Prostate Cancer - Surgical Students Society of Melbourne
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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
Uncontrolled cell division
95% vs 4%
Neuroendocrine rare
Genetics - chromosome 1, 17, and the X
chromosome
Diet
Increased – high fat diet
Decreased – selenium, vitamin E
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
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
Non-metastatic prostate cancer
clinically localised or locally advanced disease
Metastatic disease
Spread beyond the prostate to lymph nodes, or to
other organs
Bone metastases are particularly common
TNM classification
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)
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%
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
PSA velocity = PSA velocity > 0.35ng/ml/yr
has greater risk of dying from CaP
Stage
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
Watchful waiting
small tumour
well differentiated (Gleason score of 6 or lower),
watchful waiting
older patients with significant other diseases
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
Radiotherapy using external beam radiation
preferred option if there are distant metastases
erectile dysfunction (up to 60%)
incontinence (5%)
Long term bowel problems (10%)
Brachytherapy
transperineal implantation of radioactive seeds
into the prostate (rare)
alone or in combination with external beam
radiotherapy
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
Androgen suppression
Monthly or three-monthly depot injections of
Goserelin (Zoladex)
Increased cardiovascular risk 30%
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
American Cancer Society
Annual PSA + DRE
▪ age > 50 + >10-year life expectancy
▪ high-risk younger men
+: 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)
Single-chain glycoprotein
Hydrolyzes peptide bonds, liquidifying semen
Upper limit of normal for PSA is 4 ng/m
Diagnostic
Prognostic
Monitoring
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
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