Dr Mukosai SimonDepartment of SurgeryUniversity Teaching Hospital5th year lecture 24th April 2015

Layout of PresentationIntroductionRisk factorsDiagnosisGradingTNM classificationImagingTreatmentQuestions

IntroductionProstate cancerDiseaseHormonal managementMost common malignancy in elderly menSecond most common cause of death in elderly men

Prostate Cancer: EtiologyRisk Factors Currently Under Investigation Racial origin Environmental factors Dietary factorsGenetic factors

Risk factors for Prostate CancerIncreased riskFamily historyFirst degree relationFamily history of BRCA gene mutationRaceScandinavianAfrican AmericanDecreased riskRaceAsianDiet high in:Plant Vitamin AIsoflavonoidsLycopenesSeleniumVitamin E

Prostate Cancer: DiagnosisMethod of DetectionDRELocalized 50% - 60% at time of diagnosis1,2PSALocalized 90% at time of diagnosis1Pathologically confined two thirds of time

Diagnostic triad

Transrectal ultrasound biopsy

Gleason Grading System

TNM Classification System (T)TXPrimary tumor cannot be assessedT0No evidence of primary tumorT1Clinically unapparent tumornot palpable or visible by imagingT1aTumor found incidentally in tissue removed at transurethral resection of the prostate (TURP); 5% or less of tissue is cancerousT1bTumor found incidentally in tissue removed at TURP; more than 5% of tissue is cancerousT1cTumor identified by prostate needle biopsy because of elevated PSAT2Palpable tumor confined within the prostateT2aTumor involves half of a lobe or lessT2bTumor involves more than half of a lobe, but not both lobesT2cTumor involves both lobesT3Palpable tumor extending through prostate capsule and/or seminal vesicle(s)T3aUnilateral extracapsular extensionT3bBilateral extracapsular extensionT3cTumor invades seminal vesicle(s)T4Tumor is fixed or invades adjacent structures other than the seminal vesiclesT4aTumor invades bladder neck and/or external sphincter and/or rectumT4bTumor invades levator muscles and/or is fixed to pelvic wall

TNM Classification System (N)N+Involvement of regional lymph nodesNXRegional lymph nodes cannot be assessedN0No regional lymph node metastasesN1Metastasis in a single regional lymph node, 2 cm but not >5 in greatest dimension, or multiple regional lymph nodes, none >5 cm in greatest dimensionN3Metastasis in regional lymph node >5 cm in greatest dimension

TNM Classification System (M)M+Distant metastatic spreadMXPresence of distant metastases cannot be assessedM0No distant metastasisM1Distant metastasisM1aInvolvement of nonregional lymph nodesM1bInvolvement of bone(s)M1cInvolvement of other distant sites

Imaging TestsBone ScanLow detection rate.Provides additional information in patients with skeletal symptoms.Computed Tomography (CT)Useful for staging in T4 disease.Recommended in patients with Gleason score of 8 to 10, clinical stage T3 or T4.

Typical regions of metastatic disease

Bone scan of metastases

Radiography

Bone scan

Treatment OptionsWatchful waitingTherapies of curative intentRadical prostatectomyRetropubicPerinealLaparoscopicRadiotherapyExternal beam radiationBrachytherapyCryotherapyHormonal therapytestosterone deprivationLHRH-ABilateral orchidectomyAntiandrogen

Therapies of Curative IntentRadical prostatectomyRetropubicPerinealLaparoscopicRadiotherapyExternal beam radiationBrachytherapyCryotherapy

Radical ProstatectomyAdvantagesPrimary treatmentStage-dependent

DisadvantagesMajor operationErectile dysfunctionIncontinenceBowel complications

External Beam RadiationAdvantagesEfficacy equal to prostatectomyOutpatient procedure

DisadvantagesErectile dysfunction Chronic bowel complicationsIncontinence

BrachytherapyAdvantages As effective as EBRT or surgery

Disadvantages Urinary voiding symptomsErectile dysfunctionRectal discomfortEdema

CryotherapyAdvantagesShort hospital stayRelatively noninvasive

DisadvantagesErectile dysfunctionUrinary problems (short-term) Unknown long-term effectiveness

Hormonal Therapy: Current Treatment OptionsBilateral orchidectomyLHRH-ALHRH-A + antiandrogen (CAB) Bilateral orchidectomy + antiandrogen (CAB)

Blockade of androgen action

LHRH-AAdvantagesAs effective as bilateral orchidectomy in decreasing testosterone levelsAdministered every 1, 3, 4, or 12 monthsPotentially reversible

DisadvantagesHot flashesDecreased libidoErectile dysfunction

Management of Advanced Prostate CancerInhibit testosterone productionSurgical castrationMedical castration with an LHRH-ABlock androgen receptor bindingAntiandrogen

What percentage of men with clinically significant prostate cancer will have a normal PSA level?5%20%40%

If the result of is 8 ng/ml. You therefore advise him to consider a trans-rectal ultrasound guided biopsy. What percentage of tumours are missed at biopsy?1%20%40%

THANK YOU

What percentage of men with clinically significant prostate cancer will have a normal PSA level?20%Catalona W, Smith D, Ratliff T, Basler J

If the result of is 8 ng/ml. You therefore advise him to consider a trans-rectal ultrasound guided biopsy. What percentage of tumours are missed at biopsy?20%

Rabbani F, Stroumbakis N, Kava BR, Cookson MS, Fair WR

Prostate cancer is an important health problem that affects mainly older menEach year over 20000 men are diagnosed with prostate cancer and 9500 die from the diseaseThere is no good evidence to indicate whether a population screening programme would reduce mortalityBecause of the uncertainties surrounding PSA testing it is important that you give men who request a test balanced information to help them make an informed decisionUp to 20% of men with clinically significant prostate cancer will have a normal PSA levelAbout two thirds of men with an elevated PSA level will not have prostate cancer detectable at biopsyUp to 20% of tumours are missed at trans-rectal ultrasound guided biopsy

The relative risk of prostate cancer is increased: Twofold if the patient has one first degree relative with prostate cancer diagnosed at age 70 or youngerFourfold if the patient has two relatives with prostate cancer if one of them is diagnosed at age 65 or youngerSeven- to 10-fold if the patient has three or more affected relatives

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