Prostate Cancer

PROSTATE CANCER. DR. MUGALO E.L. MBchB,M.MED SURG/UROLOGY.

INTRODUCTION. • Most Common Malignancy in Men • Usually Slowly Progressive and Without Symptoms Until Late in the Disease • Prior to PSA Marker, 50 % Were Metastatic at Diagnosis; Now < 15 %

RISK FACTORS. • Family history of Ca.prostate-risk higher (2 fold)in first degree relatives(brother or father) than in second degree relative (grandfather or uncle). • African american race. • Higher age (especially age >65).

Data from our region • Statistics: ---------------------Population--------New cases 2004 – USA: 295,000,000 220,000 – Kenya: 33,000,000 23,000 – Tanzania: 36,000,000 25,000 – Uganda: 26,400,000 18,400

PRESENTATION. • Age-usually present at age ≥65 (3040% of men>50 years of age have prostete cancer) • Most patients are asymptomatic • Advanced cancer symptoms includehematuria,urinary obstruction,bone pain from bone metastasis,lower limb edema,deep perineal pain,erectile dysfunction.

DIAGNOSIS-DRE

DIAGNOSIS-TRANSRECTAL NEEDLE BIOPSY.

Indications for biopsy. • • • • • • •

Abnormal DRE Abnormal PSA Rising PSA or elevated PSA velocity TECHNIQUE At least 10 systematic core biopsies. Use TRUS guided biopsy. Patient without anus(after AP resection)-CT or MRI guided biopsy.

CA. PROSTATE. • HISTOLOGICAL TYPES• adenocarcinoma>95% arise from the gland epithelial cells. • Non-adenocarcinoma<5%-TCC,small cell carcinoma,sarcoma. • LOCATION OF CA.PROSTATE. • Peripheral zone -70% • Transition zone -20% • Central zone 5-10% • Anterior prostate -Rare

McNeal Model of the Prostate

AJC/UICC TNM STAGING SYSTEM • T = Tumor Stage – Tx : Tumor not evaluable – T1 : Localized [ T1a small < 5%; T1b > 5%] • T1c : impalpable – found because of elevated PSA

– T2 : Intracapsular: [T2a in 1 lobe; T2b > 1 lobe] – T3 : Local Invasion: [T3a extracapsular; T3b involves seminal vesical]

AJC/UICC TNM STAGING SYSTEM • N = Nodes – Nx : Not evaluable – No : No Regional Node Metastases – N1 : Metastasis to Regional Node(s)

• M = Metastases – Mx : Not evaluable – M1 or + : Metastases are Present

Gleason TUMOR GRADING SYSTEM • Donald Gleason (1961, ff) – Gleason Grade: Grade assigned to each of 2 most common tumor patterns (from 1 to 5) – Gleason Score: Sum of the Two Gleason Grades • Usually Expressed as “3 + 3,” “3+4,” “4+4” etc

• The Higher the Score, The less

AJC/UICC TNM STAGING SYSTEM

AJC/UICC TNM STAGING SYSTEM

T1c – Normal DRE; Elevated PSA

PATTERNS OF METASTASIS

PATTERNS OF METASTASIS • Common sites include-pelvic LN,bone ,lungs,liver.

Local cancer spread. • Capsular penetration near the neurovascular bundle.common in the peripheral zone. • More common in patients with a higher clinical stage,higher gleason score,higher preoperative PSA.

TREATMENT- options for treatment • Localized Disease: – Surgery • Radical Perineal Prostatectomy • Radical Retropubic Prostatectomy

– Radiation Therapy • External Beam Radation (Teletherapy) • Radioactive Seed Implants (Palladium103 or Iodine125 ) (Brachytherapy)

• Combined

– No Therapy

RADICAL PERINEAL PROSTATECTOMY

RADICAL RETROPUBIC PROSTATECTOMY

RADIATION THERAPY

OPTIONS FOR TREATMENT • Advanced (Metastatic) Disease – Bilateral Orchiectomy – Estrogen Therapy • Diethylstilbestrol • TACE

– Androgen Agonist Therapy • Goserilin (Zoladex) • Leuprolide (Leupron)

OPTIONS FOR TREATMENT

OPTIONS FOR TREATMENT • Prognosis – Survival

10-yr Survival

– Surgical Removal – Limited to Capsule – ExtracapsularExtension – Distant Metastases 20-35 %

>80% 55 %

• Many Patients will Have Elevated PSA After Treatment but show No Evidence of Disease for Many Years • Many Patients Are Elderly at Diagnosis and May Die of Intercurrent Illness Not Related to Prostate Cancer

PREVENTION. • 1.PCPT(prostate cancer Trial) use of fenesteride in >18,000 men aged ≥55,normal DRE,and PSA≤3.0 were randomosed to fenesteride 5mg po q day or to placebo and followed for 7 years.[N Engl J Med,349:213.2003]. a).finesteride decreased the risk of deveolping prostate cancer by 25%, but men taking finesteride were more likely to have high grade cancers and sexual side effects (e.g. erectile dysfunction and loss of libido) • 2. REDUCE trial –evaluation of dutesteride for prevention of prostate cancer.Result pending. • 3.SELECT trial-examinig the use of Vit E and seleniun for the prevention of prostate cancer.Men with age ≥55,normal DRE,PSA ≤4.0 are randomised to one of four treatment arms:placebo,selenium and VitE. • 4.Dietary changes may help prevent prostate cancer