Dr Mukosai Simon Department of Surgery University Teaching Hospital 5th year lecture 22nd June 2012

Layout of Presentation
Introduction
Risk factors Diagnosis Grading TNM classification Imaging Treatment Questions

Introduction
Prostate cancer Disease Hormonal management Most common malignancy in elderly men Second most common cause of death in elderly men

Prostate Cancer: Etiology

Risk Factors Currently Under Investigation Racial origin Environmental factors Dietary factors Genetic factors

Risk factors for Prostate Cancer

Increased risk Family history First degree relation Family history of BRCA gene mutation Race Scandinavian African American
Decreased risk Race Asian Diet high in: Plant Vitamin A Isoflavonoids Lycopenes Selenium Vitamin E

Prostate Cancer: Diagnosis

Method of Detection DRE

Localized 50% - 60% at time of

diagnosis1,2
PSA

Localized 90% at time of diagnosis1 Pathologically confined two thirds of time

Diagnostic triad

Transrectal ultrasound biopsy

Gleason Grading System

TNM Classification System (T)

TX Primary tumor cannot be assessed T0 No evidence of primary tumor T1 Clinically unapparent tumornot palpable or visible by imaging T1a Tumor found incidentally in tissue removed at transurethral resection of the prostate (TURP); 5% or less of tissue is cancerous T1b Tumor found incidentally in tissue removed at TURP; more than 5% of tissue is cancerous T1c Tumor identified by prostate needle biopsy because of elevated PSA T2 Palpable tumor confined within the prostate T2a Tumor involves half of a lobe or less T2b Tumor involves more than half of a lobe, but not both lobes T2c Tumor involves both lobes T3 Palpable tumor extending through prostate capsule and/or seminal vesicle(s) T3a Unilateral extracapsular extension T3b Bilateral extracapsular extension T3c Tumor invades seminal vesicle(s) T4 Tumor is fixed or invades adjacent structures other than the seminal vesicles T4a Tumor invades bladder neck and/or external sphincter and/or rectum T4b Tumor invades levator muscles and/or is fixed to pelvic wall

TNM Classification System (N)

N+ NX N0 N1
N2

N3

Involvement of regional lymph nodes Regional lymph nodes cannot be assessed No regional lymph node metastases Metastasis in a single regional lymph node, <2 cm in greatest dimension Metastasis in a single regional lymph node, >2 cm but not >5 in greatest dimension, or multiple regional lymph nodes, none >5 cm in greatest dimension Metastasis in regional lymph node >5 cm in greatest dimension

TNM Classification System (M)

M+ MX Distant metastatic spread Presence of distant metastases cannot be assessed M0 No distant metastasis M1 Distant metastasis M1a Involvement of nonregional lymph nodes M1b Involvement of bone(s) M1c Involvement of other distant sites

Imaging Tests
Bone Scan Low 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 Options
Watchful waiting Therapies of curative intent
Radical prostatectomy Retropubic Perineal Laparoscopic Radiotherapy External beam radiation Brachytherapy Cryotherapy

Hormonal therapytestosterone deprivation

LHRH-A Bilateral orchidectomy Antiandrogen

Therapies of Curative Intent

Radical prostatectomy Retropubic Perineal Laparoscopic Radiotherapy External beam radiation Brachytherapy Cryotherapy

Radical Prostatectomy
Advantages Primary treatment

Stage-dependent

Disadvantages Major operation Erectile dysfunction Incontinence Bowel complications

External Beam Radiation

Advantages Efficacy equal to prostatectomy Outpatient procedure Disadvantages Erectile dysfunction Chronic bowel complications Incontinence

Brachytherapy
Advantages As effective as EBRT or surgery Disadvantages Urinary voiding symptoms Erectile dysfunction Rectal discomfort Edema

Cryotherapy
Advantages Short hospital stay Relatively noninvasive Disadvantages Erectile dysfunction Urinary problems (shortterm) Unknown long-term effectiveness

Hormonal Therapy: Current Treatment Options

Bilateral orchidectomy
LHRH-A LHRH-A + antiandrogen (CAB) Bilateral orchidectomy + antiandrogen

(CAB)

Blockade of androgen action

LHRH-A
Advantages As effective as bilateral orchidectomy in decreasing testosterone levels Administered every 1, 3, 4, or 12 months Potentially reversible Disadvantages Hot flashes Decreased libido Erectile dysfunction

Management of Advanced Prostate Cancer

Inhibit testosterone production
Surgical castration Medical castration with an LHRH-A

Block androgen receptor binding

Antiandrogen

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 men Each year over 20 000 men are diagnosed with prostate cancer and 9500 die from the disease There is no good evidence to indicate whether a population screening programme would reduce mortality Because 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 decision Up to 20% of men with clinically significant prostate cancer will have a normal PSA level About two thirds of men with an elevated PSA level will not have prostate cancer detectable at biopsy Up to 20% of tumours are missed at trans-rectal ultrasound guided biopsy