Adenocarcinomaprostate
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Transcript of Adenocarcinomaprostate
Common in western world One in six American men will be diagnosed
with prostate cancer during his lifetime Europe, the annual incidence rates were
214 per 1000 men
DRE PSA TRUS Biopsy and histopathology
• simple, cost effective method• Positive predictive value from 21% to 53%• Good staging method• sensitivity of 52% and specificity of 80%• MAY UNDER/OVER ESTIMATE
J URO 1999;161:835-9
The normal PSA are <4 ng/ml threshold PSA level for detection of cancer
is 4.0 ng/ml BUT 25% will have a normal or low PSA PSA <10 ng/ml - low risk of peri-prostatic
spread and metastases
PSA >20 ng/ml-An increased risk of peri-prostatic spread, seminal vesicle involvement and distant metastases
GENERAL RULES PSA >10 ng/ml indicates
capsularpenetration in more than 50% patients
PSA >50 ng/ml – metastatic disease.
prostate specific Not cancer specific BPH, prostatitis, tuberculosis etc borderline zone of 4-10ng/ml
Extended biopsy is more preferable cancer detection rate- 40%, sextant biopsy -20% to 25%
REV UROLOGY 2007 SUMMER,9(3):93-98
NATURAL HISTORY OF PROSTATE CANCER IS DIFFICULT TO PREDICT
Men with similar stage ,glisson score,psa can have markedly different outcome
Localized prostate cancer (T1 – T3a N0)
Locally advanced disease (T3b-T4 N0)
Metastatic disease: Any T, N+ or Any T, Any N &distant metastasis (M+)
Low risk (cT1-T2a and Gleason score 2-6 and PSA< 10)
Intermediate risk (cT2b-T2c or Gleason score = 7or PSA 10-20)
High Risk (cT3a or Gleason score 8-10 or PSA > 20)
PSA doubling time re-biopsy score , tumor volume stage progression patient preference.
RP -removal of the entire prostate gland between the urethra and the bladder, with resection of both seminal vesicles
is recommended for the organ confined prostate cancer with life expectancy of >10 years
Importance-to determine adjuvant therapy
Only ePLND
removal of obturator, external iliac, and hypogastric lymph nodes
int j radtn oncol biol phys 2012 jun;83(2) 624-9
• No direct RCT between surgery vs RT• Retrospective analysis not much of
difference between both modalities
• radical&palliative
• EBRT• EBRT+BT• BT
• Patient supine
• Hands over chest
• Immobilization –
• Four field BOX
• Shrinking field technique
• Superior border-L4-L5-to include the common iliac nodes
• Inferior border-1.5 -2cm below the junction of prostatic and membranous urethra –just below the ischial tuberosities
• Lateral margin-1-2 cm from the lateral boney pelvis
Anterior -pubic symphysis
Posterior margin-S2-S3 junction to include the pelvic and presacral nodes+sparing posterior rectal wall
Cystogram – supine ,catheter insitu-20 ml of
contrast+10ml of air introduced into bladder
20 ml of contrast into catheter balloon which is pulled down to bladder base
AP film in simulator-2cm margin is given with bladder base as center
Depends on risk Low risk-a minimum dose of 70 - 74 Gy is
(external with / without brachytherapy) Ideal-75-79 GY for low risk Intermediate &high risk-can extent to 81GY.
Permanent Temporary
Permanent-Ideal-are those with favorable risk prognostic features who have a high likelihood of organ-confined disease
• PSA levels 10ng/mL or less,
• Gleason scores less than 6-7,
• Clinical stages T1b- T2a
• prostate volume of < 50 cm3 and
• good International Prostatic Symptom Score (IPSS)
International Prostate Symptom Score (IPSS) is an 8 question (7 symptom questions + 1 quality of life question)
IPSS result of 7 symptoms questions
Score Correlation[1]
0-7 Mildly symptomatic
8-19 Moderately symptomatic
20-35 Severely symptomatic
• more easily optimize the delivery of RT to the prostate
• reducing the potential for under-dosage ,• reduces radiation exposure • radiobiologically more efficacious in terms
of tumor cell kill for patients with increased tumor bulk or adverse prognostic features.
.
Indication-positive surgical margins, seminal vesicle invasion and/or extracapsular extension
recommended doses are 60-64Gy
radiother oncol.2008 jul88(1)
Clinically localized disease Neo adjuvant/concomitant/adjuvant-
prolongs survival in radiation managed patients
When ever used cab should use Indicated in all high risk + locally advanced
+ metastatic disease(2-3 yrs) Short term androgen deprivation in
intermediate risk (4-6 months)
Hot flushes vasomotor instability Osteoporosis Obesity insulin resistance Greater risk of DM, cardiac diseses
mainstay of treatment -of long term hormonal therapy
local therapy- with radiation therapy preferred
EBRT-for painful or unstable skeletal metastases
DOSE -800 CGY –SINGLE fraction(Level of evidence: 1b)
Fractionated RT for bone metastases may be considered-spinal cord compression
Strontium89 Samarium153 improve bone pains in upto 70% patients
• reduce bone pains • skeletal-related events including fractures• inhibit osteoclast-mediated bone resorption and
osteoclast precursors effective-HRPCresponse rate of 70-80%
• Androgen deprivation- suppressing the secretion of testicular androgens –
surgical medical castration
• Anti-androgens -inhibiting the action of the circulating androgens at the level of their receptor in prostate cells
Simple&quickest way to achieve a castration level
Usually- obtained in less than 12 hours main drawback- negative psychological
effect
Currently the predominant forms of ADT Synthetic analogues of LHRH interfere with the hypothalamic-pituitary-
gonadal axis initially stimulate pituitary LHRH receptors
inducing a transient rise in LH and FSH release
compete with testosterone and DHT for binding sites on their receptors in the prostate cell nucleus
promoting apoptosis and inhibiting Prostate Cancer growth
Steroidal& non steroidal Both competes with androgen at receptor
but
long-term CAB- which stimulates prostate cell apoptosis
fails to eliminate the entire malignant cell population
after a variable period-tumor invariably relapse- averaging 24 months
Androgenindependent state of growth
• Role of Radiotherapy in Ca Prostate is time-tested.
• All stages and risk groups are benefitted with RT.
• In future , Radiobiology research , Molecular Pathways and Technological innovations are the keys to enhance the treatment.