PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.
-
Upload
brooke-hale -
Category
Documents
-
view
218 -
download
0
Transcript of PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.
![Page 1: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/1.jpg)
PROSTATE CANCER
Dr.GOVINDRAJAN
Department of Urology & Renal Transplantation
SRMC & RI
![Page 2: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/2.jpg)
PROSTATE GLAND
Present only in the male (base of the urinary bladder)
Prostatic secretions - add volume to semen
Most common male organ for occurrence of benign or malignant tumors.
![Page 3: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/3.jpg)
ZONAL ANATOMY McNeal (1968) - Zonal anatomy of
prostate
Three zones:
Peripheral zone (60-70% of CaP origin) Central zone (5 –10% of CaP origin) Transition zone (10-20% of CaP origin)
![Page 4: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/4.jpg)
PROSTATE CANCER (Ca P) Incidence: Men >65 Yrs
Incidence Increases With Age
Longevity More
So In Future More Cases
![Page 5: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/5.jpg)
RISK FACTORS FOR Ca P
Hereditary Prostate Cancer
First Degree Relative with CaP – 5 to 11 fold risk
5-α Reductase Polymorphism (SRD5A2 gene)
Cytochrome P459C17 & Cytochrome P4503A4
Androgen receptor- CAG repeat
![Page 6: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/6.jpg)
OTHER FACTORS
VITAMIN STATUS
Low levels of Vitamin D – Increased risk Vitamin E Supplementation – Decreased risk
DIET
Saturated Fatty Acids - Increased risk Lycopene (Tomato sauce) - Decreased risk Selenium - Decreased risk
![Page 7: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/7.jpg)
MISCELLANEOUS FACTORS
Vasectomy? - 1.5 times more risk
Cigarette smoking - both + and – results
Heavy alcohol - lower risk
Sexual activity (infection) - increased risk
IGF 1 (taller men) - more risk
![Page 8: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/8.jpg)
PATHOLOGY OF Ca P
95% of Ca P - Adenocarcinoma
Other 5% :
90% - Transitional cell carcinoma
Remaining - Neuroendocrine sarcomas
- Squamous cell carcinoma
![Page 9: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/9.jpg)
PATHOLOGY
PERIPHERAL ZONE 60- 70% of Ca P origin
TRANSITIONAL ZONE 10-20% of Ca P origin
CENTRAL ZONE 5-10% of Ca P origin
TURP / open prostatectomy does not eliminate risk of Ca P
![Page 10: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/10.jpg)
GLEASON GRADING SYSTEM
Most commonly used
Glandular architecture on low power microscope
Prognosis and progression correlates well
![Page 11: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/11.jpg)
STAGING- WHITMORE & JEWETT
A1 - Tumor found incidentally at TURP, < 5% tissue
A2 - Tumor found incidentally at TURP, > 5% tissue
B1 - Tumor less than one half of lobe
B2 - Tumor involves both lobes
C1 - Extracapsular extention
C2 - Infiltration to seminal vesicles
D - Disseminated disease
![Page 12: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/12.jpg)
TNM STAGING
T1a - Less than 5% of resected tissue has Ca P, normal DRE
T2a - More than 5% of resected tissue has Ca P, normal DRE
T2 - Palpable tumor confined to prostate
T3 - Tumor extends beyond prostate & seminal vesicle
T4 - Tumor fixed or invades other structures like bladder neck,rectum
![Page 13: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/13.jpg)
TNM STAGING… Nx - Regional nodes not assessed
N 0 - No nodes
N 1 - Single node 2cm or smaller
N 2 - Node 2-5cm or multiple nodes
N 3 - Node more than 5cms
Mx - Not assessed
M 0 - No distant metastasis
M 2 - Non regional nodes , bones& viscera
![Page 14: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/14.jpg)
STAGING
EARLY STAGE T1 AND T2 (TNM) A AND B (W & JEWETT)
LOCALLY ADVANCED T3,T4,N1 (TNM) C (W & JEWETT)
ADVANCED METASTATIC DISEASE STAGE M (TNM)• STAGE D (W & JEWETT)
![Page 15: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/15.jpg)
CLINICAL SYMPTOMS
EARLY STAGE• Asymtomatic• Cancer is in the peripheral zone
LOCALLY ADVANCED DISEASE• Obstructive / irritative voiding• Retention of urine• Hematuria• Renal failure• Pelvic pain
METASTATIC DISEASE• Bone pain• Spinal cord compression symptoms • Paraperesis• Paraplegia
![Page 16: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/16.jpg)
CLINICAL SIGNS Distended bladder Nodes-iliac, inguinal, supraclavicular Lower limb edema Paraperisis Paraplegia
DIGITAL RECTAL EXAM Nodular Indurated Asymmetrical Firm to hard in consistency
![Page 17: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/17.jpg)
DIGITAL RECTAL EXAM …
Differential diagnosis (Hard prostate)
Chronic granulomatous prostatitis Prostatic calculi Prostatic infarction
![Page 18: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/18.jpg)
LOCAL SPREAD OF Ca P
Prostatic capsule Seminal vesicle Bladder neck Trigone – ureters -renal failure Rectum - rare – due to strong Denonviller’s
fascia
LYMPH NODES Obturator node - commonest and earliest Iliac Presacral Paraaortic
![Page 19: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/19.jpg)
DISTANT METASTASIS
Bones commonest, osteoblastic type
Lumbar vertebrae, pelvic bone (Cord compression)
Proximal femur
Thoracic spine
Ribs, sternum
Skull
![Page 20: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/20.jpg)
LABORATORY INVESTIGATIONS
Blood urea, S .Creatinine
Anemia
Thrombocytopenia
Acid phosphatase
Alkaline phosphatase (Bone metastasis,liver metastasis)
![Page 21: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/21.jpg)
LABORATORY INVESTIGATIONS
PROSTATE SPECIFIC ANTIGEN
Glycoprotein secreted by prostatic epithelium,aids in semen liquefaction
Normal up to 4 ng/ml Mild elevation 4-10 ng/ml Significant elevation more than 10 ng/ml Suggestive of bone metastasis DRE does not raise PSA levels significantly Prostate biopsy raises PSA TURP significantly raises PSA
![Page 22: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/22.jpg)
IMPORTANCE OF PSA TESTING
Diagnosis
Pre-operative staging
Monitoring response to therapy
Detecting recurrence after therapy
![Page 23: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/23.jpg)
TRANS RECTAL ULTRASOUND
More sensitive than DRE
Hypoechoic lesions
Local staging
Sextant biopsy
Brachytherapy,cryosurgery
![Page 24: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/24.jpg)
BONE SCAN
Radionuclide bone scan for secondaries
PSA > 20 ng / ml
Bone pain
More sensitive than X-ray
False +ve results Fractures,arthritis etc
![Page 25: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/25.jpg)
ROLE OF X- RAY
Axial skeleton
Osteoblastic secondaries
Chest X- ray Pulmonary metastasis Miliary pattern
![Page 26: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/26.jpg)
CT SCAN & MRI
Not routinely done
When radical prostatectomy is being planned
CT - Nodes
MRI -Perivesical extension
![Page 27: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/27.jpg)
TREATMENT
EARLY PROSTATIC CARCINOMA T1&T2(TNM)A&B(W&JEWETT)
WATCHFUL WAITING >70YRS SMALL WELL DIFFERENTIATED TUMORS
![Page 28: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/28.jpg)
TREATMENT…
RADICAL PROSTATECTOMY
•Less than 60 yrs•Good general health•Life expectancy >10yrs•No life threatening ancillary disease•Removal of entire prostate and seminal
vesicle•Pelvic lymphadenectomy for staging•Preservation of distal sphincter •Preservation of cavernosal nerves-to
prevent impotence
![Page 29: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/29.jpg)
RADICAL PROSTATECTOMY…
Retropubic route Laproscopic Survival >10yrs
Complications Bleeding Incontinence Erectile dysfunction (nerve sparing
technique)
![Page 30: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/30.jpg)
RADICAL RADIOTHERAPY External beam therapy 6500-7500 Gy to prostate and nodes BRACHYTHERAPY
Placement of radioactive seeds inside tumor under TRUS guidance
ADVANTAGES As good as surgery No incontinence
DISADVANTAGES Radiation cystitis Radiation prostatitis
![Page 31: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/31.jpg)
TREATMENT…
LOCALLY ADVANCED DISEASE
> 70 YRS ASYMTOMATIC WATCHFUL WAITING
EXTERNAL BEAM RT HORMONAL ABALATION RT&HORMONAL ABALATION
![Page 32: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/32.jpg)
TREATMENT METASTATIC DISEASE
BILATERAL ORCHIDECTOMY•Gold standard •Done under local anesthesia•Rapid lowering of serum testosterone
level•Side effects less•Testicular prosthesis –cosmetic result
![Page 33: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/33.jpg)
TREATMENT METASTATIC DISEASE
OESTROGENS STILBESTEROL (1MG) - 3 TIMES DAILY
COMPLICATIONS Cardiovascular-ischemia, infarction CVA Thromboembolic complications Gynecomastia
![Page 34: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/34.jpg)
TREATMENT METASTATIC DISEASE
LHRH AGONISTS CAUSES PITUTARY DESENSITISATION BY
ALTERING PULSATILE RELEASE OF LHRH DIMINISHED LH FALL IN TESTOSTERONE-<50NG/ML
ADVANTAGES LESS CVS COMPLICATIONS LESS GYNECOMASTIA
![Page 35: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/35.jpg)
TREATMENT METASTATIC DISEASE
DISADVANTAGES• Flare phenomenon due to initial rise of testosterone.• Might worsen symptoms
GIVE ANTI ANDROGEN BEFORE STARTING THERAPY
COST-RS 6000 FOR 3 MONTHLY DEPOT INJECTION
![Page 36: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/36.jpg)
TREATMENT METASTATIC DISEASE
ANTI-ANDROGENS• COMPETITIVELY INHIBITS DHT RECEPTORS
• FLUTAMIDE (250MG) 3TIMES
• BICALUTAMIDE 50MG OD
• WITH HORMONAL ABALATION COMPLETE ANDROGEN BLOCKAGE
![Page 37: PROSTATE CANCER Dr.GOVINDRAJAN Department of Urology & Renal Transplantation SRMC & RI.](https://reader033.fdocuments.us/reader033/viewer/2022061306/55148756550346b2598b4dd1/html5/thumbnails/37.jpg)
TREATMENT METASTATIC DISEASE
CHEMOTHERAPY•Very limited role
RADIOTHERAPY•Local RT for isolated bone secondaries
•Hemibody RT –multiple secondaries•Strontium 89-painful bone metastasis