PROSTATE CANCER

Presented By:
Anupama Inaganti
2/28/06
Prostate Cancer
Prostate Cancer
 Prostate cancer is the most
common cancer in America
 After lung cancer, prostate
cancer is the leading cause of
cancer-related deaths among
men in the U.S
 Prostate cancer is a relatively
slow-growing cancer, the 5-
year survival rate for prostate
cancer diagnosed at all stages
is 98%. The relative 10-year
survival rate is 84% and the
15-year survival rate is 56%.
 Epidemiology

 Worldwide incidence of prostate cancer - red and swollen indicates a higher

rate.
 Epidemiology
 AGE -- >45 the incidence raises rapidly
 RACE, ETHNICITY – Black > White, Hispanic, Asian
 GENETIC FACTORS -- 2-3X increase if First Degree
family member and increases if more family members are
involved
 ? Diet– High animal fat diet– increases serum
testostorone
 Prostatitis– has increased risk especially by Gonococcal
and Syphilis
 Pathogenesis
 Susceptibility loci for prostate cancer have been
proposed on multiple chromosomes including
chromosome 1
 Mutations or deletions in one of two tumor
suppressor genes (PTEN, KLF6) have been
proposed
 Presence of BRCA1/2 mutations may increase the
risk of developing prostate cancer at least two to
five-fold
 Clinical Features
 Urinary urgency, nocturia,
frequency, and hesitancy
 New onset erectile
dysfunction
 Bone pain
 Local pain
 Hematuria
 Decreased urination
 Tiredness 2ndry to Anemia
 Uncontrolled bleeding 2ndry
to destruction of blood
clotting factors
 Diagnosis
Diagnosis :
PSA
DRE
BIOPSY

Causes of an Elevated PSA

•Benign prostatic Hyperplasia (BPH)
•Prostate cancer
•Prostate infection
•Prostate biopsy
Diagnosis:
 Diagnosis:

 Red line, corresponding to prostate cancer patients, has a sharp peak at 10%
 Blue line corresponds to the distribution of free PSA in patients whose
biopsies did not show prostate cancer
 Most patients with prostate cancer have a free PSA less than 15%
 Patients with free PSA over 25% usually have benign prostate hyperplasia
 Complexed ACT PSA shown to be more accurate than free/total PSA
 Diagnosis:

Total PSA Range 2.5 to 4.0 ng/ml

Age Range (Years)
%Free
<60 (yrs) >=60 (yrs) All Ages
PSA
<7 84 95 91
7-15 25 49 43
16-25 10 27 22 Total PSA Range 10.01 to 20.0 ng/ml
Age Range (Years)
>25 2 7 6

%Free PSA <60 (yrs) >=60 (yrs) All Ages

Total PSA Range 4.01 to 10.0 ng/ml <7 93 97 97

Age Range (Years)
7-15 43 71 67
%Free PSA <60 (yrs) >=60 (yrs) All Ages 16-25 22 47 45

<7 87 95 93 >25 5 15 15

7-15 27 50 48

16-25 12 27 27
>25 3 7 7
 Diagnosis:

 PS velocity-- assess the rate of

PSA change over time

 PSA velocity cutoff of 0.75

ng/mL per year distinguished
patients with prostate cancer
from those with either BPH or
no prostate disease with a
specificity of 90 and 100
percent, respectively
 Diagnosis

 PS Density– Prostate volume

affects the sensitivity and
specificity of PSA and the
median values of PSAD. PSAD
of 0.08 increases the PSA
specificity specially at a cut-off
point of 2.5ng/ml in prostates
smaller than 40ml.
 Serum PSA is then normalized
by prostate volume to give a
prostate density, with higher
PSA density values (greater than
0.15) being more suggestive of
prostate cancer than BPH
 Diagnosis:

 Abnormal DRE
 DRE can detect tumors in the
posterior and lateral aspects of
the prostate gland
 PPV of an abnormal DRE for
prostate cancer varies from 5 to
30 percent
 All men with induration,
asymmetry, or palpable
nodularity of the prostate gland
require further diagnostic
studies to rule out prostate
cancer, particularly if they are
over the age of 45
 Diagnosis:

 Prostate biopsy

 TRUS (TransRectal U/S)

 gold standard for prostate
cancer diagnosis
 relatively simple office
technique
 biopsy gun from any suspicious
areas (by DRE or TRUS)
followed by six tissue cores
from the base, midzone, and
apical areas of the right and left
lobes of the gland
 Complications: hematospermia,
hematuria, rectal bleeding
 Diagnosis:
 Gleason grade
 tumors are graded from
one to five based upon the
degree of glandular
differentiation and
structural architecture
 A primary and secondary
score are reported, and
combined to form the
combined Gleason score
 Diagnosis:

 Clinical Staging
 major means of determining prognosis and selecting
therapy
 frequently underestimates the extent of tumor found at
surgery
 Diagnosis:

 Radionuclide bone scan.

 Positive radionuclide bone scan
indicates extraprostatic spread
and eliminates the potential for
curative surgery.
 Yield of bone scans in men with
serum PSA values less than 10
ng/mL is extremely low.
 Combination of Gleason grade,
serum PSA concentration, and
clinical stage may be
particularly useful to predict the
likelihood of a positive bone
scan.
 Diagnosis:
 CT is often recommended as
part of the staging evaluation,
inability of CT scans to
diagnose extra capsular
extension and seminal vesicle
invasion accurately is well
known
 MRI with lymphotropic
super paramagnetic iron
oxide nanoparticles has higher
sensitivity for detecting nodal
metastases
 Endorectal coil MRI can
determine with reasonable
accuracy the likelihood of either
seminal vesicle involvement or
extra capsular extension
 Diagnosis:

 TNM Staging
 clinical stage, or "c" stage
determined by the DRE
and/or TRUS
 a pathological stage, or
"p" stage determined after
a pathologist has
evaluated a radical
prostatectomy specimen
 Partin Tables

 charts allows patients and their physicians to more accurately estimate the
probability that surgical intervention will result in complete removal of the tumor
 Treatment:

 Radical Prostatectomy
 clinical stage T1 and T2
prostate cancer
 perioperative morbidity
rates are less than 10
percent
 Treatment
 Cryosurgery ablation
 Liquid nitrogen or argon gas
flows into the prostate through
the probe and rapidly extracts
heat from the gland. in turn,
facilitates the rapid
development of ice crystals,
which is critical for cell death.
 limited to men with T1 to T3
tumors
 Salvage therapy refers to the
application of cryotherapy to
men with locally recurrent
disease
External Beam Therapy
 Brachytheraphy

 Permanent or
temporary rx
 Maximum of 3 doses
in temporary are
given and permanent
decay off in time
 More radiation is
given to a local spot
and decreases less
tissue damage
Treatment:
 Medical Management

 B/L orchidectomy
 Bilateral orchiectomy is the
standard by which other forms of
hormone therapy are measured
 much to offer when cost,
procedural ease, compliance, and
an immediate decrease in
circulating testosterone are
considered
 Male menopausal symptoms and
bone loss
 Treatment:

 LHRH Agonist–
Leuprolide and Gosrelin
 They can intially increase
Testostorone and worsen
flare up of Prostate ca.
 The depot last for 1 month
 LHRH antagonists---
Abarelix
 Abarelix has shown to be
as effective as Agonists
 Antiandrogens

 Flutamide, Bicalgutamide, Nilatumide

 All block the LH receptors

 Are not much superior to placebo if given alone

 Combination Rx
 Significant increases in progression-free survival
 Goserelin plus flutamide
Antiandrogens
Treatment
Initial Evaluation
Evaluation of Disease
Follow up
TURP
 Any Questions???
(No Questions Please..)
Thank You