Transcript Prostate Cancer - Surgical Students Society of Melbourne

Akbar Ashrafi
Surgical Students Society of Melbourne
September 2010
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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
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Uncontrolled cell division
95% vs 4%
Neuroendocrine rare
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Genetics - chromosome 1, 17, and the X
chromosome
Diet
 Increased – high fat diet
 Decreased – selenium, vitamin E
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Hormones
 5-alpha-reductase inhibitor -  CaP, but
histologically more aggressive (Prostate cancer
prevention trial)
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Largely asymptomatic
Poor symptom-disease correlation
Local disease:
• Weak stream, hesitancy, sensation of incomplete
emptying, urinary frequency, urgency, urge
incontinence
• Same symptoms as BPH
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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
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Incidental / Screening
 PSA
 DRE
 TURP
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Rectal exam
• Irregular, hard prostate
• Nodules, asymmetry, immobile, palpable seminal
vesicles, induration of prostate
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Systemic
• Cachectic, bone pain, anorexia, weight loss
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Obstructive
• Palpable bladder
• Renal angle tenderness
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PSA
Urine microscopy + culture
UEC
Transrectal USS and biopsy
• 20% false negative rate
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Uroflow measurement, post void residual
urine, cystoscopy
MRI, CT, Bone scan
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Non-metastatic prostate cancer
 clinically localised or locally advanced disease
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Metastatic disease
 Spread beyond the prostate to lymph nodes, or to
other organs
 Bone metastases are particularly common
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TNM classification
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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)
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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%
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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
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PSA velocity = PSA velocity > 0.35ng/ml/yr
has greater risk of dying from CaP
Stage
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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
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Watchful waiting
 small tumour
 well differentiated (Gleason score of 6 or lower),
watchful waiting
 older patients with significant other diseases
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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
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Radiotherapy using external beam radiation
 preferred option if there are distant metastases
 erectile dysfunction (up to 60%)
 incontinence (5%)
 Long term bowel problems (10%)
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Brachytherapy
 transperineal implantation of radioactive seeds
into the prostate (rare)
 alone or in combination with external beam
radiotherapy
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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
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Androgen suppression
Monthly or three-monthly depot injections of
Goserelin (Zoladex)
 Increased cardiovascular risk 30%
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Bilateral orchidectomy as an alternative to
continuous LHRHa therapy
Bicalutamide (Cosudex 50 mg) , a nonsteroidal anti-androgen
 In combination with LHRHa or surgical castration
 Monotherapy
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American Cancer Society
 Annual PSA + DRE
▪ age > 50 + >10-year life expectancy
▪ high-risk younger men
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+: 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)
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Single-chain glycoprotein
Hydrolyzes peptide bonds, liquidifying semen
Upper limit of normal for PSA is 4 ng/m
Diagnostic
Prognostic
Monitoring
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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
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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