. Please accept, Sir, the assurances of my highest consideration.

THE GOOD OF HEALTH  

Best regards  R.M.

EAP 1321

I am 75 years old and was diagnosed with a malignant tumor in the prostate.
I used to consult Dr. João Pisco who, after analyzing with the observation of the biopsy, advised me of an intervention that took place on December 21, 2017 with a hospital stay of a few hours, easy and without complications.
My PSA values ​​before and after the intervention are as follows:
08-11-2017 – 6.32
04-01-2018 – 3.08
05-02-2018 – 1.41
The discomfort prior to the intervention was very great since I had to get up 4 to 5 times a night to urinate what had stopped happening completely. For all this, I have only to thank, thank you very much, not only to Dr. Pisco, but also to all his team who treated.
J.W.

EAP 1068

In the past 21 July 2016 I underwent a surgical intervention for treatment by embolization of a tumor in the prostate. This intervention was carried out by Professor Dr. Martins Pisco and his team, who praised for the care, attention and merit of the high professionalism they dedicated to me during and after the operation. For everything they are creditors of the highest esteem, consideration and respect.
Well there
V. M. A.

A. T. EAP 115:  Dear Professor João Martins Pisco,

date July 2018 seven years on the date you submitted me to the embolization of the prostate. I would like to inform you of my state of health after this intervention:

– I left from that date on to do any type of medication;

– I did not suffer any kind of side effects; –

I normalized the urinary output (in the previous three years I had 3 hospitalizations due to interruption);

– the last PSA (November 2017) scored 0.02 ng / mL;

– my sex life has not suffered any damage, “I forgot” that I have a prostate.

I want to thank you for the quality of life that the Professor has given me. Three other friends of mine also resorted equally to their services with equal success.

I remain indignant at the attitude of Portuguese health institutions regarding the recognition of practices.

Thank you very much

Loulé February 2, 1818

A. T.

16. Pregnancy after the Chemoembolization

Three kids of the wife of a patient treated after chemoembolization. In spite of they have been married for many years pregnancy was only possible after the procedure due to retrograde ejaculation associated to x blockers taken for BPH.

17. Free Comunications

1.  Abstract Nº: 271- Prostate arterial chemoembolization for prostate cancer- SIR 2017

2-NEW TREATMENT FOR PROSTATE CANCER – PROSTATIC ARTERY CHEMOEMBOLIZATION CIRSE 2017

João Pisco, Tiago Bilhim, Manuel Pinto Ribeiro, Amadeu Brigas, Lúcia Fernandes, Nuno Costa, António G. Oliveira

Purpose – To evaluate the short and mid term results of prostatic artery Chemoembolization (PACE) for patients with prostate cancer (Pca).

Materials and Methods – Between March 2015 and February 2017, 30 patients with Pca underwent PACE. Gleason score ranged between 6 and 10 and staging was T2NoMo.

For PACE, Chelidonium majus Mother-Tincture 1cc was injected and following that, Docetaxel 1cc mixed with Lipiodol 0.5 were injected in prostatic arteries. Embolization of these arteries was performed with Embospheres 150-300µm.

Results – Mean patients age was 68.4 y. Patients whose PSA did not decrease under 2 ng/mL after PACE were considered initial biochemical failure as occurred in 5 (16.7%) patients. Of the 25 patients with technical success there were 23 (92%) initial biochemical success and 2 (8%) initial biochemical failure. Between 1 and 12 months there were 5 (28%) additional patients with biochemical failure and 18 patients (72%) with biochemical success. Twelve patients were evaluated at mid-term between 12 and 18 months with 2 (16,6%) mid-term failures. From the 25 patients with technical success there were 16 (64%) with biochemical success. There was a major complication a bladder wall ischemia treated by surgery.

Conclusion – PACE for prostate cancer is a new, safe and promising outpatient procedure for Pca with good short and mid term results.

 

3- February 21, 2018- Dubai, Pan Arabe Interventional Radiology Association Congress Prostate Cancer.

Is there a role for catheter in prostate cancer?

18. Published papers

Safety and Efficacy of Prostatic Artery Chemoembolization for Prostate Cancer-Initial Experience.

Journal of vascular and interventional radiology : JVIR. 2018 Jan 15

João Pisco, Tiago Bilhim, Nuno V Costa, Manuel Pinto Ribeiro, Lucia Fernandes, António G Oliveira

To evaluate outcome of prostatic artery chemoembolization for patients with prostate cancer (PCa).This single-center prospective cohort study was conducted between August 2013 and July 2016 in 20 patients with PCa who underwent chemoembolization. Mean patient age was 67.5 years ± 6.4. Gleason score was 6-10, and staging was T2N0M0. Fifteen patients refused prostatectomy and 5 wanted to stop hormonal therapy because of side effects. For chemoembolization, Chelidonium majus mother tincture 1 mL was slowly injected into the prostatic arteries. Docetaxel 1 mL and 150-300 μm Embosphere (Merit Medical Systems, Inc, South Jordan, Utah) microspheres 0.5 mL were thoroughly mixed, and the mixture was slowly injected by the same route. Embolization of prostatic arteries was finished with 150-300 μm Embosphere microspheres. Technical success was defined as bilateral prostatic artery embolization. Biochemical failure was defined as prostate specific antigen (PSA) decrease to < 2 ng/mL followed by recurrence when PSA increased to > 2 ng/mL within 1 month after success.Technical success was 80.0% (16/20 patients). Biochemical failure was 18.7% (3/16 patients). There was 1 short-term biochemical recurrence at 4 months and 2 midterm recurrences (12-18 months). Biochemical success at 12-18 months was 62.5% (10/16 patients). Adverse events (31.3%) included a small area (2 cm2) of bladder wall ischemia, which was removed by surgery (n = 1); transient acute urinary retention (n = 1) and urinary urgency (n = 1) for 1 week; sexual dysfunction (n = 2), which completely recovered after 10 and 12 months, respectively.

Prostatic artery chemoembolization allowed a biochemical response in patients with localized PCa and is a promising treatment.

Interventional Radiology Department, Hospital Saint Louis, Avenida David Mourão Ferreira 27, 4D, Lisbon, Lumiar 1750-220, Portugal., Interventional Radiology Department, Hospital Saint Louis, Avenida David Mourão Ferreira 27, 4D, Lisbon, Lumiar 1750-220, Portugal; Radiology Department, Nova Medical School, Lisbon, Portugal., Interventional Radiology Department, Hospital Saint Louis, Avenida David Mourão Ferreira 27, 4D, Lisbon, Lumiar 1750-220, Portugal; Radiology Department, Nova Medical School, Lisbon, Portugal. Electronic address: nunocosta@radiology.win ., Oncology Department, Hospital Da Cruz Vermelha Portuguesa, Lisbon, Portugal., Department of Pharmacy, Universidade Federal do Rio Grande do Norte, Natal, Brazil.

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