Gene Researchers: Curing Blindness

As one of the premier patient care, teaching and research ophthalmology departments in the country, Scheie is a world leader in research and consistently ranks among the top five programs in the nation in funding by the National Eye Institute.

“Scheie one the of the top-funded eye research programs in the country,” said Joan O’Brien, MD, chair of ophthalmology, “but almost all of our scientists are physician/scientists who bring this research back to their patients. Marrying the science to patient care allows us to treat vision loss in a personalized manner.”

Gene therapy is just one of the areas of focus for researchers at Scheie. With the rapidly expanding knowledge about genetic diseases, researchers can target the biology of eye diseases and develop personalized treatment for patients.

Using Gene Therapy to Cure Blindness

The work of Penn researchers received a great deal of publicity after they brought sight to children who suffer from inherited retinal diseases. Leber congenital amaurosis (LCA) is a group of inherited blinding diseases that damages light receptors in the retina. It usually begins stealing sight in early childhood and causes total blindness by the time patients reach their 20s or 30s.

Clinical trials conducted at The Children’s Hospital of Philadelphia (CHOP) have shown that gene therapy safely restored vision in young people with this rare form of congenital blindness. The treatment consists of injecting one eye with a virus genetically engineered to carry a normal version of the gene that causes LCA.

Although the patients have not achieved normal eyesight, their vision improved from detecting movements to reading lines on an eye chart. Three children, who previously sat at the back of the class relying on electronic screens and assistance from teacher aides, now, sit in the front of the class. One joins classmates on the playground for a game of softball and another joins them for soccer.

“For children and young adults with congenital blindness gene therapy is the best chance for restoring and improving their sight,” said Jean Bennett, MD, PhD, and lead author of the study. “With the success we have had in treating one eye, we are cautiously preparing to begin treatment of the other eye. Penn and CHOP are leaders in developing ocular gene therapy and are poised to move forward quickly with this promising research.”

Providing World-Class Care

Along, with their research, Penn Eye Care specialists provide the most up-to-date methods of treatment for the full range of eye disorders, from routine eye examinations to the most advanced ocular surgery.

For more information about eye care and ophthalmology research at Penn Medicine or to schedule an appointment with a Penn ophthalmologist, please visit PennMedicine.org or call 800-789-PENN (7366).

Watch a video of study participants before and after treatment.

Focusing on Vision

At Scheie Eye Institute and the F.M. Kirby Center for Molecular Ophthalmology, scientists investigate the causes of important eye conditions including macular degeneration, diabetic retinopathy, hereditary retinal degenerations, cataract and severe myopia that may be treatable with molecular therapies.

In addition to the gene therapy work being done by Jean Bennett, PhD, and Albert Maguire, MD, nearly 50 physician/scientists are involved in translational ophthalmology research at Penn, many of them bringing their research directly to the patients they treat.

Alexander Brucker, MD

Dr. Brucker is one of the most prolific investigators at Scheie Eye Institute. As a retina specialist, Dr. Brucker’s research focuses on medications and treatments for diabetic retinopathy, diabetic macular edema and age-related macular degeneration. He is also a member of the executive committee of the Diabetic Retinopathy Clinical Research Network (DRCRnet), the NEI-sponsored collaborative network dedicated to facilitating multicenter research of diabetic eye conditions.

Vatinee Y. Bunya, MD

Dr. Bunya is currently the principal investigator for several dry eye studies focused on studying different components of the tear film. In addition, she serves as a co-investigator for an international Sjogren’s syndrome study and is part of a multidisciplinary team working on the development of a new blepharitis reading center. She will soon begin her K12 research training grant, which focuses on the development of new topical therapies for dry eye disease.

Joshua Dunaief, MD, PhD

Dr. Dunaief is the recipient of the prestigious Cogan Award from the Association for Research in Vision and Ophthalmology. His research and clinical practice focus on age-related macular degeneration (AMD), a common cause of irreversible blindness in the U.S. Evidence suggests that cumulative oxidative damage contributes to AMD and aging in general and his research has found that AMD retinas have iron overload, which can increase oxidative stress. Dr. Dunaief’s lab is working to understand retinal iron homeostasis and how it may lead to treatments for AMD. His lab has found that treating genetically engineered mice with an oral iron-binding drug prevents both retinal degeneration and a Parkinson’s disease-like movement disorder.

Juan Grunwald, MD

Dr. Grunwald is world renowned for his research on blood flow in the retina. Currently, he is photographing the retinas of patients with kidney disease to identify retinopathy. The tiny blood vessels in the retina reflect vascular issues throughout the body and the photos provide a non-invasive way to obtain information about vascular disease. Dr. Grunwald is also an investigator on the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) and the Retinopathy in Chronic Renal Insufficiency Cohort study (RCRIC).

John Kempen, MD, MPH, MHS, PhD

Known nationally and internationally as an expert in ocular inflammatory diseases—such as uveitis, scleritis, and others—as well as ocular complications of AIDS, Dr. Kempen is the principal investigator for the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study, the first NIH-sponsored multicenter clinical research study in the field of uveitis. Following up on the results of the study, Dr. Kempen is now expanding his research to examine cancer-related mortality among patients with ocular inflammation who are being treated with immunosuppressive drugs.

Alan M. Laties, MD

Dr. Laties’ lab focuses on understanding the mechanisms of hereditary retinal degenerations and age-related macular degeneration (AMD), to perform pre-clinical evaluation of drug therapies, and to fast track laboratory results to patient care.

Maureen G. Maguire, PhD

As director of the Center for Preventive Ophthalmology and Biostatistics, Dr. Maguire’s current research projects include directing the coordinating center for the NIH-funded Comparison of Age-related Macular Degeneration Treatments Trials, a multicenter, randomized clinical trial involving 1,200 patients with choroidal neovascularization.

Eydie G. Miller-Ellis, MD

As a glaucoma specialist and director of the glaucoma service, Dr. Miller-Ellis’ research interests include medical and surgical interventions for glaucoma, and diagnostic techniques for the evaluation of glaucoma. She was the principal investigator for the Advanced Glaucoma Intervention Study and the Ocular Hypertension Treatment Study, two pivotal multicenter clinical trials sponsored by the National Institutes of Health that helped define glaucoma management. She is also the principal investigator for an upcoming multicenter clinical trial that will evaluate the relative efficacy of medical and surgical management of glaucoma.

Kenneth S. Shindler, MD, PhD

Dr. Shindler’s research area is optic neuritis, an inflammatory disease of the optic nerve that often occurs as part of the neurodegenerative disease multiple sclerosis. (MS). Dr. Shindler’s studies are helping to identify new drug therapies and drug combinations to prevent nerve damage in MS, and such therapies will also likely have benefits for other neurodegenerative diseases.

Dwight Stambolian, MD, PhD

Dr. Stambolian’s lab focuses on gene discovery of complex and single-gene disorders. His research projects include searching for the genes for myopia (near-sightedness), age-related macular degeneration (AMD), Nance Horan Syndrome (a disorder linked to the X-chromosome causing eye and dental abnormalities) and Tcm gene causing microphthalmia or small eyes.

Kalliopi Stasi, MD, PhD

As a cornea specialist and a clinician scientist, Dr. Stasi’s current research project, in collaboration with Penn’s Institute for Regenerative Medicine, focuses on establishing a method for culturing cornea/limbal stem cells and studying their properties in a way that they can be used in the future for transplantation in order to treat limbal stem cell deficiency from a variety of ocular conditions, from ocular burns to post-cancer to congenital diseases.

Richard Stone, MD

Dr. Stone is director of the Applied Ophthalmic Neurobiology Laboratory, studying control mechanisms regulating ocular physiology and development. His studies have addressed the mechanisms responsible for myopia (near-sightedness). His studies have identified several signaling pathways that appear to be involved in controlling eye development, a number of which have now been extended to children. These include the identification of a drug-inhibiting myopia progression in children, the first such clinical innovation in several centuries, and the idea that the daily light-dark cycle might influence eye development.

Gui-shuang Ying, PhD

Dr. Ying is the principal investigator of the Data Coordinating Center for a multicenter study “Telemedicine Approaches to Evaluating Acute-phase Retinopathy of Prematurity (e-ROP)”, a four-year study funded by the National Eye Institute. Retinopathy of prematurity (ROP) is the leading cause of treatable childhood blindness, but is becoming an increasing problem in underserved areas of the U.S. and Canada, and epidemic rates are being found in rapidly developing countries The e-ROP study evaluates the validity, reliability, feasibility and cost-effectiveness using telemedicine to examine the eyes of at-risk babies. The study will enroll 2,000 babies with birth weight of 1250 grams (2.76 pounds) or less from 10 neonatal intensive care units in the United States. The study hopes to greatly reduce the number of examinations needed to be performed by specially trained ophthalmologists, and significantly increase the number of babies who receive appropriate timely evaluations.

Penn Provides Specialized Care for Pituitary Disease

The symptoms can be vague. Headaches, weight loss or gain, fatigue, and cold intolerance: Symptoms that might be dismissed as menopause or stress. But these symptoms can sometimes mask pituitary disease.

The Penn Pituitary Center was created to diagnose and treat people with pituitary disease. The center's multidisciplinary team of endocrinologists, neurosurgeons, radiation oncologists, neuroradiologists, interventional radiologists and neuro-opthalmologists are recognized internationally for their expertise in the diagnosis and treatment of neuroendocrine diseases.

The pituitary gland is about the size of a pea and sits in a small cavity at the base of the brain. It produces major hormones that control bodily functions.

“If the pituitary gland’s functions are compromised by disease or a tumor, hormone production is impaired and an individual will experience symptoms,” says endocrinologist Julia Kharlip, MD.

"The symptoms may go unexplained for months or sometimes years until the problem is uncovered by an astute clinician or when the patient’s peripheral vision begins to be affected by a growing pituitary tumor," Dr. Kharlip continues. "The good news is that although these diseases are insidious, once diagnosed, they can be treated successfully, restoring quality of life and preserving vision.”

The Penn Pituitary Center provides the latest specialized care for patients with pituitary disease including:

• Acromegaly
• Cushing's disease
• Hyperprolactinemia
• Gonadotroph and other clinically nonfunctioning pituitary adenomas
• Pituitary and hypothalalmic lesions
• Hypopituitarism
• Diabetes insipidus

Because these are complex disorders, care of one patient involves multiple specialists.

“Seeing so many doctors may sound daunting, but our center coordinator makes navigating the multiple visits easier for families, often scheduling all appointments on the same day. All physicians at Penn have access to electronic medical records and images. Once a patient starts their journey, there is no more logging of the bulky stacks of handwritten notes or image envelopes from visit to visit," Dr. Kharlip said.

“Once all of us had a chance to evaluate the patient individually, the specific case is discussed among the team at a conference, where we can form a consensus of opinion about treatment plans from all disciplines,” says Dr. Kharlip. "When several treatment options are reasonable, we involve the patient in choosing the approach that is best for him or her."

Every person’s experience with pituitary disease is unique and deserves a treatment plan tailored to their needs. Consequently, patients with pituitary disease benefit from the observations and expertise of many medical fields including endocrinology, ophthalmology and neurosurgery.

“We can offer patients advanced care that community hospitals may not be able to offer because we have the expertise and technology only an advanced academic institution like Penn Medicine has,” says Dr. Kharlip.

Surgical expertise

Pituitary disease affects nearly 22 percent of the U.S. population. It is often caused by a tumor and surgery is almost always part of the treatment plan. The good news is most pituitary tumors are benign, or non-cancerous.

“Having surgery when the pituitary is damaged can be dangerous. Before surgery, the endocrinology team works with patients to make sure their hormones are at safe levels,” said Dr. Kharlip.

Sean Grady, MD, is the chairman of the department of neurosurgery at Penn Medicine. He says the procedure to remove pituitary tumors is straightforward, but its complications can be substantial.

“Pituitary tumors are usually removed with minimally invasive techniques through a patient’s nasal cavity,” says Dr. Grady. “It requires no incisions, and patients usually go home within three days.”

But because of the tumor’s location within the brain, it’s important for patients to have their surgery performed by a team whose experience and expertise ensures the best possible outcomes.

“We perform two to three surgeries like this per week,” says Dr. Grady. “Not only does our surgical team have vast experience with this type of procedure, the entire team within Penn’s Pituitary Center is aware of the alternatives to surgery when surgery may not be the best option.”

After surgery, patients may receive radiation treatment to prevent recurrence or shrink any part of the tumor that could not be surgically removed.

“Penn offers patients the latest approaches in radiation treatment,” says Dr. Kharlip. “From Gamma Knife® radiation therapy, which delivers a single high dose of gamma radiation to the tumor, to proton therapy which is only offered in a handful of locations within the country, to traditional radiation therapy, patients have the benefit of Penn’s expertise throughout their entire treatment.”

For more information about the Penn Pituitary Center, or to make an appointment, please call 800-789-PENN (7366) or visit PennMedicine.org.

Advanced Neuro Critical Care

It might look like every other intensive care unit (ICU) in a hospital, but Penn Medicine’s Neuro ICU is a highly specialized unit with experts trained to monitor, treat and rehabilitate patients with neurological issues.

W. Andrew Kofke, MD, specializes in anesthesiology and critical care and is co-director, with Joshua Levine, MD, of the 22-bed unit.

“While we act very similar to a regular ICU, our staff is trained and specialized to look for specific issues and complications neurosurgery and neurology patients may encounter as they recover,” says Dr. Kofke.

The Neuro ICU is part of the Penn Comprehensive Neuroscience Center. It is a level I trauma center and acute brain injury center, treating and monitoring patients who have experienced head trauma, spinal cord injuries, epilepsy, brain infections, strokes and patients who have had neurosurgery, including removal of tumors on the pituitary gland.

Bringing Penn Medicine Expertise to the Community

Patients throughout the region are realizing they don’t have to travel to Philadelphia to see a Penn Medicine physician. In many suburban communities, Penn Medicine is right around the corner.

Beginning with the opening of its first multispecialty site in Radnor in the 1990s, Penn has focused on bringing its expert services and nationally recognized physicians to the communities it serves. Following the model established in Radnor, multispecialty Penn Medicine medical buildings were opened in Bucks County and Cherry Hill, NJ.

In 2010, Penn Medicine extended its reach into the suburbs with two new state-of-the-art medical centers, Valley Forge and Woodbury Heights.

Valley Forge

Valley Forge, a 90,000-square-foot outpatient medical building at the intersection of Chesterbrook Boulevard and Swedesford Road in Chester County, opened in July 2010. It is home to a large family medicine practice, on-site laboratory and radiology services and specialists.

This location also serves as a primary care training site for University of Pennsylvania School of Medicine students.

Designed as a “green building” and Leadership in Energy and Environmental Design- (LEED) certified, the building’s design reduces water runoff and uses less energy. Construction is also under way for a same-day surgery center that is expected to open in 2012.

Woodbury Heights

Located at 1006 Mantua Pike in Woodbury Heights, New Jersey, this facility is a 30,000-square-foot outpatient medical building with Penn primary care, obstetrics and gynecology, specialty care physicians, on-site laboratory services, and physical therapy.

Bucks County

Like the other community-based medical centers, the Bucks County facility provides expert primary care and specialty health care, plus a full range of services to residents of Bucks County. Now families can see their primary care physician, consult with a specialist, get lab work and radiology services all in one place.

Cherry Hill

Cherry Hill was the first multispecialty facility to bring Penn Medicine physicians to South Jersey. Along with a large family medicine practice, lab and radiology, physicians from several specialties see patients at Cherry Hill.

Radnor*

The model for Penn’s community-based practices, Radnor offers services in over 40 medical specialties. In addition to physician appointments, Penn Medicine patients also have access to on-site lab and radiology services, a pharmacy and optical shop.

A variety of on-site health education programs are offered in the spring and fall. Open to the public at no charge, the Mainly Your Health programs feature Penn Medicine physicians and clinicians who discuss the latest treatment advances and ways to stay healthy. The Mainly Your Health lecture series is being expanded to several other Penn Medicine community locations.

*A facility of the Hospital of the University of Pennsylvania

Information about all Penn Medicine hospitals and locations including services available, driving directions and visitor information is available at PennMedicine.org.

Finding Relief from Knee Pain

Knee pain is a common complaint and it has many causes. At Penn Medicine, teams from orthopaedics, sports medicine, radiology, and physical therapy and rehabilitation work together to help patients find relief from knee pain.

An accurate diagnosis of the cause of the knee pain is the first step in developing the appropriate treatment plan.

Getting the Whole Picture

X-rays are usually the first step in diagnosing knee pain or injury. When a patient shows up with knee pain, he or she is evaluated by a Penn orthopaedic specialist who performs a focused exam that matches the symptoms to what is seen on film.

“X-rays are good screening tools for assessing the bones and structures,” said Nancy Major, MD, from Penn Radiology. “We get multiple views of the knee joint and almost always move forward with an MRI that lets us see inside the knee joint.”

Magnetic resonance imaging, or MRI, allows the radiologist and orthopaedic specialists to look inside the joint at cartilage, ligaments and tendons. It may even show small fractures that don’t show up on the X-ray.

“The X-ray and MRI can help the physician and the patient determine the best way to manage the knee pain,” Dr. Major said.

Non-surgical Options

If reducing pain is the primary goal of treatment, joint preservation is the next priority, according to John Kelly IV, MD, Penn sports medicine specialist.

“We look for ways to treat the patient and the knee,” Dr. Kelly said. “A stronger knee often means a reduction in the stress that causes pain. Weight reduction and physical therapy may help alleviate the pain and improve the patient’s health.”

If strengthening is not enough, Dr. Kelly said the least invasive treatment methods are often the best, especially for younger patients.

“People are living longer so a knee replacement for someone in his or her 40s may have to last 50 years,” Dr. Kelly said. “If we can treat the pain with injections or arthroscopic (minimally invasive) surgery and postpone major surgery for a few years, the patient stands a better chance of long-term success.”

Joint Replacement Improves Quality of Life

Often, joint replacement surgery is the best solution for managing debilitating knee pain or injuries. Undoubtedly one of the greatest medical advances for improving patients’ quality of life over the past 40 years, knee replacements have been performed in millions of Americans, easing pain, improving range of motion, and keeping them active.

“Younger people aren’t ready to slow down and they are not going to let their pain dictate their activities,” said Craig Israelite, MD, orthopaedic surgeon at Penn Presbyterian Medical Center. “It used to be we wouldn’t even consider joint replacement for a patient under the age of 60. But now, with new materials that are more durable and longer lasting, we can help younger patients and get them back to their life.”

In addition to performing a large number of surgeries, Penn orthopaedic surgeons also perform more complex and complicated knee replacement procedures, as well as many minimally invasive procedures. They are also continually working to improve the fit and function of joint replacements. The ultimate goal is to make the replacement feel and act as normal as possible, especially for knees.

Back in Action

Every patient experiencing knee pain finds themselves in physical therapy at some point during their treatment. The ultimate goal is to return to normal activities without pain and physical therapy builds strength in the knee and improves the range of motion.

“The first thing we do with knee patients is an evaluation of the problem, what are the pain levels, whether or not they have had surgery and what type of surgery and what is the normal activity level to which the patient needs to return,” said Brian Leggin, PT, DPT, OCS with Good Shepherd Penn Partners Penn Therapy and Fitness.

Extension, range of motion of the knee and strengthening the thigh and hip muscles are key components to rehabilitation, according to Leggin. Without full extension—being able to straighten the leg without a bend at the knee—patients will walk with a limp.

As the range of motion improves, the therapy focuses on activities that make the leg stronger. Studies have demonstrated that improving strength leads to better function. Leggin also said studies show that following surgery, patients make the biggest gains in the first three months of therapy and after six months, most return to a normal level of activity.

People experiencing knee pain from arthritis or injury can find more information or schedule an appointment with a Penn orthopaedic specialist at PennMedicine.org or by calling 800-789-PENN (7366).

Advanced Reproductive Care

Penn Fertility Care has helped thousands of couples become families. Last year alone, fertility specialists at Penn performed more than 400 in vitro fertilization procedures. Fertility treatments have advanced considerably throughout the last 40 years as evidenced by development of reproductive options including in vitro fertilization, cryopreservation of sperm, eggs and embryos, micromanipulation of gametes and embryos, preimplantation genetic diagnosis and third-party reproduction.

IVF

In vitro fertilization (IVF) is the most successful infertility treatment, according to Anuja Dokras, MD, PhD, medical director of Penn Fertility Care’s in vitro fertilization program.

It is commonly used when the fallopian tubes are severely damaged or absent, and for other indications such as unexplained and male factor infertility. For IVF, the ovaries are stimulated with hormones to produce multiple egg-containing follicles. The eggs are retrieved surgically and immediately transferred to the laboratory where they are fertilized and cultured for a few days. On a predetermined date, the developing embryos are inserted into the uterus for further growth and implantation.

Due to its high success rate, IVF has been used more frequently in recent years as a therapy for all causes of infertility.

Micromanipulation

Micromanipulation of eggs and sperm can help make IVF more effective, especially in cases of male infertility. According to Dr. Dokras, intracytoplasmic sperm injection (ICSI) is a technique whereby a sperm is inserted directly into the harvested egg. Specialized tools are used to pick up an individual sperm and inject it into the inner part (cytoplasm) of the egg allowing sperm that cannot swim (decreased motility) or bind to an egg to fertilize it.

“We have success with this procedure in cases of severe male infertility,” said Dr. Dokras. “If the man produces no sperm, we can also use sperm taken through a testicular biopsy to fertilize the egg.”

Other micromanipulation methods used in infertility treatments include the use of a laser to make a small opening in the shell surrounding the egg (zona) to help the embryo attach to the uterus.

If one or both parents are carriers or affected by a genetic or chromosomal disorder, embryo biopsy for preimplantation genetic diagnosis (PGD) may be performed before the embryos are transferred to the uterus, Dr. Dokras said. This allows couples to make informed decisions about their next steps in the IVF process by ensuring that embryos unaffected by the genetic or chromosomal disorder are selected for transfer to the uterus.

Third-Party Reproduction

Donated eggs, sperm and embryos have helped many couples realize their dream of starting a family. In other cases, a gestational carrier, or surrogate, helps couples create their family.

“Third-party reproduction is a process where one person (known or anonymous) provides eggs, sperm or embryos to another person or couple so that they may become pregnant,” said Dr. Dokras. "For women who are unable to carry a pregnancy, and for those who have experienced multiple pregnancy losses, surrogacy can be the answer."

Penn has a successful egg donation program that promotes responsible, healthy outcomes.

The donor embryo program is a relatively new service for patients who have not had success with IVF and other fertility treatments. Penn Fertility Care receives donated cryopreserved embryos from patients who have gone through successful in vitro fertilization treatment. Using donated embryos is an excellent form of treatment for couples that have been unsuccessful in achieving pregnancy through assisted reproductive technologies with their own eggs and sperm (or gametes).

Couples who choose to have their child carried by surrogate make most of the arrangements on their own and Penn fertility specialists work with the parties to facilitate the process. IVF is the most common method for achieving pregnancy with a surrogate.

“The third party’s assistance is limited to the reproductive process and does not involve raising the child,” Dr. Dokras said. “This may not be a traditional method to have a baby, but these services have helped to build families around the world.”

Assisted reproduction involving a third-party requires additional considerations including medical, financial and legal issues.

For more information or to schedule an appointment with Penn Fertility Care, please visit PennMedicine.org or call 800-789-PENN (7366).

Every Option for Treating Prostate Cancer

According to the American Cancer Society, more than 2 million men in the U.S. count themselves as prostate cancer survivors. Men worried about developing prostate cancer, making decisions about their treatment, or trying to stay well after treatment, will find a full spectrum of care at Penn Medicine.

Prostate cancer is the most common cancer in American men, and in most men it grows very slowly. It occurs when cells in the prostate gland grow out of control. There are often no early prostate cancer symptoms, but some men have urinary symptoms and discomfort. In 2010, an estimated 218,000 men in the U.S. were newly diagnosed with prostate cancer and an estimated 32,000 deaths were attributed to the disease.

Experts at Penn Medicine's Abramson Cancer Center say age is the strongest risk factor for prostate cancer. Prostate cancer rarely occurs before the age of 40, but the chance of having prostate cancer rises rapidly after age 50. African-American men appear to be at higher risk for developing prostate cancer than men of other races.

Many men who come to Penn Urology have already had a positive prostate biopsy. Before a treatment plan is developed, Penn urologists get a complete diagnosis. This may include an endorectal coil MRI of the prostate gland and pelvis. This technique, developed at Penn Medicine, currently represents the optimal method for visualizing the local anatomy and assessing the extent of the disease.

After the evaluation, patients are encouraged to seek an opinion with a Penn radiation oncologist with special expertise in prostate cancer and have an extensive discussion with the urologist as well. They are provided with a comprehensive list of management options, which may include “active surveillance,” surgery or radiation therapy.

Active Surveillance

Sometimes called “watchful waiting,” active surveillance involves diligent monitoring of the prostate. According to Alan J. Wein, MD, PhD (Hon), chief of Penn Urology, active surveillance may be an excellent option for men with low-volume disease that does not appear aggressive.

“Just like any treatment, this is not for everyone. But especially for older patients with a low PSA, limited disease and a biopsy that has shown the disease is not aggressive, active surveillance may be a good option,” Dr. Wein said. “When this option is selected, patients agree to diligent monitoring of their condition and all (doctor and patient) must agree to the changes that move them from surveillance to active management.”

Prostatectomy

Radical prostatectomy is surgical removal of the whole prostate gland plus some of the tissue around it, including the seminal vesicles. It is used most often if it looks like the cancer has not spread outside of the gland.

Radical prostatectomy is done as both as a nerve-sparing open surgical procedure and a robotic-assisted minimally invasive procedure. Penn’s urologic surgeons at the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center and Pennsylvania Hospital are experts in both approaches.

“Not everyone is a candidate for surgery,” said Dr. Wein. “We consider factors such as patient life expectancy, general health and stage of the cancer before considering surgery. The patient must consider, as well, his willingness and that of his family, to accept the risks, both general and specific, of the procedure.”

In the last few years, robotic-assisted prostatectomy has become the surgical option of choice for many men. When David I. Lee, MD, founded Penn’s robotic urology program in 2005, he was one of the first urologists in the region performing robotic-assisted prostatectomy.

“Prostate cancer strikes both young and older men,” Dr. Lee said. “For younger, healthier patients surgery may be the best treatment.”

According to Dr. Lee, robotic prostatectomy allows the surgeon a three-dimensional view of the prostate. The robot also provides magnification of the prostate and surrounding area, allowing the surgeon to see small vessels.

Patient outcomes are similar for both open radical prostatectomy and robotic prostatectomy.

Radiation Therapy

Penn Radiation Oncology provides access to the most advanced technologies and treatments available for prostate cancer including intensity-modulated radiation therapy and proton therapy.

Like surgery, radiation therapy is a primary treatment for prostate cancer, but it is non-invasive. External beam radiation is used to kill cancer cells and prevent them from dividing. Penn’s state-of-the-art external beam radiation tools for treating prostate cancer include photon (X-ray) beams and proton particle beams.

Photon beams are delivered by a linear accelerator, according to Neha Vapiwala, MD, chief of genitourinary cancer service for Penn Radiation Oncology. Intensity-modulated radiation therapy (IMRT) allows for bending and shaping of the photon beams to better conform to the size and contour of the tumor or target. Image-guided radiation therapy (IGRT) uses modern imaging techniques to identify the target throughout the treatment.

“Proton beam therapy is an incredible new tool we’ve just added to our armamentarium in the fight against prostate cancer,” Dr. Vapiwala said. “For many prostate cancer patients who are considering non-invasive treatment, proton therapy is a potential option.”

Penn Medicine's Roberts Proton Therapy Center is the largest and most advanced facility in the world for this targeted form of cancer radiation. Proton therapy is external beam radiotherapy in which proton beams are directed at the tumor. The radiation dose that is given through proton particles is very targeted, and exposure to surrounding normal tissues can be reduced or eliminated. This allows the radiation dose delivered to the tumor to be increased beyond conventional radiation. The possible result is a better chance for curing cancer with fewer harmful side effects.

Ongoing studies at Penn are currently investigating whether the favorable dose delivery of proton therapy results in less exposure and reduced side effects for patients with prostate cancer.

Cryotherapy

Despite the best efforts of both radiation oncologists and urologic surgeons, sometimes prostate cancer recurs. For those rare cases, cryoablation of the prostate gland may be used.

“Cryotherapy is a viable treatment option for local recurrence of prostate cancer,” said Joseph F. Harryhill, MD, Penn urologist at Pennsylvania Hospital. “When cancer recurs after radiation therapy, surgery can be difficult. We now have sophisticated equipment that allows us to precisely target the area to be treated.”

During cryotherapy treatment, Dr. Harryhill uses ultrasound to guide the placement of thin needles into the area being treated. Argon gas is used to form ice at the end of the needles. Cancer cells are more sensitive to cold than regular cells, so the freezing destroys the cancer cells.

Pennsylvania Hospital is one of the few facilities in the region offering this secondary therapy for prostate cancer.

For more information or to schedule an appointment, please visit PennMedicine.org, PennCancer.org, or call 800-789-PENN.

Teenagers Face Unique Challenges

Adolescence can be a challenging time. Many teenage girls experience irregular or absent menstrual bleeding, pelvic pain, excessive hair growth and ovary cysts. These symptoms may be the sign of an endocrine disorder.

The glands of the endocrine system release hormones that regulate many bodily processes, including menstrual and reproductive function. Fortunately, endocrine disorders can be managed by a reproductive endocrinologist.

Suleena Kansal Kalra, MD, is a reproductive endocrinologist who specializes in adolescent reproductive health at Penn Medicine. A reproductive endocrinologist is an obstetrician/gynecologist with specialized training and expertise who diagnoses, manages and treats endocrine disorders that affect menstrual and reproductive function.

For adolescent females, the normal changes related to puberty may occur too early, too often or not at all, according to Dr. Kalra. In some young women, these irregularities can be attributed to an endocrine disorder that could affect their future fertility and overall reproductive health.

Dr. Kalra provides specialized, one-on-one care for adolescents experiencing endocrine disorders that can affect reproductive health. She is available to see adolescent women at Penn Fertility Care at Pennsylvania Hospital and at the Radnor facility.

Penn Fertility Care offers a full range of adolescent reproductive health services, including evaluation and treatment for:

• Abdominal pain
• Amenorrhea
• Congenital uterine anomalies
• Dysmenorrhea
• Endometriosis
• Fertility-preserving surgery
• Hirsutism
• Irregular menstrual bleeding
• Ovarian cysts
• Polycystic ovary syndrome (PCOS)
• Reproductive options for cancer patients
• Reproductive surgery

For more information or to make an appointment with a Penn reproductive endocrinologist, call 800-789-PENN (7366) or log on to PennMedicine.org.