Ca prostate
Upcoming SlideShare
Loading in...5
×
 

Ca prostate

on

  • 4,559 views

lecture by Dr. Ahmed Rehman

lecture by Dr. Ahmed Rehman

Statistics

Views

Total Views
4,559
Slideshare-icon Views on SlideShare
4,559
Embed Views
0

Actions

Likes
1
Downloads
104
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Ooo

Ca prostate Ca prostate Presentation Transcript

  •  
  • By Dr Ahmed Rehman FCPS (URO) Assistant Professor UROLOGY
  • CA prostate Incidence and Epidemiology
    • Most common cancer diagnosed in males >65
    • second commonest cause of death from cancer in the western world
    • 1 in 6 men (FUNCTIONING TESTIS ) will get prostate cancer
    • Role of ethnicity & geography
    • PSA testing has had a major impact
  • Mo among Men in the United States
  •  
  • Cancer Incidence Rates* for Men, US, 1975-2000
  • CA prostate mortality
  • Risk Factors
    • Age
    • Race
    • Family history/age of onset
    • Diet / fat
    • Cadmium, cigarette
    • Suspected but Not confirmed
        • Vasectomy
        • Infections
        • sex
  • Etiology
    • Oncogene
      • Familial CAP ----chromosome 1
    • Suppresser gene
      • 8p,10p,13p,16q,17p, 18p, p53
    • Epithelial stromal interactions/growth factors
  • Pathology
    • Classification
      • >95%------------------ adenocarcinoma
      • 5%------------------
            • 90%-------------- TCC
            • 10%--------------neuroendocrine (small cell) CA
            • --------------sarcomas
  • PROSTATE CANCER Tumor distribution Oesterling J, et al. Cancer: Principles & Practice of Oncology . 5th ed. 1997;1322-1386. Transition zone Central zone Peripheral zone % of glandular tissue in prostate % of cancers in zone 10% 25% 65% 5-10% 70% 20%
  • Histopathological Grading
    • Gleason grading system
      • Grade 1-5
      • Score = primary + secondary grade
        • Well diffentiated (G1) 2-4
        • Mod diff (G2) 5-6
        • ??? 7(primary ?)
        • Poorly dif (G3-4) 8-10
      • Prognosis
  •  
    • Early Disease : asymtomatic
    • Peripheral zone : none
    • Transition zone : LUTS / UTIs / retention
    • Progressive Disease
    • Hematuria, Hematospermia, Decreased ejaculate volume
    • Impotence
    • Advanced Disease
    • Bone pain (back) & pathological #
    • Cord compression / nerve involvement
            • Paraesthesias / weakness
            • Urinary / fecal incontinence
    • Constitutional symptoms
    • Obstructive uropathy
    • Bleeding tendencies / DIC, anemia, pancytopenia
    • Limb edema, Intestinal obstruction, Lymphadenopathy
    • Other manifestations of distant mets
    SIGNS AND SYMPTOMS / PRESENTATIONS
  • Detection of cancer: the challenge
    • DRE----- s/s-----------????????
    • PSA------s/s-----------?/////////
      • Prostate specific but not cancer specific
      • Other causes
        • BPH size of prosate
        • Acute & CH prostatitis(TB), prostatic abscess
        • Manipulation, instrumentation, biopsy
      • Poorly diff CA --- not raised
  • Detection of Prostate Cancer ; The Challenge
    • DRE
    • PSA
    Currently, clinical practice guidelines recommend the use of both PSA and DRE in asymptomatic men
  • Establishing the diagnosis----- TRUS & Biopsy
  • Staging
    • Local
      • DRE, serum acid phosphatase,
      • TRUS,CT / MRI / Endorectal MRI -pelvis
    • Skeletal & visceral mets (bone, lung, liver)
      • Bone scan , Alkaline phosphatase (asymptomatic,PSA <10, >30)
      • CXR, CT scan abdomen
    • Nodal
      • (high risk----surgery /radiotherapy)
      • Involvement <10%
      • Sensitivity as low as 22-36%
      • CT /MRI (FNA), sampling / frozen sections
          • Negative bone scan,PSA>20, T3, gleason ggade (p) 4/5
  •  
  • PROSTATE CANCER Stage I T1 Clinically inapparent tumor not palpable nor visible by imaging G1 Well differentiated (slight anaplasia) T1a No MO G1 T1a Tumor incidental histologic finding in 5% or less of tissue resected N0 No regional lymph node metastasis M0 No distant metastasis
  • PROSTATE CANCER Stage II T1a N0 M0 G2, 3-4 T1b N0 M0 Any G T1a Tumor incidental histologic finding in 5% or less of tissue resected T1b Tumor incidental histologic finding in more than 5% of tissue resected N0 No regional lymph node metastasis M0 No distant metastasis T1c N0 M0 Any G T1c Tumor identified by needle biopsy (e.g., because of elevated PSA) T1 clinically inapparent tumor not palpable nor visible by imaging
  •  
  • PROSTATE CANCER Stage II ( Cont’d) T2a N0 M0 Any G T2b N0 M0 Any G T2c N0 M0 Any G T2a Tumor involves one lobe T2b Tumor involves both lobes N0 No regional lymph node metastasis M0 No distant metastasis T2 Tumor confined within prostate* *Note: Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, classified as T1c.
  • PROSTATE CANCER Stage III T3a N0 M0 Any G T3b N0 M0 Any G T3c N0 M0 Any G T3a Extracapsular extension (unilateral or bilateral) T3b Tumor invades seminal vesicle(s) N0 No regional lymph node metastasis M0 No distant metastasis T3 Tumor extends through the prostate capsule* *Note: Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is not classified as T3, but as T2.
  • PROSTATE CANCER Stage IV T4 N0 M0 Any G Any T N1 M0 Any G Any T Any N M1 Any G T4 Tumor is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall M1 Distant metastases M1a Nonregional lymph node(s) M1b Bone(s) M1c Other site(s) N1 Metastasis in regional lymph node or nodes
  • PROSTATE CANCER Distant metastatic spread Lung Bone Liver Epidural space
  •  
  •  
  •  
  • Natural History of Disease
    • Latent / indolent CA
    • Virulent
      • Clinically manifested disease
        • Time of onset & doagnosis
          • Localized
          • Locally advanced
          • Metastatic
          • Hormone refractory (HRCAP/ AICP)
  • Clinically localized Hormone refractory Local treatment Endocrine Chemotherapy Relapsed and newly diagnosed M+
  • Treatment: Localized Disease
    • T1-2
    • Options
      • Watchful waiting
      • Radical prostatectomy ( Young/ Millon / Walsh)
            • Margin +ve  adjuvent radiation
            •  radiation at relapse
      • Neoadjuvent hormone therapy + surgery
      • Radiation
        • External beam
        • Brachytherapy
      • cryosurgery
  • Treatment: Locally Advance Disease
    • T3-4
    • Options
      • Radiaton
      • Neoadjuvent hormone therapy  radiation
        • 2months before & during
  • Treatment: Recurrent Disease
    • Following RP
        • Radiation
    • Following RXT
        • Salvage RP
        • cryosurgery
  • Treatment: Metastatic Disease
    • Any T,M+N+
      • Options
        • Hormone therapy (70-80%)
          • Testosterone Pituitary gonadal axis
            • 95% testes
            • 2% Free  cell  DHT  RECEPTOR  nucleus/transcription
          • Surgical ablation
            • Bilateral Total orchidectomy
            • Bilateral Subcapsular orchidectomy / prosthesis
          • Medical ablation
  • Treatment: Metastatic Disease/ Medical ablation
    • Pituitary -------Diethylstilbesterol (Hanovan)
      • LHRH Agonists
      • Goserelin (zolladex)
      • Leuoprolid
      • Leuprorelin (Lucrin)
    • Adrenals------- Ketoconazole (DIC /cord compression)
      • Aminoglutithemide
    • Prostate --------Antiandrogens
    • Pure Antiandrogens
    • Flutamide (Eulexin/Flutamida)
    • Nilutamide
    • Bicalutamide (Casodex)
    • Steridal / Progestational Antiandrogens
    • Ceproterone Acetate (Androcur)
    • Mesesterol acetate
  • Treatment: Metastatic Disease
    • Complete androgen blockade
      • Testicular +adrenal
      • LHRH/ orchedectomy + antiandrogens
      • Better initial & prolong response but not confirmed by others.
    • Intermittent androgen blockade
      • ?delays refractory state
    • Early versus late blockade
      • Veteran’s ----- no survival benefit
      • MRC -----better survival + less complication rate
  • Treatment: HRPC Chemotherapy
    • Why refractory incomplete blockade / resistant cells
    • Responsiveness time 18 months-3years
    • Logivity 6-9 / 12 months
    • No standard chemotherapy regimen has been defined
    • Early Management of Endocrine Failure:discontinution / addition of antiandrogrns
    • No single agent or combination had improved survival in randomised trials
    • Complete remissions were rare
    • Physicians were reluctant to use chemotherapy in prostate cancer
  • Androgen-independent prostate cancer may respond to
    • Withdrawal of anti-androgens
    • Ketoconazole
    • Corticosteroids prednisolone
    • Aminoglutethimide
    • Anti-androgens
    • Oestrogens
    • Progestational agents
    • Chemotherapy
    • estramustine,mitoxantrone, vinblastine
    • etoposide, cyclophosphamide
    • Novel agents paclitoxel, Docetaxel
  • Clinically localized Hormone refractory Local treatment Endocrine Mitoxantrone+P for symptoms Relapsed and newly diagnosed M+ PROSTATE CANCER Treatment Paradigms No survival benefit
  • Clinically localized Hormone refractory Local treatment Endocrine Taxotere + P q3 wks Relapsed and newly diagnosed M+ PROSTATE CANCER Treatment Paradigms Improves Survival
  • A multimodal approach to evaluating and treating a patient with androgen – insensitive prostate cancer VOL. 5 SUPPL. 3 2003 REVIEWS IN UROLOGY
  • PROSTATE CANCER (HRPC / AIPC) Multi-modality Team VOL. 5 SUPPL. 3 2003 REVIEWS IN UROLOGY
  • Prostate cancer: algorithm
    • (DRE, TRUS, CT + bone scan)
    • Surgery
    • Radiotherapy
    • Adjuvant hormones
    Presentation Diagnosis Metastatic Localised Locally advanced
    • Hormone therapy
    • Surgery + neoadjuvant hormone therapy
    • Radiotherapy ± hormone therapy
    • Hormone therapy
    Local control Palliative Curative Observation (symptoms/PSA) (biopsy) Staging CT = computed tomography; DRE = digital rectal examination; PSA = prostate-specific antigen; TRUS = transrectal ultrasound