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Early detection of  carcinoma prostate by Dr. U.K.Shrivastava (MS,FAIS,DHA), Prof. & Head of Surgery, AIMST University, Malaysia
 

Early detection of carcinoma prostate by Dr. U.K.Shrivastava (MS,FAIS,DHA), Prof. & Head of Surgery, AIMST University, Malaysia

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    Early detection of  carcinoma prostate by Dr. U.K.Shrivastava (MS,FAIS,DHA), Prof. & Head of Surgery, AIMST University, Malaysia Early detection of carcinoma prostate by Dr. U.K.Shrivastava (MS,FAIS,DHA), Prof. & Head of Surgery, AIMST University, Malaysia Presentation Transcript

    • EARLY DETECTION OFCARCINOMA PROSTATE Dr. U.K.Shrivastava MBBS,MS,FAIS,DHAProfessor and Head of surgery AIMST University, Malaysia
    • Anatomy and Function of ProstateSituated in men in lower pelvis, at neck of bladder and in front of rectum, plum sizeIt secretes alkaline fluid 1/3 of fluid in semenFluid from prostate, seminal vesicles and Cowpers gland together make real bulk semen ejaculations, nourishes sperms,PSA comes from prostate epithelium, keeps semen in fluid form, avoid coagulation
    • Anatomy
    • Anatomy
    • Prostate CancerBecame commonly diagnosed cancer 1989Generally affects after the age of 50 yearsStarts in the peripheral zone of prostate Second leading cancer death in male after lung cancerIt is slow growing cancer, do metastasizeMost common type is adeno carcinomaEarly detection started from 1990 with PSA
    • MODALITIES• SERUM P.S.A.• DIGITAL RECTAL EXAMINATION• TRANS RECTAL ULTRA SONOGRAM• MAGNETIC RESONANCE IMAGING
    • SERUM P.S.A.• serine protease, single chain glycoprotein• It contains 90% amionoacids 10% glycopr• organ specific marker not c.a. specific• Mostly secreted from prostatic epithelium• secreted mainly transitional zone BPH• secreted mainly peripheral zone Ca.P• Involved in liquefaction of seminal coagulum
    • PSAUseful in diagnosing and staging Ca PUseful in monitoring response of treatmt.Discovery of PSA is major advancementIt has been a most valuable tumor marker Very useful in detecting early Ca prostateNormal value ranges from o to 4.0ng/ml
    • P.S.AAnnual PSA testing is recommended from50 years of ageIf it is less than 1.0ng/ml every 5 yearsIf it is lower than 2.0ng/ml alternate yearIf more than 2.0ng/ml get it every yearIt is advisable to have from same LAB
    • PSA DENSITYIntroduced by Benson 1992It is a quotient of serum PSA divided, by volume of prostate gland PSA level dependent on number of prostatic cells Very high in BPH and also in CA prostate This confirms cancerous cells leak more PSA This facts help in detecting the malignancy The volume measurement of gland is achieved by TRUS Density variable with age
    • Recent conceptMeasurement of TZ volume by TRUS ismore reliable than measuring entireprostate volume upper limit of 0.15 higher incidence of CAMost of the PSA entering the circulation arise from TZBut in cancer they come from PZCA cells produce more PSA per unit volume
    • Prostate hyperplasia
    • Ca Prostate
    • PSA VELOSITYIt is a measurement of rate of changein PSA volume over the timeConcept introduced by Carter et alBPH patients will have linear rise in PSACA patients linear rise in beginning, later exponential rise is PSA volumeCarter says 0.75ng/ml rise per year has greater chance of developing CAP
    • AGE SPECIFIC PSA REFERENCESAGE 40 - 49 == 0– 2.5ng/ml 50- 59 == 0– 3.5 ng/ ml 60- 69 == 0—4.5ng/ ml 70- 79 == 0---6.5ng/mlThe importance of this is that – It increases the sensitivity in men younger than 60yrs of age and specificity in men older than 60 years of ageOver all specificity 95%
    • PSA VELOCITY Normal value 0- 4ng/ml Half life 2 to 3 days Rate of change non BPH 0--.04ng/ml/yr BPH------.07 -0.27ng/ml/yr 0.75 ng/ml/yr risky CAAny disruption in prostatic architecture-PSAleaks in circulations
    • FREE PSA Percentage of PSA circulates in blood without a carrier protein ( unbound)PSA gets bound to alpha 1 anti chymotrypsein and alpha2 macroglobulin (ACT/AMG)It also remains free in serum PSA ACT found to be high in CAP than in BPHFree PSA low with inverse rise in PSA/ACT seen in Carcinoma of prostateHigher the free PSA in BPH
    • FREE PSAAs the percentage of f/PSA declines, theprobability of a cancer prostate increasesThe f/PSA is more discriminatory in distinguishing between cancer and BPHSize <40cc percent f/PSA 0.137and low detect 90% OF CAPSize >40cc cut of point 0.205 detect90%CA
    • FACTORS INFLUENCING SERUM PSA LEVELS• Prostatitis• BPH and Carcinoma• Biopsy• DRE• TRUS• Cystoscopy• Ejaculation• Variable with age/race/ volume• U T I , vigorous exercise ,any sexual drive
    • PSAPSA screening recommended annually all men >50 yearsFamily history, black men –PSA testing at 40yearsIt is very helpful in detecting organ confined cancer prostateTotal prostatectomy can achieve the cure
    • DIGITAL RECTAL EXAMINATIONCancer detected by DRE are generallylocally advanced in50% of casesShould never be abandoned, may detect at times with normal serum PSA<4ng/mlPositive predictive value of DRESerum PSA-- 0– 2.9ng/ml------4-11% 3.00-- 9.9ng/ml-----33—83%DRE--- any nodule, hardness, fixity to R. mucosa
    • DREIt should always be combined with serum PSA testing for early detectionAlways advisable to have DRE either annually or twice in a year above 50 yrsAny suspicious finding --- Advise TRUS followed with sextant biopsy
    • DIGITAL RECTAL EXAMINATION
    • PSA/ DREPSA and DRE– complementary to each other 25% men of Ca P have PSA < 4ng/mlCancer detected with DRE- 75%will have metastasisPSA – gets decreased after– orchiectomy, LHRH agonist, Flutamide , 5 alpha reductase inhibitor – helpful in medical treatment. of BPH
    • TRUS It helps in seeing deep into the prostatic tissues and finds the hypo echoic zone It detects the size of prostate seminal vesicles spread of ca beyond prostate Not to be used1st line screening study lacks specificity, expensive , not helpfulin diagnosis, if already detected by DRE/PSA
    • TRUS
    • TRUS Limitation that ,most hypo echoic lesions are not cancerIt could be cancer, infarct or even abscessAlways insure during bx for wide area sampling of prostatic tissues Indications--------- raised PSA abnormal DREPZ 30-50% cancer may be of isoechoicTZ up to 80% may be isoechoic
    • TRUS guided BXIt can be---Directed biopsySextant biopsy ,now 12 core bx doneAnterior biopsy from TZLateral lobe biopsyExtended field biopsy
    • Gleason Scores1 The pathologist examine the bx cores and assign the no 1-5to most common pattern seen2 Grade of 1 means cancer cells more like a normal cell3 Pathologist further identifies the second most common pattern and grade 1-5 so it ranges from 2-10 4 5-7 common type of slow growing tumor 8-10 aggressive tumors
    • TRUS BXCan be done as OPD procedureit takes about 15 minutesPrecautions---- enema local anesthesia prior antibiotics stop aspirinComplications ---- haematuria haemospermia
    • MRI (endo rectal coil)This test is complimentary to TRUSIn the event of malignancy this tells about the growth really confined to organ only or gone beyond thatInvolvement of seminal vesicles pelvic lymph nodes and bladder can be detected It is expensive------ NOT a screening tool
    • ALGORITHM FOR EARLY DETECTIONDRE PSA DIOGNOSTIC ACTIONNegative < age spec range annual PSA and DRENegative > age spec. range TRUS bx and sextant bxPositive Any value TRUS bx and sextant bx
    • ADVANTAGEHelp to pick up significant disease before it becomes symptomaticHelp to monitor men who have higher risk of developing cancerHelp to pick up aggressive cancer early when treatment is feasibleHelp in investigating the prostatic disease when the value of PSA high
    • DISADVANTAGE2/3 of men with raised PSA --- no cancerSome with normal PSA can have cancerIt does not tell whether cancer is fast/ slow natureSlow growing cancer does not affect the life of the patient to that extent Raised value demands bx its own hazard
    • CONCLUSIONTo screen or not to screen ? Screening supported by— Disease is burdensome PSA detects curable tumor No cure for metastatic diseasesPSA levels are strong predictor of future CAStudies are still on for guidelines for earlydetections of carcinoma of prostate
    • PREVENTION AND SUPPLEMENTS• If its Heart Healthy---its Prostate healthy• Whatever is good for heart, good for Pros• Univ. of Arizona work on Selenium.• Role of natural Vitamin E d gamma tocopherol ,d alpha tocopherol,best dietary• found, in soya products,tofu,soya nuts• Omega-3fatty acids good role• Heart healthy oil-Soya, canola and ,Olive
    • Supplements• Plant estrogen supplements- by reducing• androgen, but can lead to Erectile dysf.• Breast tenderness, loss of libido hair loss• and DVT• Use of Aspirin good but bleed tendency , salicylic acid found in fruits and vegi. Use of Soya very good in , in all forms
    • Supplements• Drugs a Androgen b DutastrideExercise always goodKeep cholesterol low and HDL high