PROSTATE CANCERLETS DEBATE !!!!

Dr Fred C TylerMBChB FRCS FCS UROL

Case Presentation

• Mr D N• 44yr referred PSA 6,49• Low libido, poor erections• PMH : Hypertension• PSH: Nil• Alllergies: Nil• Smoking : 20/d• OH : social

Case Presentation

• Abdo: soft NAD • Genitalia: NAD• PR: BPH

• Testosterone 20.48

Case Presentation

• Cystoscopy: Narrow bladder neck ,nil else

• TRNB Prostate: One tiny focus of Gleason 6/10 ( 3 +3)

0.5 mm of one core Prostatitis

Prognostic Grouping

• Group 1 T1a-c NO, M0,PSA <10, GLS < 6 T2a

• Group 2a T1a-c N0 M0 PSA < 20 GLS 7 PSA 10-20 GLS <6

T2a,b PSA <20 GLS ,7• Group 2b T2c N0 ,M0 ,Any PSA, Any GLS T1 -2 PSA > 20 or GLS >8Group 3 T3a-bGroup 4 T4

MR D N

• Low risk• Group 1

WHAT NOW !!!!!!

EUA Guidelines

• Clinical Stage 1c 40%-50% of new cases• SPGC 4 study showeds advatage of RP over

WW but on;ly 5% of thise patients were PSA screened

• Prevalence of under scoring GLS grades

Watchful Waiting

• T1a well or moderately differentiated if > 10 yrs life expectancy restaging with TURP and TRNB advised

• T1b to T2b standard rx for well or moderately diff tumours in asymptomatic patients with life expectancy < 10 yrs.

• NB Criteria– PSA <10. GLS <6, < 2 positve biopsies, < 50% of the

biopsy involved.

Radical Prostatectomy

• Reduced cancer mortality and risk of metastases in men <65yr with little or no benefit 10 or more years after surgery

• Standard rx if <65yrs age and who except rx related complications.

• Role of Laparoscopic and Robot assisted Radical prostatectomy…..

Extended pelvic node dissection

• No benefit in low risk CAP

Recommendations for Radical Prostatectomy

• Neoadjuvant GNRH for 3 months is not recommended for T1 – T2 disease.

• Nerve sparing surgery may be attempted for Low risk Disease: T1c, GLS 7, PSA ,10

Definitive Radiation Therapy• Transperineal Interstitial Brachytherapy– T1c-T2a– GLS ,7 (3+4)– PSA<10– Prostate vol <50ml– No previous TURP, Good IPSS

• Localised CAP: T1c T2c , N0, M0,

– 3D CRT +- IMRT even for young patients who refuse surgery ???

– Low , Intermediate,high risk patients benefit from dose escalation.

Cryosurgery of the Prostate

• Low risk CAP : PSA<10, <T2a,GLS<6• Intermediate Risk: PSA > 10, GLS 7, Stage.T2b• 5 yr BDFR inferior to RP in low risl patients.

• All other minimally invasive options are experimental……….

Our patient……

• 3 months after diagnosis PSA 4.27 (9%) • 3 months later PSA 3.39• 3months later PSA 4.51.