Prostate Cancer:   Causes, Diagnosis, and Treatment Options Bruce B. Garber, MD, FACS Clinical Associate Professor Drexel ...
Introduction <ul><li>The prostate: </li></ul><ul><li>  -is a gland located below the bladder </li></ul><ul><li>  -is only ...
-Urine flows from the bladder through the urethra,    which is surrounded by the prostate -An enlarged prostate can cause ...
Incidence <ul><li>-Lung, colon, breast, and prostate cancer are the most  </li></ul><ul><li>common solid organ cancers </l...
Prostate Cancer: US Mortality and Incidence, 1973–1997  SEER Cancer Statistics Review 1973-1997. National Cancer Institute...
Prostate Cancer: Causes <ul><li>Risk Factors Currently Under Investigation: </li></ul><ul><li>Racial origin: African Ameri...
Prostate Cancer: Diagnosis  <ul><li>Methods of Detection: </li></ul><ul><li>1. Prostate exam (digital rectal exam, DRE) </...
Gleason Pathologic Scoring System  for Prostate Cancer Gleason DF. In: Tannenbaum M, ed.  Urologic Pathology: The Prostate...
Prostate Cancer Staging Systems  <ul><li>Stages A, B, C, D  </li></ul><ul><li>TNM system (stage T1C is most common) </li><...
Whitmore-Jewett  Classification Stage A Microscopic cancer confined to the prostate and too small to be felt by digital re...
Whitmore-Jewett  Classification Stage B Cancer large enough to be felt on DRE B1  Small nodule on one lobe  of prostate B2...
Whitmore-Jewett  Classification Stage C A large cancer involving nearly the entire gland C1  Cancer may have spread  a sma...
Whitmore-Jewett  Classification Stage D Widespread (metastatic) cancer D1  Cancer in pelvic lymph  nodes D2  Cancer in bon...
Prostate Cancer: Treatment Options  <ul><li>Non-curative therapies: </li></ul><ul><li>  1. Androgen deprivation </li></ul>...
Non-curative Hormonal Therapy:  Currently Available Agents  <ul><li>LHRH-agonists: </li></ul><ul><li>Zoladex ®  (goserelin...
Therapies of Curative Intent: <ul><li>Radical prostatectomy (total prostate removal) </li></ul><ul><ul><li>Retropubic (abd...
Radical Prostatectomy <ul><li>Advantages </li></ul><ul><li>Can remove all the cancer </li></ul><ul><li>Disadvantages </li>...
External Beam Radiation (EBRT) <ul><li>Advantages </li></ul><ul><li>Efficacy similar to prostatectomy </li></ul><ul><li>Ou...
Brachytherapy (radioactive seed implant) <ul><li>Advantages   </li></ul><ul><li>Efficacy similar to EBRT  or surgery  </li...
Cryoablation of the Prostate   (Cryosurgery, Cryotherapy)   CRYO = GREEK WORD FOR COLD   ABLATION = DESTRUCTION
What is Cryoablation? <ul><li>Cryoablation: cancer treatment by freezing to </li></ul><ul><ul><li>-40 º Centigrade  </li><...
<ul><li>Transrectal ultrasound guided  </li></ul><ul><li>Transperineal placement of 6-8 cryo (freezing) probes </li></ul><...
Technology <ul><li>Temperature shown in real time </li></ul><ul><li>Argon gas freezes prostate rapidly with excellent cont...
Current Technology: 6-8 Probe Argon Cryosurgery System, Total Gland Ablation <ul><li>6-8 Cryo probes in prostate </li></ul...
Prostate Cryoablation  Probes inserted in between scrotum & rectum Transrectal ultrasound guides the procedure
Targeted Cryoablation of the Prostate (TCAP) Before  Probes Placed  Prostate frozen
Prostate Cryoablation Techniques <ul><li>Total Gland Ablation </li></ul><ul><li>Nerve-Sparing </li></ul><ul><li>Focal  </l...
Total Prostate Cryoablation
Nerve-Sparing Prostate Cryoablation
Focal Prostate Cryoablation
Results of Total Prostate Cryoablation <ul><li>89% of 590 men followed for 7 years were disease-free based on PSA levels, ...
Cryoablation   <ul><li>Advantages </li></ul><ul><li>Outpatient </li></ul><ul><li>Minimally-invasive  </li></ul><ul><li>Can...
Summary: Prostate Cryoablation <ul><li>A well-established treatment for localized prostate cancer </li></ul><ul><li>Covere...
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Prostate Cancer: Causes, Diagnosis, and Treatment Options Bruce B ... Prostate Cancer: Causes, Diagnosis, and Treatment Options Bruce B ...

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  • Prostate Cancer: Causes, Diagnosis, and Treatment Options Bruce B ... Prostate Cancer: Causes, Diagnosis, and Treatment Options Bruce B ...

    1. 1. Prostate Cancer: Causes, Diagnosis, and Treatment Options Bruce B. Garber, MD, FACS Clinical Associate Professor Drexel University College of Medicine Graduate Hospital Philadelphia, PA
    2. 2. Introduction <ul><li>The prostate: </li></ul><ul><li> -is a gland located below the bladder </li></ul><ul><li> -is only present in men </li></ul><ul><li> -surrounds the urethra </li></ul><ul><li> -can undergo benign or malignant change </li></ul>
    3. 3. -Urine flows from the bladder through the urethra, which is surrounded by the prostate -An enlarged prostate can cause difficulty passing urine -The prostate is not in the rectum, but can be palpated during a digital rectal exam
    4. 4. Incidence <ul><li>-Lung, colon, breast, and prostate cancer are the most </li></ul><ul><li>common solid organ cancers </li></ul><ul><li>-Over 200,000 men are diagnosed with prostate </li></ul><ul><li>cancer each year in the U.S. </li></ul><ul><li>-African-American men have the highest incidence </li></ul>
    5. 5. Prostate Cancer: US Mortality and Incidence, 1973–1997 SEER Cancer Statistics Review 1973-1997. National Cancer Institute. Bethesda, MD.
    6. 6. Prostate Cancer: Causes <ul><li>Risk Factors Currently Under Investigation: </li></ul><ul><li>Racial origin: African American > all other races </li></ul><ul><li>Dietary factors: fatty foods implicated </li></ul><ul><li>Genetic factors: familial prostate cancer; prostate cancer genes have been discovered </li></ul>
    7. 7. Prostate Cancer: Diagnosis <ul><li>Methods of Detection: </li></ul><ul><li>1. Prostate exam (digital rectal exam, DRE) </li></ul><ul><li>2. Prostate-specific antigen (PSA) blood test </li></ul><ul><li>(free, total, complexed, velocity) </li></ul><ul><li>If either is abnormal: </li></ul><ul><ul><li>Ultrasound-guided prostate needle biopsy </li></ul></ul>
    8. 8. Gleason Pathologic Scoring System for Prostate Cancer Gleason DF. In: Tannenbaum M, ed. Urologic Pathology: The Prostate. Philadelphia, Pa: Lea & Febiger; 1977:171-197.
    9. 9. Prostate Cancer Staging Systems <ul><li>Stages A, B, C, D </li></ul><ul><li>TNM system (stage T1C is most common) </li></ul>
    10. 10. Whitmore-Jewett Classification Stage A Microscopic cancer confined to the prostate and too small to be felt by digital rectal exam A1 Cancer well differentiated and confined to one site A2 Cancer moderately or poorly differentiated or present in more than one site
    11. 11. Whitmore-Jewett Classification Stage B Cancer large enough to be felt on DRE B1 Small nodule on one lobe of prostate B2 Large nodule, several small nodules, or a nodule containing poorly differentiated cells
    12. 12. Whitmore-Jewett Classification Stage C A large cancer involving nearly the entire gland C1 Cancer may have spread a small distance beyond the gland C2 Cancer has invaded the neighboring tissue
    13. 13. Whitmore-Jewett Classification Stage D Widespread (metastatic) cancer D1 Cancer in pelvic lymph nodes D2 Cancer in bone or other organs
    14. 14. Prostate Cancer: Treatment Options <ul><li>Non-curative therapies: </li></ul><ul><li> 1. Androgen deprivation </li></ul><ul><ul><li>-LHRH-agonists </li></ul></ul><ul><ul><li>-Bilateral orchiectomy </li></ul></ul><ul><ul><li>-Antiandrogens </li></ul></ul><ul><li> 2. Chemotherapy </li></ul><ul><li>3. Observation </li></ul><ul><li>Potentially curative therapies: </li></ul><ul><ul><li>1. Radical prostatectomy </li></ul></ul><ul><ul><ul><li>Retropubic </li></ul></ul></ul><ul><ul><ul><li>Perineal </li></ul></ul></ul><ul><ul><ul><li>Laparoscopic/Robotic </li></ul></ul></ul><ul><ul><li>2. Radiotherapy </li></ul></ul><ul><ul><ul><li>External beam radiation </li></ul></ul></ul><ul><ul><ul><li>Brachytherapy (radioactive seed implant) </li></ul></ul></ul><ul><ul><li>3. Cryo (freezing) </li></ul></ul>
    15. 15. Non-curative Hormonal Therapy: Currently Available Agents <ul><li>LHRH-agonists: </li></ul><ul><li>Zoladex ® (goserelin acetate implant) </li></ul><ul><li>Lupron Depot ® (leuprolide acetate for depot suspension) </li></ul><ul><li>Viadur™ (leuprolide acetate implant) </li></ul><ul><li>Eligard ® </li></ul><ul><li>Vantas ® </li></ul><ul><li>Antiandrogens: </li></ul><ul><li>Casodex ® (bicalutamide) </li></ul><ul><li>Eulexin ® (flutamide) </li></ul><ul><li>Nilandron  (nilutamide) </li></ul>Lupron Depot ® is a registered trademark of TAP Pharmaceuticals, Inc. Copyright © 2001 Bayer Corporation. Viadur™ is a trademark of ALZA Corporation under license to Bayer Corporation. Eulexin ® is a registered trademark of Schering-Plough Pharmaceuticals. Nilandron  is a registered trademark of Aventis.
    16. 16. Therapies of Curative Intent: <ul><li>Radical prostatectomy (total prostate removal) </li></ul><ul><ul><li>Retropubic (abdominal incision) </li></ul></ul><ul><ul><li>Perineal (incision under scrotum) </li></ul></ul><ul><ul><li>Laparoscopic/Robotic (multiple ports) </li></ul></ul><ul><li>Radiotherapy </li></ul><ul><ul><li>External beam radiation </li></ul></ul><ul><ul><li>Brachytherapy (radioactive seed implant) </li></ul></ul><ul><li>Cryoablation (freezing) </li></ul>
    17. 17. Radical Prostatectomy <ul><li>Advantages </li></ul><ul><li>Can remove all the cancer </li></ul><ul><li>Disadvantages </li></ul><ul><li>Major operation </li></ul><ul><li>Erectile dysfunction </li></ul><ul><li>Incontinence </li></ul><ul><li>Scar tissue </li></ul><ul><li>Rectal injury </li></ul><ul><li>Wound infection, blood clots, heart attack, etc. </li></ul><ul><li>Often doesn’t remove all of the cancer </li></ul>
    18. 18. External Beam Radiation (EBRT) <ul><li>Advantages </li></ul><ul><li>Efficacy similar to prostatectomy </li></ul><ul><li>Outpatient </li></ul><ul><li>Disadvantages </li></ul><ul><li>Erectile dysfunction </li></ul><ul><li>Chronic bowel and bladder irritation (cystitis, proctitis) </li></ul><ul><li>Requires roughly 7 weeks of </li></ul><ul><li>daily treatment </li></ul><ul><li>Increased risk of rectal & bladder cancer! </li></ul>
    19. 19. Brachytherapy (radioactive seed implant) <ul><li>Advantages </li></ul><ul><li>Efficacy similar to EBRT or surgery </li></ul><ul><li>Outpatient; one treatment </li></ul><ul><li>Disadvantages </li></ul><ul><li>Chronic bowel & bladder </li></ul><ul><li>irritation </li></ul><ul><li>Erectile dysfunction </li></ul><ul><li>Seed migration 33% </li></ul><ul><li>Can’t treat large prostates </li></ul><ul><li>Increased risk of rectal & bladder cancer! </li></ul>
    20. 20. Cryoablation of the Prostate (Cryosurgery, Cryotherapy) CRYO = GREEK WORD FOR COLD ABLATION = DESTRUCTION
    21. 21. What is Cryoablation? <ul><li>Cryoablation: cancer treatment by freezing to </li></ul><ul><ul><li>-40 º Centigrade </li></ul></ul><ul><li>No surgical incision, minimal blood loss, no radiation </li></ul><ul><li>Immediate cancer cell death </li></ul><ul><li>Dead cells are slowly reabsorbed by the body </li></ul><ul><li>Outpatient procedure, with rapid return to normal activities </li></ul><ul><li>FDA-approved, covered by Medicare & most carriers </li></ul><ul><li>New technology: <2% of Urologists currently offering Cryoablation </li></ul>
    22. 22. <ul><li>Transrectal ultrasound guided </li></ul><ul><li>Transperineal placement of 6-8 cryo (freezing) probes </li></ul><ul><li>Transperineal placement of 5-6 temperature sensing probes </li></ul><ul><li>Urethral warming device to preserve urethra & limit side effects </li></ul>TARGETED CRYOABLATION OF THE PROSTATE (TCAP)
    23. 23. Technology <ul><li>Temperature shown in real time </li></ul><ul><li>Argon gas freezes prostate rapidly with excellent control </li></ul><ul><li>Two freeze/thaw cycles immediately kill cancer cells </li></ul><ul><li>Total procedure time about 60-90 minutes </li></ul><ul><li>Computer creates “map” of the prostate </li></ul><ul><li>Provides real-time guidance </li></ul><ul><li>Identifies and guides probe placement </li></ul>
    24. 24. Current Technology: 6-8 Probe Argon Cryosurgery System, Total Gland Ablation <ul><li>6-8 Cryo probes in prostate </li></ul><ul><li>5-6 Temperature monitoring </li></ul><ul><li>probes </li></ul><ul><li>Argon Gas = rapid response, excellent freeze control </li></ul><ul><li>Helium Gas = rapid thawing </li></ul>
    25. 25. Prostate Cryoablation Probes inserted in between scrotum & rectum Transrectal ultrasound guides the procedure
    26. 26. Targeted Cryoablation of the Prostate (TCAP) Before Probes Placed Prostate frozen
    27. 27. Prostate Cryoablation Techniques <ul><li>Total Gland Ablation </li></ul><ul><li>Nerve-Sparing </li></ul><ul><li>Focal </li></ul>
    28. 28. Total Prostate Cryoablation
    29. 29. Nerve-Sparing Prostate Cryoablation
    30. 30. Focal Prostate Cryoablation
    31. 31. Results of Total Prostate Cryoablation <ul><li>89% of 590 men followed for 7 years were disease-free based on PSA levels, 87% were disease-free on repeat biopsy </li></ul><ul><li>Rate of rectal injury: 0 - 0.5% </li></ul><ul><li>Rate of urinary incontinence: <5% </li></ul><ul><li>Erectile dysfunction common, but can be successfully treated in almost all men </li></ul>
    32. 32. Cryoablation <ul><li>Advantages </li></ul><ul><li>Outpatient </li></ul><ul><li>Minimally-invasive </li></ul><ul><li>Can treat radiation failures </li></ul><ul><li>Can be repeated </li></ul><ul><li>Better than radiation for high grade cancer (Gleason 7-10) </li></ul><ul><li>Disadvantages </li></ul><ul><li>Erectile dysfunction </li></ul><ul><li>Urinary problems (short-term) </li></ul><ul><li>Shorter track record than surgery or radiation </li></ul>
    33. 33. Summary: Prostate Cryoablation <ul><li>A well-established treatment for localized prostate cancer </li></ul><ul><li>Covered by Medicare & most carriers </li></ul><ul><li>Minimally invasive: no surgical incision </li></ul><ul><li>Minimal blood loss--blood transfusion not needed </li></ul><ul><li>Better than radiation for high risk (e.g. high Gleason score) disease </li></ul><ul><li>Can treat cancer recurrence after radiation (EBRT or seeds) </li></ul><ul><li>Does not increase risk of rectal or bladder cancer </li></ul><ul><li>Avoids radiation cystitis and proctitis </li></ul><ul><li>Avoids seed migration seen with brachytherapy </li></ul><ul><li>Can be combined with hormonal therapy </li></ul><ul><li>Outpatient procedure for most men </li></ul><ul><li>Unlike any other treatment, can be repeated if necessary </li></ul><ul><li>Rapid return to normal activities </li></ul><ul><li>More rapid recovery than after radical prostatectomy </li></ul><ul><li>Erectile dysfunction frequent but treatable </li></ul>

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