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Prostate cancer
As. MUDr. Jan Pokorný, FEBU
Head: Doc. MUDr. Robert Grill, Ph.D.
Vice-head: As. MUDr. Lukáš Bittner, FEBU
Urologická klinika 3. LF UK a FNKV
Prostate cancer
Epidemiology:
Incidence:
ČR 80/100 000
USA 120/100 000
Mortality:
ČR 15/100 000
Prostate cancer
Epidemiology:
ČR
Prostate cancer
Epidemiology:
Prostate cancer:
EU – 2nd in men mortality for cancer (1st lung cancer)
USA – 1st in men mortality for cancer
Prostate cancer
Epidemiology:
Risk factors:
Increasing age, race (afroamericans), heredity
Exogenous factors:
Diete, UV radiation, alcohol consumption, risk sexual behavior, infection (HPV?)
Prostate cancer
Epidemiology:
Increasing age:
The prostate cancer incidence in per cent generaly correlates to the patient´s age
Prostate cancer
Epidemiology:
Basic check-up:
Discussion about the mass screening
Expenses
Unapparent (asymptomatic) tumors treatment
Prostate cancer
Epidemiology:
Basic check-up:
Recommended:
Screening in risk population – positive family history
Positive clinical symptoms In patients who actively visit doctor and ask for
check-up
Prostate cancer
Epidemiology:
Basic check-up:
Recommended:
Digital rectal examination in all men in all time
PSA only in recommended case (previous slide)
Prostate cancer
Epidemiology:
Basic check-up:
Recommended:
Start PSA test between 45-50 years
Start PSA test in the positive family history case between 40-45 years
Prostate cancer
Epidemiology:
Basic check-up:
Recommended:
In patient unfit for treatment (age, co-morbidity, weak life prognosis) there is NO INDICATION FOR PSA TESTING !!!
Prostate cancer
Diagnosis:
Basic exams:
Digital rectal exam (DRE)
Prostate specific antigen (PSA)
Prostate cancer
Diagnosis:
DRE:
Prostate cancer
Diagnosis:
DRE:
Prostate shape, volume, consistence, demarcation
Semen vesicules examination
Bimanual palpation (in anesthesia)
Prostate cancer
Diagnosis: DRE:
95 % of cancer originates from the peripheral zone of prostate
Suitable for palpation
Prostate cancer
Diagnosis:
Prostate specific antigen (PSA):
33 kD molecular weigh glycoprotein
(Proteases enzyme)
Gene in 19th chromosome
Half-life period 3-5 days
Prostate cancer
Diagnosis:
Prostate specific antigen (PSA):
Produced almost exclusively by the epithelial cells of the prostate
Prostate-specific marker, no cancer-specific
High sperm concentration
Prostate cancer
Diagnosis:
Prostate specific antigen (PSA):
Venous blood sample The exact cut-off level of what is considered to be
a normal PSA value has yet to be determined Generally used cut-off level: 4-4.2 ng/ml Values of approximately < 2-3 ng/ml are often
used for younger men
Prostate cancer
Diagnosis:
Prostate cancer diagnosis:
PSA elevation or DRE suspicion
Prostate biopsy – Transrectal USG
(TRUS biopsy)
PCA3 (Prostate Cancer Antigen 3)
Prostate cancer
Diagnosis:
TRUS prostate biopsy:
Prostate morphology Peripheral zone biopsy Min. of 12 samples, according to prostate volume
correction In case of negative first biopsy repet one is
needed
Prostate cancer
Diagnosis:
TRUS prostate biopsy:
Biopsy gun
Prostate cancer
Diagnosis: Prostate Cancer Antigen 3 (PCA3):
Genetic marker Cancer - specific
Urine sampled after DRE
Additional test, no standard
Prostate cancer
Diagnosis: Prostate Cancer Antigen 3 (PCA3):
Indications: PSA elevation and negative prostate biopsy
Decision on re-biopsy
No treatment in PCA3 elevation only
Prostate cancer
Diagnosis:
Prostate Cancer Antigen 3 (PCA3):
Some studies present the PCA3 level and Gleason Score correlation (tumor aggressiveness)
Prostate cancer
Diagnosis:
Morphology:
Histological types:
Acinar adenocarcinoma Papilar (ductal) carcinoma Small cell carcinoma Ring cell carcinoma Sarcomatoid carcinoma (No PSA production)
Prostate cancer
Diagnosis:
Grading:
Gleason grade
Prostate cancer
Diagnosis:
Grading:
Gleason score: The Gleason score is the sum of the most
dominant and second most dominant (in terms of volume) Gleason grade. If only one grade is present, the primary grade is doubled.
Examples include: GS 2+2, GS 3+4, GS 4+3 etc.
Prostate cancer
Diagnosis:
Grading:
Gleason scoce correlates to the tumor dedifferentiation (aggressiveness)
Prostate cancer
Diagnosis:
Staging: DRE TRUS
CT scan and bone scan in PSA value > 20 ng/ml (in case of GS ≥ 7 even in PSA value > 10 ng/ml)
MRI
Prostate cancer
Diagnosis:
Staging:
TNM classification: T1 – Clinically unapparent tumour not palpable or
visible by imaging T2 – Tumour confined within the prostate T3 – Tumour extends through the prostatic
capsule T4 – Tumour is fixed or invades adjacent
structures other than seminal vesicles
Prostate cancer
Diagnosis:
Staging:
TNM classification:
N1 – Lymph nodes involvement
M1 – Distant metastases (non-regional lymph nodes, bones, liver, lungs)
Prostate cancer
Diagnosis:
Staging:
Prostate cancer
Diagnosis:
Staging:
Prostate cancer
Diagnosis:
Prognotic factors:
Gleason score (Tumor aggressiveness) PSA level Age and biological condition
Prostate cancer
Treatment: Localised prostate cancer (T1-T2):
Watchful Waiting / Active Monitoring Surgery – Radical Prostatectomy Radiation therapy (Tele, Brachy) Experimental – Kryosurgery, HIFU ( High
Intensity Focused Ultrasound)
Prostate cancer
Treatment:
Watchful waiting (WW): Deferred treatment Treatment starts in case of clinical symptoms
developement No cure intention Suitable for patients with shorter life expectancy
Prostate cancer
Treatment:
Active surveillance or monitoring (AS): Deferred treatment with cure intention Active monitoring of tumor activity (PSA, repet
TRUS biopsy – progression of number of positive samples, Gleason Score progression etc.)
Treatment starts at the moment of progression Well-informed patient only
Prostate cancer
Treatment:
Radical prostatectomy:
Complete prostate, prostate capsule, vesicles and prostate part of urethra removal
Lymphadenectomy only in indicated cases
Prostate cancer
Treatment:
Radical prostatectomy:
Retropubic access
Open surgery Laparoscopy Robot - assisted
Prostate cancer
Treatment:
Radical prostatectomy:
T1-2 stages
„Younger“ patients – life expectancy > 10 years
Prostate cancer
Treatment:
Radical radiation therapy:
Teleradiotherapy:
External beam of radiation of prostate, vesicles and surrounding tissues, in special cases of regional lymph nodes
Prostate cancer
Treatment:
Teleradiotherapy:
Linear accelerators Three-dimensional conformal radiotherapy (3D-
CRT) and intensity modulated external beam radiotherapy (IMRT)
Dose escalation Adverse events minimalization
Prostate cancer
Treatment:
Teleradiotherapy:
Innovative techniques:
Proton beam accelerators Carbon ion beam accelerators
Prostate cancer
Treatment:
Teleradiotherapy:
T1-2 stages and no plan of radical prostatectomy
T3-T4, N1 stages
Prostate cancer
Treatment:
Transperineal Brachytherapy:
Effective technique in T1-2 stages, PSA ≤ 10 ng/ml, GS ≤ 6 and prostate volume ≤ 50-60 ml
Prostate cancer
Treatment:
Transperineal Brachytherapy:
Transperineal access, USG guided technique
Permanent radioactive implats application (Palladium-103)
Prostate cancer
Treatment:
Transperineal Brachytherapy:
Local anesthesia only
One-shot application
Prostate cancer
Treatment: Local advanced prostate cancer (T3-T4, N1):
Watchful waiting
Radiation therapy (Teleradiotherapy)
Prostate cancer
Treatment:Metastatis prostate cancer:
Watchful waiting Hormonal therapy Chemotherapy Palliative therapy
Prostate cancer
Treatment:
Hormonal therapy: Stage M1
Endogeneous androgen production: Testicles 90 – 95 % Adrenal glands 5 – 10 %
Prostate cancer
Treatment:
Hormonal therapy:
Testosterone is essential
for the prostate tissue
growth and prostate
cancer growth as well
http://www.oncoprof.net
Prostate cancer
Treatment:
Hormonal therapy:
LHRH analogs – central blocade Antinadrogens – peripheral blocade Ketokonazole – adrenal production blocade Surgical– bilateral orchiectomy Combinations
Prostate cancer
Treatment:
Chemotherapy: Taxans – Docetaxel, Cabazitaxel Estramustin
Treatment of relapse after hormonal therapy in stage M1
Prostate cancer
Treatment:
Palliative therapeutic options:
Bone metastases:
(Bone resorption inactivation) Bisphosphonates Denosumab
Painful bone metastases – i.v. aplication of radionuclides (Stroncium)
Prostate cancer
Treatment:
Palliative therapeutic options:
Urinaty retention:
TURP (Transurethral Prostate Resection) Urethral catheter, epicystostomia Ureteral stents Nephrostomy tube
Prostate cancer
Treatment:
Palliative therapeutic options:
Opoids Blood supplementation Corticosteroids Surgical treatment of pathological bone fractures
and vertebral compression
Prostate cancer
Follow-up :
Basic periodic exam.:
PSA
DRE
Prostate cancer
Follow-up :
PSA elevation - restaging
CT
Bone scan
Prostate cancer
Follow-up :
In special cases:
PET – CT
MRI
Prostate cancer
Prognosis:
Generally excellent (in T1-N1 stage generally complete cure)
Majority of patients in M1 stage survive years!
Prognosis estimation: Entering Gleason score, PSA, biological condition