CA of Prostate:IncidenceCA of Prostate:Incidence

•In a 50 y/o manIn a 50 y/o man

•In autopsy: 40%In autopsy: 40%

•Clinical: 10%Clinical: 10%

•Death: 3%Death: 3%

•Most common non-cutanous diagnosed Most common non-cutanous diagnosed cancercancer

•Second cause of cancer deathSecond cause of cancer death

Risk factorsRisk factors

• Age: peak 68 yrs, 63% in >65 yrsAge: peak 68 yrs, 63% in >65 yrs

• Race: African-AmericanRace: African-American

• Family history (4-7 times)Family history (4-7 times)

• Fatty meal ( 2 times)Fatty meal ( 2 times)

• AndrogenAndrogen

• IGF-1IGF-1

• Inflamation and infectionInflamation and infection

CA of prostate (Pathology)CA of prostate (Pathology)

• Adenocarcinoma 95%Adenocarcinoma 95%

• Transitional cell carcinoma 5%Transitional cell carcinoma 5%

• Peripheral zone 60-70%Peripheral zone 60-70%

• Transitional zone 10-20%Transitional zone 10-20%

• Central zone 5-10%Central zone 5-10%

• Basal cell layer, ArchitectureBasal cell layer, Architecture

• PIN: HGPIN, LGPINPIN: HGPIN, LGPIN

Grade and stageGrade and stage

• Gleason grade and scoreGleason grade and score

• Well differentiated:2-4Well differentiated:2-4

• Moderate differentiated :4-6Moderate differentiated :4-6

• Poor differentiated : 8-10Poor differentiated : 8-10

• 7 ???7 ???

• Staging by DRE and TRUS Staging by DRE and TRUS notnot biopsy biopsy

CA of prostate (progression)CA of prostate (progression)

• Volume and grade are important Volume and grade are important factorsfactors

• Lymph node: obturator,common iliac, Lymph node: obturator,common iliac, periaorticperiaortic

• Bone: lumbar vertebra,femur,pelvisBone: lumbar vertebra,femur,pelvis

• Visceral: lung, liver, adrenal glandVisceral: lung, liver, adrenal gland

CA of prostate (clinical CA of prostate (clinical findings)findings)

• Mostly asymptomaticMostly asymptomatic

• Obstructive and irritative urinary Obstructive and irritative urinary symptomsymptom

• Bone pain, cord compressionBone pain, cord compression

• LymphedemaLymphedema

• DREDRE

CA of prostate (paraclinical CA of prostate (paraclinical finding)finding)

• AzotemiaAzotemia

• AnemiaAnemia

• Acid phosphataseAcid phosphatase

• Alkaline phosphatase (bone Alkaline phosphatase (bone metastasis)metastasis)

• PSAPSA

CA of prostate and PSACA of prostate and PSA

• Not specificNot specific

• PSA velocity:0.75 ng/yr in 18 monthsPSA velocity:0.75 ng/yr in 18 months

• PSA density:0.12 gm in BPH,>0.1-0.15PSA density:0.12 gm in BPH,>0.1-0.15

• PSA and age: 40-49 yrs 2.5,70-79 yrs PSA and age: 40-49 yrs 2.5,70-79 yrs 6.56.5

• Molecular form: 90% bound, F/T>25%Molecular form: 90% bound, F/T>25%

CA of prostate (imaging)CA of prostate (imaging)

• TRUS: BX, staging, volume, TRUS: BX, staging, volume, brachytherapybrachytherapy

• Endorectal MRI,MRS Endorectal MRI,MRS (sensitivity 50-90%)(sensitivity 50-90%)

• CT and MRI: R/O node metastasis, CT and MRI: R/O node metastasis, sensitivity 40-50%sensitivity 40-50%

• Bone scan: most common Bone scan: most common metastasis, negative if PSA<10 ngmetastasis, negative if PSA<10 ng

CA of prostate (treatment)CA of prostate (treatment)

• Watchful waitingWatchful waiting

• Radical prostatectomyRadical prostatectomy

• EBRTEBRT

• BrachytherapyBrachytherapy

• Cryosurgery + HIFUCryosurgery + HIFU

• Hormone therapyHormone therapy

• Systemic chemotherapySystemic chemotherapy

Watchful waitingWatchful waiting

• No therapeutic benefit for radical Rx No therapeutic benefit for radical Rx of early stage prostate cancerof early stage prostate cancer

• Small, well diferentiated pc are Small, well diferentiated pc are associated with very slow growth associated with very slow growth raterate

• Appropriate treatment for highly Appropriate treatment for highly selected patients: old wit small well selected patients: old wit small well diferentiated cancersdiferentiated cancers

Radical prostatectomyRadical prostatectomy

• Prognosis correlates with the Prognosis correlates with the pathologic stage and gradepathologic stage and grade

• Retropubic, perineal, laparascopicRetropubic, perineal, laparascopic• Immediate complications: blood loss, Immediate complications: blood loss,

rectal injury, ureteral injuryrectal injury, ureteral injury• Late complications: urinary Late complications: urinary

incontinence, impotenceincontinence, impotence• Total incontinence:3%, stress 20%Total incontinence:3%, stress 20%

Radical prostatectomyRadical prostatectomy

• Return of incontinence is gradualReturn of incontinence is gradual• Age is the single most important Age is the single most important

factor in restoration of incontinencefactor in restoration of incontinence• Nerve sparing surgeryNerve sparing surgery• Preservation of potency depend on Preservation of potency depend on

age, preoperative sexual function age, preoperative sexual function and preservation of one or both and preservation of one or both neurovascular bundleneurovascular bundle

RaditherapyRaditherapy

• External beam radiotherapy (XRT)External beam radiotherapy (XRT)

• Conformal radiotherapyConformal radiotherapy

• Less normal tissues is irradiatedLess normal tissues is irradiated

• Better PSA responseBetter PSA response

• BrachytherapyBrachytherapy

• Precise dose of radiotherapy by TRUS Precise dose of radiotherapy by TRUS can be applied can be applied

CryotherapyCryotherapy

• For treatment of localized prostate For treatment of localized prostate cancercancer

• 5 probe by TRUS5 probe by TRUS

• Cell destruction needs -25 to -50cCell destruction needs -25 to -50c

• Morbidity is significantMorbidity is significant

• Long term results are unknownLong term results are unknown

• In short term result in –ve post treatment In short term result in –ve post treatment biopsy and low or undetectable PSAbiopsy and low or undetectable PSA

Hormonal therapy for PC. Hormonal therapy for PC. GnRH-agonists GnRH-agonists

• Leuproreline, Busereline, GoserelineLeuproreline, Busereline, Gosereline• All product are equal in casteration in All product are equal in casteration in

terms of effectivenessterms of effectiveness• First injection will result in temporary First injection will result in temporary

increase of serum testostroneincrease of serum testostrone• Side effects: impotence, loss of libido, Side effects: impotence, loss of libido,

hot flashes, anemia, osteoprosis, hot flashes, anemia, osteoprosis, weight gain, mood changesweight gain, mood changes

Hormone therapy pc Hormone therapy pc GnRH antagonists GnRH antagonists• Directly blocking the GnRH receptorsDirectly blocking the GnRH receptors

• Available in depot injectionsAvailable in depot injections

• Avoid the flare-up reactionAvoid the flare-up reaction

• Faster suppression of testosterone Faster suppression of testosterone than GnRH agoniststhan GnRH agonists

• Side effects: as GnRH agonists + Side effects: as GnRH agonists + histamine mediated reactionshistamine mediated reactions