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Introduction to Prostate Cancer

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Akbar Ashrafi Surgical Students Society of Melbourne September 2010. Introduction to Prostate Cancer. Background. Most common solid tumour in males Second highest cause of cancer death in men Affects men > 50 years Global increase in prostate cancer deaths since 1985

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akbar ashrafi surgical students society of melbourne september 2010
Akbar Ashrafi

Surgical Students Society of Melbourne

September 2010

Introduction to Prostate Cancer

background
Background
  • Most common solid tumour in males
  • Second highest cause of cancer death in men
  • Affects men > 50 years
  • Global increase in prostate cancer deaths since 1985
  • Unusual malignancy
pathophysiology
Pathophysiology
  • Uncontrolled cell division
  • 95% vs 4%
  • Neuroendocrine rare
aetiology
Aetiology
  • Genetics - chromosome 1, 17, and the X chromosome
  • Diet
    • Increased – high fat diet
    • Decreased – selenium, vitamin E
  • Hormones
    • 5-alpha-reductase inhibitor -  CaP, but histologically more aggressive (Prostate cancer prevention trial)
symptoms
Symptoms
  • Largely asymptomatic
  • Poor symptom-disease correlation
  • Local disease:
    • Weak stream, hesitancy, sensation of incomplete emptying, urinary frequency, urgency, urge incontinence
    • Same symptoms as BPH
symptoms1
Symptoms
  • Metastatic disease
    • Bone pain or sciatica
    • Paraplegia secondary to spinal cord compression
    • Lymph node enlargement
    • Loin pain or anuria due to ureteric obstruction by lymph nodes
    • Lethargy (anaemia, uraemia)
    • Weight loss, cachexia
presentation
Presentation
  • Incidental / Screening
    • PSA
    • DRE
    • TURP
signs
Signs
  • Rectal exam
    • Irregular, hard prostate
    • Nodules, asymmetry, immobile, palpable seminal vesicles, induration of prostate
  • Systemic
    • Cachectic, bone pain, anorexia, weight loss
  • Obstructive
    • Palpable bladder
    • Renal angle tenderness
investigations
Investigations
  • PSA
  • Urine microscopy + culture
  • UEC
  • Transrectal USS and biopsy
    • 20% false negative rate
  • Uroflow measurement, post void residual urine, cystoscopy
  • MRI, CT, Bone scan
staging
Staging
  • Non-metastatic prostate cancer
    • clinically localised or locally advanced disease
  • Metastatic disease
    • Spread beyond the prostate to lymph nodes, or to other organs
    • Bone metastases are particularly common
  • TNM classification
gleason score
Gleason score
  • Gleason score estimates the grade of prostate cancer according to its differentiation
  • Gleason grade 1 to 5
  • Gleason score is the sum of the two most prominent grades
  • Gleason grades
    • ranges from 2 (well-differentiated) to 10 (poorly differentiated)
prognostic value
Prognostic value
  • The Gleason score is the best prognostic indicator for prostate cancer
    • <4: well differentiated; ten-year risk of local progression 25%
    • 5-7: moderately differentiated; 50%
    • > 7: poorly differentiated; 75%
other prognostic factors
Other Prognostic factors
  • PSA >20
  • PSA density = PSA value by the volume of the prostate measured by trans-rectal ultrasound
          • PSA density > 0.304 => increased prostate cancer detection
          • at 2 and 5 years
  • PSA velocity = PSA velocity > 0.35ng/ml/yr has greater risk of dying from CaP
  • Stage
active surveillance
Active Surveillance
  • Preferred option for low-risk cancers
  • Serial PSA assessment and repeat prostate biopsy every 1-2 years
  • Any evidence of disease progression => offer radical treatment
  • 1/3 will need treatment
  • Carefully selected patients will not miss a window for cure with this approach
  • Avoid risks of radical treatment
watchful waiting
Watchful waiting
  • Watchful waiting
    • small tumour
    • well differentiated (Gleason score of 6 or lower), watchful waiting
    • older patients with significant other diseases
radical prostatectomy
Radical prostatectomy
  • Radical prostatectomy
    • extra-prostatic extension but no evidence of distant metastases
    • Early stage high risk cancer or patient who has failed to respond to radiotherapy
    • Laparoscopic vs open vs robotic
    • Complications
      • erectile dysfunction (up to 80%)
      • incontinence (up to 20% )
      • 40% have positive surgical margins
radiotherapy
Radiotherapy
  • Radiotherapy using external beam radiation
    • preferred option if there are distant metastases
    • erectile dysfunction (up to 60%)
    • incontinence (5%)
    • Long term bowel problems (10%)
  • Brachytherapy
    • transperineal implantation of radioactive seeds into the prostate (rare)
    • alone or in combination with external beam radiotherapy
high intensity focussed ultrasound
High Intensity Focussed Ultrasound
  • ablate/destroy the tissue of the prostate
  • high success rate with a reduced risk of side effects in preliminary studies
  • dubious studies - 94% of patients with a pretreatment PSA) of less than 10 ng/mL were cancer-free after three years
metastatic prostate ca
Metastatic Prostate Ca
  • Androgen suppression
  • Monthly or three-monthly depot injections of Goserelin (Zoladex)
    • Increased cardiovascular risk 30%
  • Bilateral orchidectomy as an alternative to continuous LHRHa therapy
  • Bicalutamide (Cosudex 50 mg) , a non-steroidal anti-androgen
    • In combination with LHRHa or surgical castration
    • Monotherapy
screening
Screening
  • American Cancer Society
    • Annual PSA + DRE
      • age > 50 + >10-year life expectancy
      • high-risk younger men
  • +: screening will identify early prostate cancer and reduce likelihood of CaP mortality
  • -: screening will detect cancers that are not biologically significant (ie those that die with prostate cancer rather than from it)
slide25
PSA
  • Single-chain glycoprotein
  • Hydrolyzes peptide bonds, liquidifying semen
  • Upper limit of normal for PSA is 4 ng/m
  • Diagnostic
  • Prognostic
  • Monitoring
literature on screening
Literature on screening
  • Canadian and Austrian studies suggest that mortality rates are lower with PSA screening
  • US data:  1% per year since 1990
  • Scandinavian study in 2002 => reduced disease-specific mortality with radical prostatectomy compared to watchful waiting
summary
Summary
  • Prostate cancer is common
  • Prostate cancer is generally asymptomatic
  • PSA is a useful screening tool in selected patients
  • Management depends on patient preference, grade and stage of cancer
  • Active surveillance is a recognised management option
ad