early detection of carcinoma prostate by dr. u.k.shrivastava (ms,fais,dha), prof. & head of...
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EARLY DETECTION OF EARLY DETECTION OF CARCINOMA PROSTATECARCINOMA PROSTATE
Dr. U.K.ShrivastavaDr. U.K.Shrivastava
MBBS,MS,FAIS,DHAMBBS,MS,FAIS,DHA
Professor and Head of surgeryProfessor and Head of surgery
AIMST University, MalaysiaAIMST University, Malaysia
Anatomy and Function of ProstateAnatomy and Function of Prostate
Situated in men in lower pelvis, at neck of bladder and in front of rectum, plum sizeIt secretes alkaline fluid 1/3 of fluid in semenFluid from prostate, seminal vesicles and Cowper's gland together make real bulk semen ejaculations, nourishes sperms,PSA comes from prostate epithelium, keeps semen in fluid form, avoid coagulation
AnatomyAnatomy
AnatomyAnatomy
Prostate CancerProstate Cancer
Became commonly diagnosed cancer 1989 Generally affects after the age of 50 years Starts in the peripheral zone of prostate Second leading cancer death in male after lung
cancer It is slow growing cancer, do metastasize Most common type is adeno carcinoma Early detection started from 1990 with PSA
MODALITIESMODALITIES
• SERUM P.S.A.
• DIGITAL RECTAL EXAMINATION
• TRANS RECTAL ULTRA SONOGRAM
• MAGNETIC RESONANCE IMAGING
SERUM P.S.A.SERUM P.S.A.
• serine protease, single chain glycoprotein• It contains 90% amionoacids 10% glycopr • organ specific marker not c.a. specific• Mostly secreted from prostatic epithelium• secreted mainly transitional zone BPH• secreted mainly peripheral zone Ca.P• Involved in liquefaction of seminal
coagulum
PSAPSA
Useful in diagnosing and staging Ca P
Useful in monitoring response of treatmt.
Discovery of PSA is major advancement
It has been a most valuable tumor marker
Very useful in detecting early Ca prostate
Normal value ranges from o to 4.0ng/ml
P.S.AP.S.A
Annual PSA testing is recommended from
50 years of age
If it is less than 1.0ng/ml every 5 years
If it is lower than 2.0ng/ml alternate year
If more than 2.0ng/ml get it every year
It is advisable to have from same LAB
PSA DENSITYPSA DENSITY
Introduced by Benson 1992It is a quotient of serum PSA divided, by volume of prostate gland PSA level dependent on number of prostatic cells Very high in BPH and also in CA prostate This confirms cancerous cells leak more PSA This facts help in detecting the malignancy The volume measurement of gland is achieved by TRUS Density variable with age
Recent conceptRecent concept
Measurement of TZ volume by TRUS is
more reliable than measuring entire
prostate volume
upper limit of 0.15 higher incidence of CA
Most of the PSA entering the circulation
arise from TZ
But in cancer they come from PZ
CA cells produce more PSA per unit volume
Prostate hyperplasiaProstate hyperplasia
Ca ProstateCa Prostate
PSA VELOSITYPSA VELOSITY
It is a measurement of rate of change in PSA volume over the time Concept introduced by Carter et al BPH patients will have linear rise in PSA CA patients linear rise in beginning, later exponential rise is PSA volume Carter says 0.75ng/ml rise per year has greater chance of developing CAP
AGE SPECIFIC PSA AGE SPECIFIC PSA REFERENCESREFERENCES
AGE 40 - 49 == 0– 2.5ng/ml 50- 59 == 0– 3.5 ng/ ml 60- 69 == 0—4.5ng/ ml 70- 79 == 0---6.5ng/ml The importance of this is that – It increases the sensitivity in men younger than 60yrs of age and specificity in men older than 60 years of age Over all specificity 95%
PSA VELOCITYPSA VELOCITY
Normal value 0- 4ng/ml
Half life 2 to 3 days
Rate of change non BPH 0--.04ng/ml/yr
BPH------.07 -0.27ng/ml/yr
0.75 ng/ml/yr risky CA
Any disruption in prostatic architecture-PSA
leaks in circulations
FREE PSAFREE PSA
Percentage of PSA circulates in blood without a carrier protein ( unbound)
PSA gets bound to alpha 1 anti chymotrypsein and alpha2 macroglobulin (ACT/AMG)It also remains free in serum PSA ACT found to be high in CAP than in BPHFree PSA low with inverse rise in PSA/ACT seen
in Carcinoma of prostateHigher the free PSA in BPH
FREE PSAFREE PSA
As the percentage of f/PSA declines, the
probability of a cancer prostate increases
The f/PSA is more discriminatory in
distinguishing between cancer and BPH
Size <40cc percent f/PSA 0.137and low
detect 90% OF CAP
Size >40cc cut of point 0.205 detect90%CA
FACTORS INFLUENCING FACTORS INFLUENCING SERUM PSA LEVELSSERUM PSA LEVELS
• Prostatitis• BPH and Carcinoma • Biopsy• DRE• TRUS• Cystoscopy• Ejaculation• Variable with age/race/ volume• U T I , vigorous exercise ,any sexual drive
PSAPSA
PSA screening recommended annually
all men >50 years
Family history, black men –PSA testing
at 40years
It is very helpful in detecting organ confined cancer prostate
Total prostatectomy can achieve the cure
DIGITAL RECTAL EXAMINATIONDIGITAL RECTAL EXAMINATION
Cancer detected by DRE are generally
locally advanced in50% of cases
Should never be abandoned, may detect
at times with normal serum PSA<4ng/ml
Positive predictive value of DRE
Serum PSA-- 0– 2.9ng/ml------4-11%
3.00-- 9.9ng/ml-----33—83%
DRE--- any nodule, hardness, fixity to R. mucosa
DREDRE
It should always be combined with
serum PSA testing for early detection
Always advisable to have DRE either
annually or twice in a year above 50 yrs
Any suspicious finding --- Advise TRUS
followed with sextant biopsy
DIGITAL RECTAL EXAMINATIONDIGITAL RECTAL EXAMINATION
PSA/ DREPSA/ DRE
PSA and DRE– complementary to each other 25% men of Ca P have PSA < 4ng/ml Cancer detected with DRE- 75%will have metastasisPSA – gets decreased after– orchiectomy, LHRH agonist, Flutamide , 5 alpha reductase inhibitor – helpful in medical treatment. of BPH
TRUSTRUS
It helps in seeing deep into the prostatic
tissues and finds the hypo echoic zone
It detects the size of prostate
seminal vesicles
spread of ca beyond prostate
Not to be used1st line screening study
lacks specificity, expensive , not helpful
in diagnosis, if already detected by DRE/PSA
TRUS TRUS
TRUSTRUS
Limitation that ,most hypo echoic lesions are not cancerIt could be cancer, infarct or even abscessAlways insure during bx for wide area sampling of
prostatic tissues Indications--------- raised PSA abnormal DREPZ 30-50% cancer may be of isoechoicTZ up to 80% may be isoechoic
TRUS guided BXTRUS guided BX
It can be---
Directed biopsy
Sextant biopsy ,now 12 core bx done
Anterior biopsy from TZ
Lateral lobe biopsy
Extended field biopsy
Gleason ScoresGleason Scores
1 The pathologist examine the bx cores and assign the no 1-5to most common pattern seen 2 Grade of 1 means cancer cells more like a
normal cell 3 Pathologist further identifies the second most common pattern and grade 1-5 so it ranges from 2-10 4 5-7 common type of slow growing tumor 8-10 aggressive tumors
TRUS BXTRUS BX
Can be done as OPD procedure it takes about 15 minutes Precautions---- enema local anesthesia prior antibiotics stop aspirin Complications ---- haematuria haemospermia
MRI (endo rectal coil)MRI (endo rectal coil)
This test is complimentary to TRUS
In the event of malignancy this tells about
the growth really confined to organ only
or gone beyond that
Involvement of seminal vesicles pelvic
lymph nodes and bladder can be detected
It is expensive------ NOT a screening tool
ALGORITHM FOR EARLY ALGORITHM FOR EARLY DETECTIONDETECTION
DRE PSA DIOGNOSTIC ACTIONNegative < age spec range annual PSA and DRENegative > age spec. range TRUS bx and sextant bx Positive Any value TRUS bx and sextant bx
ADVANTAGEADVANTAGE
Help to pick up significant disease before it becomes symptomaticHelp to monitor men who have higher risk of developing cancerHelp to pick up aggressive cancer early when treatment is feasibleHelp in investigating the prostatic disease when the value of PSA high
DISADVANTAGEDISADVANTAGE
2/3 of men with raised PSA --- no cancer
Some with normal PSA can have cancer
It does not tell whether cancer is fast/ slow
nature
Slow growing cancer does not affect the
life of the patient to that extent
Raised value demands bx its own hazard
CONCLUSIONCONCLUSION
To screen or not to screen ? Screening supported by— Disease is burdensome PSA detects curable tumor No cure for metastatic diseases PSA levels are strong predictor of future CA Studies are still on for guidelines for early detections of carcinoma of prostate
PREVENTION PREVENTION AND SUPPLEMENTSAND SUPPLEMENTS
• If its Heart Healthy---its Prostate healthy
• Whatever is good for heart, good for Pros
• Univ. of Arizona work on Selenium.
• Role of natural Vitamin E d gamma tocopherol ,d alpha tocopherol,best dietary
• found, in soya products,tofu,soya nuts
• Omega-3fatty acids good role
• Heart healthy oil-Soya, canola and ,Olive
SupplementsSupplements
• Plant estrogen supplements- by reducing
• androgen, but can lead to Erectile dysf.
• Breast tenderness, loss of libido hair loss
• and DVT
• Use of Aspirin good but bleed tendency
, salicylic acid found in fruits and vegi.
Use of Soya very good in , in all forms
SupplementsSupplements
• Drugs
a Androgen
b Dutastride
Exercise always good
Keep cholesterol low and HDL high