Interventional Radiology    Minimally Invasive

A new non-surgical prostate cancer treatment offered at the University of Texas Medical Branch virtually eliminates the side effects of impotence and incontinence that can occur when patients receive the traditional treatment for prostate cancer - surgical prostate removal.

UTMB’s Chairman of Radiology Dr. Eric Walser is one of only a few physicians in the world and the only physician in Texas who performs this groundbreaking procedure. Using a state-of-the-art, MRI-guided laser ablation instrument developed at UTMB, he zaps away the cancer without removing the prostate.

With national standards for prostate cancer screening changing so dramatically over the past year, many men are confused about what it means to have prostate cancer, whether they should be tested for it and what they should do if they test positive.

The American Urological Association released new prostate cancer screening guidelines saying men under 55 should no longer receive routine prostate screening and that men over 80 should not receive it if they have a life expectancy less than 10 to 15 years. The association determined the odds of preventing prostate cancer death with a PSA (prostate specific antigen) blood test for men ages 55 to 69 amounted to one life spared for every 1,000 men screened over a decade.

This is on the heels of the U.S. Preventive Services Task Force’s statement last May, saying that much more harm than good was being done to men who underwent screening, biopsy and surgical removal of their prostate gland. The vast majority of prostate cancers are so slow-growing that they may never cause a problem. On the other hand, the impotence and incontinence that can result when the sensitive nerves surrounding the prostate are damaged or severed during surgery can be devastating.

The gist of all this is that the standard treatment - surgical prostate removal - causes more damage than the disease ever would have.

“The problem is, most men who test positive, even if the risk is one in 1,000 of dying of prostate cancer,” said Walser, “still just want to get it out of there. You never know if you are going to be that one.”

In the past, there was no way for doctors to remove prostate cancer without removing the whole prostate gland. This is because the available imaging technology was not powerful enough to illuminate the cancer and the available laser ablation technology was not focused enough to remove the cancer without damaging surrounding tissue. But in recent years, the technology has improved significantly.

“Our approach pairs the most advanced MRI imaging to identify cancer-suspicious areas in the prostate and the most advanced laser technology to remove it completely, with virtually no risk of impotence or incontinence,” said Walser.

Walser, who has been performing this procedure for three years, says this new way of treating prostate cancer offers selected men much more peace of mind than active surveillance or “watchful waiting,” the traditional alternative to radical treatment. Active surveillance is an invasive method to follow these patients and involves blood draws and often multiple prostate biopsies repeated yearly. “Watchful waiting” is less invasive but requires monitoring of patient symptoms and repeated transrectal clinical exams. Neither method actually treats cancer in the prostate. Additionally, prostate MRI images may be able to separate aggressive from very slow growing prostate cancers and help physicians identify men needing earlier treatments.

NIH-funded clinical trials of this new procedure so far show that it is safe and effective, with results from several trials just published online in the journal Radiology and an ongoing study being conducted at the University of Chicago Medical school.

For those patients whose prostate cancer is large, aggressive or has spread outside of the pelvis, ablation therapy may not be able to fully eliminate it. In those cases, UTMB’s Department of Urology offers the patient a wide range of minimally invasive surgical options, including a highly advanced robotically-assisted laparoscopic option for prostate removal. UTMB’s radiation oncology department also has methods to treat prostate cancer with focused radiation therapy.

Treating kidney cancer when you can’t afford to lose a kidney...

A prime objective with kidney cancer (also known as renal cell carcinoma or RCC) is to remove it. The surgical options for resecting (cutting-out) kidney cancer are well-developed and usually pretty straightforward. The kidney containing the tumor is removed (nephrectomy) or just a part of the kidney might be removed if the tumor is small (partial nephrectomy). All of this is just fine–for those who have a second kidney that is normal and can pull duty for the one about to be lost. But some people don’t have this option due to chronic kidney disease from diabetes, high blood pressure or other conditions. New minimally invasive therapies may offer a solution.

Years of these conditions can lead to so much kidney damage that these patients cannot afford to lose even a part of one kidney– They risk permanent renal failure and may need kidney dialysis treatment for the rest of their lives. New minimally invasive therapies may offer an alternate solution.

The patient in the photos has 2 kidney cancers in his right kidney (arrows) and has no options for surgery due to long-standing kidney disease and poor function. What are his options?

1. Remove the kidney and probably start dialysis treatments three times per week for the rest of his life. This is very difficult for families’ finances/schedule and for the patient’s sense of well-being
2. Do nothing and hope the cancers grow slowly and don’t spread. This is unlikely to happen.
3. Perform regional tumor therapy consisting of needle-puncture and ablation (destruction) of the tumors only, while preserving as much of the kidney as possible. This option was chosen for this patient to treat his cancer in a way that maximized tumor destruction but minimized risk of permanent renal failure.

The photos on this page show the “Cryoprobes” inserted into the tumors with guidance by a CT (computed tomography) scanner. “Ice-balls” (white arrows)  form as the freezing process envelopes the tumors. This treatment takes about 2 hours and involves an overnight hospital admission. Post procedure pain is minor and goes away in less than a week with pain medications or just Advil/Tylenol.

In this example, the patient’s renal function dropped slightly after the procedure but returned to baseline about a week later. He requires no dialysis. To monitor how successfully we killed these tumors, a CT or MRI scan is repeated in about 3 months. If some tumor remains alive, additional treatment is considered and is generally easier and safer than the first procedure.

In 2011, the New England Journal of Medicine published a study that showed lung cancer deaths could be significantly reduced when patients with heavy smoking histories but no symptoms received low-dose CT chest scans once a year over a three-year period. The study showed a 20 percent decrease in mortality in patients who received the CT scans compared to those who received chest X-rays. CT lung cancer screening is recommended for people 55 and older who have a significant smoking history -- more than 10 years. It is also recommended for former smokers who quit less than 15 years ago.

Since that study came out, medical institutions across the country have begun introducing the screening protocol for patients who fit certain criteria even though insurance companies have not yet incorporated lung cancer screening into their reimbursement programs.

The University of Texas Medical Branch offers a lung cancer screening program at both its Galveston and League City locations. The procedure is painless and takes less than a minute. The cost is $300 at time of service with no insurance reimbursement currently available.

CT lung cancer screening is recommended for people 55 and older who have a significant smoking history -- more than 10 years. It is also recommended for former smokers who quit less than 15 years ago.

UTMB's first lung cancer screening patient was Barbara Garcia, UTMB's residency program manager who is also a mother of two grown daughters and a grandmother of six, all of whom live in Texas City, where Garcia lives as well.

Garcia was recruited as UTMB's first lung cancer screening patient by one of her colleagues, Dr. Maurice Willis, an associate professor in the division of hematology/oncology at UTMB.

Willis knew Garcia had a history of smoking. He told her he was sorry to ask but wondered how old she was. "57," she said. Willis told her she was a perfect test patient for the new screening program. She underwent the procedure in mid-June. Last week she learned that her scan was clear.

"It was a huge relief," she said, "especially since my father died of lung cancer when he was 64. I think it is wonderful that there is a test like this now. I'm so glad it's going to be available to everyone who needs it,"
The low-dose CT chest scan is a procedure that detects far smaller cancers in far greater detail than a chest X-Ray. The images are 3D, so tinier lung tumors can be detected.

"As a radiologist, my role in the lung cancer screening program is to make it painless, fast and diagnostic for our patients," said Dr. Eric Walser, director of interventional radiology and executive vice chair of radiology at UTMB.

"To reduce anxiety and delays, we work to interpret the study and inform the patient of the results as soon as the CT is completed," said Walser.

Lung cancer is typically so deadly because patients usually do not experience any symptoms until the cancer is at such an advanced stage it cannot be treated successfully.

When lung cancer is found at its earliest stages through screening however, survival rates are very high.

For patients in whom small lung cancers are detected, UTMB offers a wide range of minimally invasive treatments, including thoracoscopic tumor removal, laser ablation therapy and stereotactic (focused) radiation therapy.

The incidence and prevalence of vascular disease are on the rise, given the growing elderly population. To optimize vascular health, vascular surgeons and radiologists at UTMB Health now perform a variety of new, minimally invasive, catheter-based endovascular procedures in addition to traditional surgical approaches to therapy.

These catheter-based treatments include stenting of the carotid artery, endovascular repair of abdominal or thoracic aortic aneurysms, atherectomy or angioplasty devices used to clear lower extremity arteries of plaque, and less invasive therapies for varicose veins. Vascular surgeons offer a full range of less invasive and simpler treatment options for those with vascular problems. Treated patients often quickly resume normal activities following short hospital stays.