carcinoma prostate

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Category: Education
     
 

Presentation Description

anatomy ,etiology,scoring,grading,prediction,investigations,tre atment

Comments

By: dr.shruti (55 month(s) ago)

sir... thanks a lott...

By: ishfaq (55 month(s) ago)

thanx,i will be happy if you share your experiences regarding urology.i just came from urology conference yesterday and obsereved very intersting live surgeries and procedures. one was that of HIFU--- high intensity focused ultrasound , for localized tumour. DR ishfaq khattak, urology resident,institute of kidney diseases,peshawar,pakistan. also in prostate screenin some experimental tests are PCA -2,DD3

 

By: manjushafasate (56 month(s) ago)

very very nice presentation. thanks for giving such a wide information abt prostate cancer

By: ishfaq (55 month(s) ago)

HIFU--high intensity focused utrasound is al new modality for localized Ca prostate. some screening test are in process of devolopment like PCA-2,DD3

 

By: drmoath1987 (58 month(s) ago)

thank you very much for this nice presentation

By: ishfaq (55 month(s) ago)

HIFU--high intensity focused utrasound is al new modality for localized Ca prostate. some screening test are in process of devolopment like PCA-2,DD3

 

By: drvvkreddy (58 month(s) ago)

Nice information

By: ishfaq (55 month(s) ago)

HIFU--high intensity focused utrasound is al new modality for localized Ca prostate. some screening test are in process of devolopment like PCA-2,DD3

 
By: ishfaq (55 month(s) ago)

HIFU--high intensity focused utrasound is al new modality for localized Ca prostate. some screening test are in process of devolopment like PCA-2,DD3

 

Presentation Transcript


Prostate Cancer : 

Prostate Cancer Dr Muhammad Ishfaq SCW,Khyber Teaching Hospital,Peshawar,Pakistan, March 2009

Prostate anatomy : 

Prostate anatomy

Slide 4: 

Prostate Anatomy

Prostate Anatomy : 

Prostate Anatomy Prostate weights ~20g Measures ~3 by 4 by 2 cm Apex = inferior portion of prostate, continuous with striated sphincter. Base = superior portion and continuous with bladder neck. Prostatic urethra Covered by transitional epithelium Hugs anterior portion of gland Makes a ~30 degree bend in its mid portion (degree of angulation can vary from 0 to 90 degrees) Verumontanum just distal to urethral angulation's. ejaculatory ducts (union of seminal vesicles and each vas deferens) drain to each side of prostatic utricle (vestigial Mullerian duct structure)

Lobes of the Prostate : 

Lobes of the Prostate Anterior lobe Median lobe Lateral lobe Posterior lobe Image Source: SEER Training Website

Zones of the Prostate : 

Zones of the Prostate Peripheral Central Transitional Image Source: SEER Training Website

Prostate zones : 

Prostate zones Central zone (CZ) Cone shaped region that surround the ejaculatory ducts (extends from bladder base to the veru) Likely stems from Wolffian ducts 25% of glandular tissue in young adults Only 1-5% of prostate cancer from this region (likely because of Wolffian duct embryologic origin) Peripheral zone (PZ) Posteriolateral prostate Mesodermal in origin Majority of prostatic glandular tissue Origin of up to 70% of prostate adenocarcinoma Transitional zone (TZ) Surrounds the prostatic urethra proximal to the veru ( preprostatic urethra) Endodermal in origin In young men, accounts for only 5-10% of prostatic glandular tissue. Only ~20% of prostate cancer

Prostate Cancer Facts : 

Prostate Cancer Facts Most common tumor (non.cutaneous) in male 1/6 men diagnosed 1/34 men die of prostate cancer 70% over 65 y.o. at diagnosis 90% diagnosed at early stage Over past 20 years, survival 67% to 97% More diagnosis due to PSA

Some facts : 

Some facts Most frequently diagnosed tumor. 10% deaths due to malignancies . With PSA earlier diagnosis. Slow growing. More die with disease then of the disease. commonest in USA then Europe. Least common in south and east Asia.

Risk Factors : 

Risk Factors Environmental factors (diet,saturated fats,phto-estrogens) Genetic factors(family history) 2.4 times increased risk9first degree relative) Geography/race

Risk factors : 

Risk factors Genetics 5-10% of cases chromosome 1,17, HPC1 on ch 1 6-7 years earlier presentation Race African-American have higher incidence and more aggressive disease course. There serum testosterones level is 15% higher then Asians.

Risk factors : 

Risk factors Diet high fat diet is a risk factor. diet rich in soy may be protective. Omega 6 are positive stimulants while omega 3 are negative stimuli for Carcinoma. vit E & selenium has protective effect.vit A,D deficiency is risk factor. Hormones Androgen ablation & those using finisteride has decrease incidence.

Age wise risk : 

Age wise risk AGE RISK 0 - 39: 1 per 10149 40 – 59 : 1 per 38 60 – 69 : 1 per 14 70 – 79 : 1 per 7 0 - Death : 1 per 6 Source: ACS 2000 to 2002

Presentations of Ca Prostate : 

Presentations of Ca Prostate Asymptomatic. Incidental pathological finding BOO/abnormal DRE/raised PSA level(47%) Urinary irritative and obstructive symptoms. Metastatic symptoms bone pain,Pathological fractures,anorexia ,spinal cord compression etc. Difficult errection and ejaculation

Prostate specific antigen : 

Prostate specific antigen

Prostate specific antigen : 

Prostate specific antigen Total psa Free psa Psa velocity Psa density Psa transitional zone density

Average rate of rise in prostate-specific antigen levels with and without prostate cancer : 

Average rate of rise in prostate-specific antigen levels with and without prostate cancer

Prostate Specific Antigen : 

Prostate Specific Antigen Protein produced by cells of prostate gland Test introduced in 1986 Age influenced 40 - 49 / 2.550 - 59 / 3.560 - 69 / 4.570 - 79 / 6.5 Elevated indicates possible Carcinoma prostate PSA 4 – 10 indicates 25-35% risk of cancer diagnosis PSA 10 – 20 indicates 65% risk of cancer diagnosis PSA > 20 indicates possible metastatic disease

PSA : 

PSA It is not a diagnostic but help to identify in whom biopsy should be taken. PSA velocity or doubling time is more specific to give indication for biopsy. No identifiable PSA level give guarantee for normalcy. Assist in response to therapy. Most PSA is produced in TZ of prostate. In About 30% CA ,PSA is in normal range. Higher grade cancers cells produce less PSA. However PSA per gram of prostatic tissue is more in carcinoma.

PSA : 

PSA PSA level is increased with DRE , cystoscopy,catheter, trus. 2-3 days for normal level and 3-4 wks in case of biopsy.

PSA density; : 

PSA density; Total PSA divided by prostate volume. helps to differentiate b/w BPH and Ca in 4_10 PSA range. PSA tranzitional zone density.

Free PSA : 

Free PSA

Free PSA : 

Free PSA PSA that circulates in blood w/o carrier protein The lower the % of free PSA, the greater the risk of CaP Free PSA > 24% probably benign www.marinurology.com

Free PSA : 

Free PSA Indication for free PSA testing is PSA b/w 4____10 ng/ml and normal DRE. Can be lower in prostatitits However 95% cancer are detected.

PSA velocity (PSA-V) : 

PSA velocity (PSA-V) Rate of Change in PSA over time. PSA-V of greater then 0.75ng/ml over one year ,suggestive of Carcinoma. (PSA2 – PSA1)/time + (PSA4 – PSA3)/time

DRE : 

DRE PSA can be falsely elevated DRE does not palpate entire prostate gland Abnormal: nodules, hard spots, soft spots, enlarged

Triad of diagnosis,--(PSA_DRE_BIOPSY) : 

Triad of diagnosis,--(PSA_DRE_BIOPSY)

Screening ;Recommendations: : 

Screening ;Recommendations: AUA: Annual PSA, DRE Caucasians > 50 y.o. Annual PSA Af-Am males > 40 OR men w/+ FH ACS: Annual tests men > 50 y.o. IF 10 years of life expected (earlier AA men, + FH) American College of Preventive Medicine: Recommends against routine screening tests (PSA/DRE) Men over 50 w/10 years life should be told about benefits & harms of screening

Biopsy : 

Biopsy

Traditional indication for Prostate Biopsy:Usually with Life Expectancy >10yrs : 

Traditional indication for Prostate Biopsy:Usually with Life Expectancy >10yrs Abnormal DRE regardless of PSA Abnormal PSA velocity (.75 ng/dL/yr) PSA > 4.0 or age appropriate range Consider decreasing in men in 40’s, 50’s or with risk factors (FH/American) Elevated PSA does not mean prostate cancer

Prostate biopsy : 

Prostate biopsy Performed during TRUS Random biopsy 6-10 are taken to get a representative sample of prostate. Abnormal hypoechoic areas on u/s are also biopsied. Possibility of infection,give prophylactic antibiotic.

Biopsy (TRUSP) : 

kidney.niddk.nih.gov/kudiseases Biopsy (TRUSP) Hypoechoic shows abnormal area needing biopsy

Slide 40: 

Transrectal sonogram of the prostate. Looking up from the feet of a patient toward his head.

Flow chart : 

Flow chart 1-PSA + DRE-----?results-------?if both results normal-?consider regular DRE and PSA 2-PSA + DRE ---?one or both result abnormal-----? possible causes BPH,Prostatitis,Carcinoma.---?consider Free PSA, if low ,--Ca suspected--?biopsy----?Gleason's scoring----? treatment options. 3- if biopsy negative then go for regular DRE and PSA.

Other Workup : 

Other Workup Bone scan CT abdomen/pelvis PET scan Chest x-ray

Carcinoma prostate staging : 

Carcinoma prostate staging TNM system

Staging ,TNM system : 

Staging ,TNM system T1 Clinical inapparent tumor not palpable or visible by imaging T2 Tumor confined to prostate(palpable or visible by imaging) T3 Tumor extending through prostatic capsule T4 Tumor fixed or invading adjacent structure other then seminal vesical

Lymph node staging : 

Lymph node staging NX-cant be assessed N0-no lymph node involved N1-lymph node involved Metastasis staging MX- Cant be assessed M0- no mets M1-distant mets present

Tumor staging : 

Tumor staging T1 T1a-incidental findings at TURP(<5% of resected tissue) T1b-incidental findings at TURP(>5% of resected tissue) T1c-identified by needle biopsy(eg because of raised PSA) T2 T2a-Involving half of one lobe or less T2b-Involving more then half of one lobe,but not both lobes. T2c-Involving both lobes T3 T3a – extracapsular extension T3b- extension into seminal vesicle(s) T4 T4a-Fixed or invading other structures apart from s.v,like bladder,ext sphincter. T4b-invasion of levator muscles,pelvic floor.

Localized and advance disease : 

Localized and advance disease

Natural history of carcinoma prostate : 

Natural history of carcinoma prostate

Slide 53: 

Death from Other Causes Death from Other Causes Symptomatic Phase Detectable Presymptomatic Phase Disease Not Detectable Remaining Expected Lifetime Progression of Disease Patient 2 Patient 3 Patient 1 Death From Prostate Cancer Death From Other Causes Patient 4

Histology : 

Histology

Histology : 

Histology 99% Adenocarcinoma 1% Other Sarcoma, small cell, other PIN –(prostate intraepithelial neoplasia) 30% men will go on to develop CaP Close follow-up recommended for 2 years visualsonline.cancer.gov

Gleason's scoring system : 

Gleason's scoring system

Gleason's scoring system : 

Gleason's scoring system Dr Donald Gleason 1976 Based on microscopic tumor pattern assessed by pathologist while examining biopsy,when carcinoma is present GS is based on degree of loss of normal architecture of gland. Technically it is tumor grade.

Gleason's scoring system : 

Gleason's scoring system Gleason's grade GG Gleason's score or GS/also called Gleason's sum Gleason's differential GD

Gleason's grades , a histolopathological specimen into 5 grades. : 

Gleason's grades , a histolopathological specimen into 5 grades.

Gleason's sum : 

Gleason's sum Primary histological grade Secondary histological grade More then 50% of total pattern seen is primary ,Less then 50% but more then 5% of total pattern seen in a histopathological slide Suppose a specimen has loss of architecture of gland more then 50 % in grade 3 and the next pattern seen is grade 4 that is less then 50 %but more then 5%. Gleason's sum is 3+4=7 More the score ,worse the prognosis However 4+3 is not equal to 3+4

Gleason's differential : 

Gleason's differential The percentage make up of any Gleason score Suppose a GS ,3+4=7 this means that More then 50% are in histological grade 3.its amount can vary from 51% to 95%. Gleason,s differential is this exact percentage eg it is 75 %,so Gleason's score can be shown as Gleason's sum 3+4=7(75/25)

Data based tables : 

Data based tables Partin table Developed by dr Alan W.Partin Han table Developed by dr Misop Han These tables are used to predict pathology preoperatively (Partin)and recurrence post operatively(Han)

Partin nonogram : 

Partin nonogram Doctors need PSA, Gleason score, and estimated clinical staging Can determine probability of: Organ-confined disease Extraprostatic extension Seminal vesical invasion Lymph node involvement

Han table : 

Han table Shows probability of prostate cancer recurrence up to 10 years following surgery. Based on accumulated data from patients. Correlates PSA level ,Gleason's score and estimated stage

D’Amico et al risk stratification for clinicallylocalized prostate cancer : 

D’Amico et al risk stratification for clinicallylocalized prostate cancer Low risk Diagnostic PSA < 10.0 ng/mL and Highest biopsy Gleason score < 6 and Clinical stage T1c or T2a Intermediate risk Diagnostic PSA > 10 but < 20 ng/mL or Highest biopsy Gleason score = 7 or Clinical stage T2b High risk Diagnostic PSA > 20 ng/mL or Highest biopsy Gleason score > 8 or Clinical stage T2c/T3

Treatment : 

Treatment

Treatment : 

Treatment Goal: Find clinically significant cancer at a point when a cure is possible Goal: Avoid excessively aggressive treatment in clinically insignificant disease Examine prognostic factors of diagnosed disease to predict if it will be significant Consider patient medical issues, age, philosophy

Prognostic indicators : 

Prognostic indicators PSA Stage Grade #positive biopsy cores %biopsy core positive This helps us predict what cancer may be significant vs. insignificant

Treatment : 

Treatment Surgery Beam RT Seed RT Hormone Experimental Observation

Management : 

Management Management of localized cancer T1,T2 Management of advance disease T3 ,T4

Management of localized tumor : 

Management of localized tumor

Pre cancerous lesions : 

Pre cancerous lesions High grade prostatic intraepithelial neoplasia Look for con cumitant cancer. No therapy Regular PSA, DRE, physical examinations. 30 % develop carcinoma in one year. Atypical small acinar proliferations. Repeat biopsy.40-50% chance of carcinoma in subsequent carcinoma. Look for con concomitant cancer

Management of localized disease (t1,t2) : 

Management of localized disease (t1,t2) Active monitoring Radical prostatectomy Radical radiotherapy+-neo- adjuvant therapy Brachytherapy

Active monitoring : 

Active monitoring Ideal for men with well differentiated tumor and relatively low PSA level. Monitoring is regular PSA quarterly,biopsy yearly. Offered to man with life expectancy of 10 years. Morbidity associated with treatment is avoided. Delay for other diseases to improve Co-morbidities prevent other treatments.

Radical prostatectomy : 

general anesthesia. Incision: 8cm Begins just below navel and extends to pubic bone. Remaining Urethra is sewn to bladder neck over a catheter. Pelvic Bone (Pubis) Urethra Prostate Rectum Bladder Radical prostatectomy Surgical Approach

Laparascopic prostatectomy : 

Laparascopic prostatectomy

Robotic prostatectomy : 

Robotic prostatectomy Surgeon operates from a console with a 3-D screen. Grasp controls to manipulate surgical tools within the patient. Robotic arms translate finger, hand, and wrist movements. Shortens learning curve of surgeons Very High-Precision Cost, Benefit unclear

Radiation therapy : 

Radiation therapy High-Powered X-Rays that damage DNA and kill prostate cancer cells. External Beam Radiation Therapy (EBRT): X-rays aimed at prostate. Brachytherapy: Radioactive seed implants into prostate.

External beam radiation : 

External beam radiation

Beam Radiation : 

Beam Radiation

Prostate Brachytherapy : 

Prostate Brachytherapy www.prostate-cancer.org

Image of Prostate With Radioactive Bead Implants : 

Image of Prostate With Radioactive Bead Implants

Management of advance disease : 

Management of advance disease

Management of advance disease : 

Management of advance disease Locally advance disease. (T3) Radical prostatectomy is not usually indicated in this group. Active monitoring in asymptomatic patient, Palliative radiotherapy +/ - hormonal therapy

Management of metastatic disease : 

Management of metastatic disease Systemic palliative treatment Early institution of hormonal treatment

Hormone Therapy : 

Hormone Therapy LHRH analogs Lupron, Zoladex Androgen blockades Cyproteron acetate flutamide,bicalutumide They are not as effective as LHRH analog www.upmccancercenters.com

Bilateral orchidectomy : 

Bilateral orchidectomy Very effective Cheaper Avoids repeated inj

Management of hormone escaped prostate cancer : 

Management of hormone escaped prostate cancer Initial response of hormone treatment is excellent but with time prostate cancer becomes androgen independent and it this time hormone treatment is ineffective, Once this occur medial survival is 6 months. Various chemotherapy regimes are used in this case Palliative care Di ethyl stilbestrol Prednisolone Local radiotherapy to bone mets

Experimental : 

Experimental Hyperthermia Laser ablation Alternative medicine Pomegranate juice Ginseng Fasting Mini-trampoline Vitamin D Vaccines

Treatment for Recurrence/Mets : 

Treatment for Recurrence/Mets Hormones Orchidectomy Radiation to mets Radioisotopes strontium-89 (Metastron) samarium-153 (Quadramet) Chemotherapy

Slide 94: 

Thank you