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PROSTATE CANCER LETS DEBATE !!!!

PROSTATE CANCER LETS DEBATE !!!!. Dr Fred C Tyler MBChB FRCS FCS UROL. Case Presentation. Mr D N 44yr referred PSA 6,49 Low libido, poor erections PMH : Hypertension PSH: Nil Alllergies : Nil Smoking : 20/d OH : social. Case Presentation. Abdo: soft NAD Genitalia: NAD

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PROSTATE CANCER LETS DEBATE !!!!

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  1. PROSTATE CANCERLETS DEBATE !!!! Dr Fred C Tyler MBChB FRCS FCS UROL

  2. Case Presentation • Mr D N • 44yr referred PSA 6,49 • Low libido, poor erections • PMH : Hypertension • PSH: Nil • Alllergies: Nil • Smoking : 20/d • OH : social

  3. Case Presentation • Abdo: soft NAD • Genitalia: NAD • PR: BPH • Testosterone 20.48

  4. Case Presentation • Cystoscopy: Narrow bladder neck ,nil else • TRNB Prostate: One tiny focus of Gleason 6/10 ( 3 +3) 0.5 mm of one core Prostatitis

  5. Prognostic Grouping • Group 1 T1a-c NO, M0,PSA <10, GLS < 6 T2a • Group 2a T1a-c N0 M0 PSA < 20 GLS 7 PSA 10-20 GLS <6 T2a,b PSA <20 GLS ,7 • Group 2b T2c N0 ,M0 ,Any PSA, Any GLS T1 -2 PSA > 20 or GLS >8 Group 3 T3a-b Group 4 T4

  6. MR D N • Low risk • Group 1

  7. WHAT NOW !!!!!!

  8. EUA Guidelines • Clinical Stage 1c 40%-50% of new cases • SPGC 4 study showeds advatage of RP over WW but on;ly 5% of thise patients were PSA screened • Prevalence of under scoring GLS grades

  9. Watchful Waiting • T1a well or moderately differentiated if > 10 yrs life expectancy restaging with TURP and TRNB advised • T1b to T2b standard rx for well or moderately diff tumours in asymptomatic patients with life expectancy < 10 yrs. • NB Criteria • PSA <10. GLS <6, < 2 positve biopsies, < 50% of the biopsy involved.

  10. Radical Prostatectomy • Reduced cancer mortality and risk of metastases in men <65yr with little or no benefit 10 or more years after surgery • Standard rx if <65yrs age and who except rx related complications. • Role of Laparoscopic and Robot assisted Radical prostatectomy…..

  11. Extended pelvic node dissection • No benefit in low risk CAP

  12. Recommendations for Radical Prostatectomy • Neoadjuvant GNRH for 3 months is not recommended for T1 – T2 disease. • Nerve sparing surgery may be attempted for Low risk Disease: T1c, GLS 7, PSA ,10

  13. Definitive Radiation Therapy • Transperineal Interstitial Brachytherapy • T1c-T2a • GLS ,7 (3+4) • PSA<10 • Prostate vol <50ml • No previous TURP, Good IPSS • Localised CAP: T1c T2c , N0, M0, • 3D CRT +- IMRT even for young patients who refuse surgery ??? • Low , Intermediate,high risk patients benefit from dose escalation.

  14. Cryosurgery of the Prostate • Low risk CAP : PSA<10, <T2a,GLS<6 • Intermediate Risk: PSA > 10, GLS 7, Stage.T2b • 5 yr BDFR inferior to RP in low risl patients. • All other minimally invasive options are experimental……….

  15. Our patient…… • 3 months after diagnosis PSA 4.27 (9%) • 3 months later PSA 3.39 • 3months later PSA 4.51.

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