CARCINOMA OF THE PROSTATE
DR. MOHAMMAD ALAMGIR
MS(UROLOGY) 3rd PART STUDENT.
CHITTAGONG MEDICAL COLLEGE.
THE PROSTATE GLAND?
The prostate is part of the male reproductive system
Its major function is to secrete a fluid to nourish
semen during intercourse
The prostate is about the size of a walnut but it can
grow with age
It is located below the urinary bladder, in front of the
rectum surrounding the urethra (the canal for the
discharge of urine that extends from the urinary
bladder to the outside)
Anatomy of the prostate gland
A) Capsules -
B) Glandular and non glandular elements-
a) outer components-
b) Inner components–
2.Non glandular portions
Ant. fibromuscular band
Facts That Every Man Over 40
What Is Prostate Cancer?
What do you
• Cancer is a cellular disease
• It is a disordered and abnormal cell growth
• In prostate cancer, as in other types of cancer, cells grow
out of control and form tumors
• If the tumor is within the gland, the cancer is said to be
localized and curable
If the cancer escapes the gland it is considered advanced
• Early detection before the cancer escapes the gland
becomes very important.
Distribution of prostate cancer
.70% in peripheral zone(PZ)
.20% in transitional zone (TZ)
.10% in cental zone( CZ)
Central gland most difficult to localize
carcinoma, because of overlaping signal
intensity with normal gland / hypertrophy.
How much threat of PROSTATE
Most common malignancy of men in US after skin
At autopsy ,CaP is found in
30% of men in age 50.
90% of men in age 90.
Despite the long latent period, 2nd most common
cause of cancer death in American men over age
About 1 in 6 men will be diagnosed with
carcinoma prostate during life time.
• As men age, prostate cells
are increasingly likely to turn
Bad News: American male has a 16.7% risk of being
diagnosed with prostate cancer
Good News: In most cases, the cancer cells are slow growing
and occur late in life – only 3.5% of U.S males die from
Prostate cancer risk factors:
Age: The risk increases with age, but 25% of
diagnoses are made under age 65.
Race: African-Americans have a rate of
incidence double that of Caucasian men
Family history of prostate cancer: Men with
a family history have two- to three-fold
increase in the risk of prostate cancer
Eating red meat increases the risk of developing prostate
cancer 2.64 times
Total fat intake and animal fat intake are associated with
Vitamin D and calcium also increase risk.
Vegetable oil is rich in alpha linolenic acid (a fatty acid)
By-products of these fats promote the growth and
seriousness of prostate cancer
So what CAN WE eat?
A balanced diet rich in fruits
Lower your intake of red
meat, processed and fried
foods. Eat more plant-based
food like soy protein.
Eat foods with lycopene
and red grapefruit) which
may be associated with a
decreased risk of prostate
Vitamin E, selenium, and
omega -3 fatty acids(fish)
have been shown to be
Classification of carcinoma
From adjacent organs.
What are the symptoms of prostate cancer?
You might not have any at all!
Often there are none, or they are not recognized
Slow urinary flow
Blood in urine or semen
Lower back or thigh pain
Possible Levels of Prostate Cancer At Diagnosis
Local-Regional Disease Spread
How does early detection
Survival rate at 5 years is
99% for those whose cancer
is still just in the prostate
Survival rate at 5 years for
those whose cancer has
spread beyond the gland
(late diagnosis) is only 31%
Early detection and screening
Digital rectal exam – Feel for nodules
PSA – How high?
Transrectal ultrasound – not for
First two tests are convenient and
inexpensive, but consequences may not
Why do I have to have a DRE?
In the DRE the doctor
examines you by feeling
the prostate gland through
the rectum with his finger
DRE improves the value
of PSA testing in early
DRE and PSA together are
often able to detect
prostate cancer better and
sooner than either test
When do I need to start getting tested?
DRE: 40 years and older every year
(American Cancer Society guidelines)
PSA: 50 years and older every year
(American Cancer Society guidelines)
If family history of prostate cancer and/or
African-American: 45 years and older every year
(American Cancer Society guidelines)
What You Should Know About the PSA Test
PSA is a glycoprotein .
It exists in two form- complexed & bound form.
Its normal value is <4ng/ml & raises wth
increasing age & size of the prostate gland.
The real value of the PSA test is in testing year
to year and observing the rate of change
Medical opinion is divided about the usefulness
of a single PSA
One test out of range could be caused by other
PSA is not prostate cancer specific
Under investigation: PSA Density,
PSA Velocity, % free PSA
PSA Density - Normalized to prostate
PSA Velocity - Change in PSA over time
(e.g., more than 15% per year)
Free PSA/Total PSA - lower ratio
suggests cancer, since more free PSA
from normal prostate is degradated (<
10% - biopsy)
Confounding Factors for PSA
Some herbal mixtures
Establishing a Diagnosis of
PSA/PSA velocity/percent-free PSA
U/S- guided biopsy
Staging and grading
Two staging systems-
Whitmore –Jewett staging.
Two grading systems-
Characterize the degree of glandular
differentiation under microscope.
It grades two most representative areas of
tumor (primary grade & secondary grade).
Adds two values together—Gleason score
2—4 well differentiated
5—6 moderately differentiated
8—10 poorly differentiated
Chemoprevention for Prostate
Finasteride = 5-alpha reductase inhibitor, blocks
intracellular conversion of testosterone to
Based on solid evidence, chemoprevention with
finasteride reduces the incidence of prostate cancer
(6% absolute; 25% relative risk reduction), but the
evidence is inadequate
Harms: erectile dysfunction, loss of libido,
gynecomastia, higher grade cancers.
Predictive models for organ-confined versus
non-organ confined disease.
In Case of a Diagnosis With a
Do not panic,
Get a second opinion on the biopsy sample by a
pathologist specializing in prostate cancer.
Your treatment decision depends on a good
assessment of the biopsy material.
Get a second opinion about your diagnosis and
treatment options from an unbiased specialist in
prostate cancer treatment.
Prostate Cancer Survival
Extent of tumor at diagnosis
Local disease - Median Survival > 5 years
Metastatic disease Median Survival 1-3 years, but
individuals may survive 10 or more years
Treatment of localized disease
Treatment of locally advanced disease
Treatment of recurrent disease
Treatment of HRPC.
Treatment of metastatic disease
Treatment of Localized
Watchful Waiting & active surveillance .
Definite radiation therapy -
External beam radiotherapy (XRT)
Cryo surgery & HIFU.
Life expectancy less than 10 years.
Diagnosis of an early-stage (T1-T2),
No medical treatment is provided.
Patient receives regular follow-up to
PSA and DRE can detect prostate cancer at a very early
Average doubling time of a prostate tumor is quite slow (2-4
Immediate radical therapy may constitute over-treatment
and an introduce unnecessary urinary and potency risks.
May be appropriate if the patient is elderly and/or in poor
health, and will live out their life spans without the cancer
May also be appropriate for a younger patient who is willing
to be vigilant and accept the risk of the cancer spreading.
Radical Retropubic Prostatectomy
“Nerve Sparing” procedure developed by Walsh
consisted of modified surgical technique to
control blood and enhance visibility within
Allowed for the identification and potential
preservation of the nerves that control erectile
Two neurovascular bundles that lie behind & on
either side of the prostate that control erectile
RRP: The Surgical
1.5-4 hours, usually
Begins just below
navel and extends to
is sewn to bladder
neck over a catheter.
The Nerve Bundles
Whole prostate - and thus the entire tumor - can
be examined histologically.
Surgeon has access to regional lymph nodes to
test if prostate cancer cells have left the tumor.
Surgical margin can be examined.
Severe or life-threatening complications are
Incontinence (Urinary Control): complete
incontinence is uncommon, although a
significant number of patients experience
some stress-incontinence. Usually improves
Impotence (Erectile Dysfunction): if both
neurovascular bundles were spared, potency
rates range from 30-86%, depending on
institution. Usually improves over time, and
other ED treatments can work.
Radiation Therapy (RT)
High-Powered X-Rays that damage
DNA and kill prostate cancer cells.
1. External Beam Radiation Therapy
(EBRT): X-rays aimed at prostate.
2. Brachytherapy: Radioactive seed
implants into prostate.
EBRT and Brachytherapy
1. Map precise area that will receive radiation.
2. Multiple treatments ~5 days/week for ~8 weeks.
Each treatment takes about 10 minutes and no
anesthesia is required.
1. 40-100 rice-sized radioactive seeds are implanted
into the prostate via ultrasound-guided needles.
Anesthesia is required.
2. All radiation inside the pellets is generally
exhausted within a year.
External Beam Radiation
Goal: Maximize damage to the prostate
and minimize damage to surrounding
tissues (i.e. bladder and rectum)
Cross-Section of Prostate
Image of Prostate With
Radioactive Bead Implants
High initial dose of radiation that slowly fades
over 1 year.
Prostate inflammation and swelling, sometimes
with severe urinary symptoms.
Other, more rare symptoms include persistent
urinary and bowel frequency and urgency.
Erectile dysfunction: similar to EBRT.
Most symptoms occur during treatments and
subside after completion.
Diarrhea, rectal irritation, fatigue, frequent and
painful urination, blood in the urine.
Erectile dysfunction: less common than radical
prostatectomy following treatment but slower
Destroys prostate cells by freezing tissue.
Old idea that is making a comeback due to
greater precision and better methods of imaging
and temperature monitoring.
Method: insertion of sub-zero cryoprobes into
prostate perineally (between scrotum and anus).
As yet unresolved how effective cryotherapy is
compared to surgery or radiation.
Treatment of locally advanced
Most Pt with T3 (T3a+ T3b ) CaP are
at the present time treated with
neoadjuvent hormone therapy followed
by external beam radiotherapy .
Treatment of Recurrent
Following radical prostatectomy –
Salvage radiation .
Following radiation therapy –
Androgen ablation therapy
If disease is local recurrence only—
Bracy therapy, Cryo surgery ,Salvage
Treatment of Symptomatic
1 . Hormonal Therapy - initial therapy for
locally advanced or metastatic disease
Estrogens (No longer used)
LHRH analogs (+/- anti-androgens)
Antiandrogens + finasteride
Second line therapies consist of one of
therapies not used before, e.g., anti-
androgens if used only LHRH analogs
Prostate cells and prostate cancer cells are dependant upon
androgens (male sex hormones) for survival and growth.
Removal of androgens kills a majority of prostate cancer cells.
Available as every 1, 3, or 4 month
Castrate levels of testosterone attainable in
a few weeks
Combined androgen blockade not superior to
LHRH therapy alone
Higher cost and more side effects than LHRH
Primary value when starting LHRH to limit the
Despite initial response rates of 80-90%, nearly
all men with advanced prostate cancer develop
hormone-resistant prostate cancer after 18-36
These “hormone-refractory” (HR) prostate cancer
cells can grow in the absence of androgens.
The behavior of HR prostate cancers differ widely
Treatment of Symptomatic, Hormone
Refractory Metastatic Disease
1.Stop Anti-androgen or Add Anti-androgen.
2. Second line regimen –
3. Cytotoxic chemotherapy
Docetaxel (every three weeks) and prednisone
improves pain and reduces need for analgesic agents
Docetaxel with estramustine
Other agents have had limited effectiveness
Continue hormone therapy to prevent flare with rising
4. Bisphosphonates - decreases skeletal complications.
4. 5. Gene threapy.
Management of Prostate Cancer
Goal: prevent pain, improve mobility,
prevent complications such as fractures
or compression, maintain acceptable
quality of life.
Methods: bis-phosphonates, radiation of
detected metastatic lesions, surgery.
Emerging Therapy: Laparoscopic
Eliminates the need for a
large incision by using a
called a laparoscopes.
Small camera attached to
the laparoscope allows the
surgeon to view inside the
Less blood loss.
No large incision.
Shorter hospital stay and earlier return to
Variable surgical margins rates.
Slower return of urinary continence.
Variable potency rates.
Risk factors are age, family history, race, and possibly diet
Overall survival excellent (many years)
Early detection can find localized cancer, but survival
benefits still uncertain
Treatment depends on grade, extent and location of
Surgery and radiation are equivalent therapeutic tools for
localized prostate cancer
Hormonal therapy is effective for metastatic prostate
Hormone refractory prostate cancer responds to
chemotherapy, with occasional long term improvement.
Can you guess who can get
Well, guess again… any
male can get prostate
Hey, Smart Guy!