Prostate cancer is the most common non-cutaneous cancer in men in North America. Risk factors include advancing age, family history, and African ancestry. Early stages are often asymptomatic, while advanced stages can cause urinary issues, bone pain, and weight loss. Diagnosis involves a PSA test, digital rectal exam, and prostate biopsy. Pathology determines Gleason score and grade. Treatment depends on risk level and includes active surveillance, surgery, radiation, hormone therapy, and chemotherapy. Advanced disease focuses on disease control and palliation of symptoms.

2. Most common non-cutaneous
malignancy in men in North America
2nd most common cause of cancer-
related deaths in men
1 in 7 men will be diagnosed WITH PR_ CA
Lifetime risk of being diagnosed with
prostate cancer is 18/100 but risk of
dying of prostate cancer is only 3/100

3. Risk factors
Established
Advancing age
Presence of androgens
Family history 1st d.relative
African ancestry

4. RISK FACTORS
Potential
High dietary fat
Obesity
Inherited mutations (BRCA1 or
BRCA2 genes)
Vitamin D or E deficiency
Selenium deficiency?

5. Early stages usually asymptomatic
Most cases detected by serum PSA
screening
Palpable nodule or firmness on DRE
Advanced stages
Urinary retention/renal failure
Bone pain
Anemia
Weight loss, fatigue
Spinal cord compression

7. Fusión TMPRSS2-ERG
• En hasta 80% de los cánceres de próstata
• ERG es un factor de transcripción
– Proliferación
– Fenotipo resistente a la castración
• TMPRSS2 es un gen que responde al AR
– Es una serina proteasa
• Es una diana molecular potencial
– El silenciamiento ERG con RNAi disminuye
proliferación

8. Prostate cáncer diagnosis
Indications for transrectal ultrasound (TRUS)
guided biopsy
Palpable nodule on DRE
Elevated serum PSA
Biopsy involves 10-18 needle cores taken mostly
from the peripheral zone of the prostate
Transrectal ultrasound alone/CT scan/MRI not
sensitive enough to make the Diagnosis

9. Enfoque diagnóstico – Cáncer de Próstata
Enfoque
diagnóstico –
cáncer de
próstata
Síntomas
urinarios o
PSA anormal
Evaluación
rectal digital
(DRE) / PSA
(si falta)
DRE: Normal
PSA: Normal
PSA de 2, o
menos
PSA de 2+
Velocidad PSA
0.75+/año
TRUB
Repetir 1-3
años
DRE: Anormal
o
PSA: Anormal
TRUB
PSA 10, o menos
+ PSA libre 15%
o menos
Repetir en 6
meses
TRUB: Biopsia transrectal eco-dirigida
PSA: Antígeno específico de próstata
No
Si
No
PSA 10+

10. - histology:
- Gleason scores

11. Prostate cáncer pathology
Adenocarcinoma
Gleason “grade” is from 1-5
based on glandular
architecture
Gleason score is the total
primary grade (1-5) +
secondary grade (1-5) = 2-10
 4-6/10=well-differentiated
 7/10=moderately differentiated
 >8/10=poorly differentiated

12. Gleason 6
www.cancernetwork.com - Cesar A Moran, 07.02.2014

13. Gleason 7
www.cancernetwork.com - Cesar A Moran, 07.02.2014

14. Gleason 8
www.cancernetwork.com - Cesar A Moran, 07.02.2014

15. Gleason 9
www.cancernetwork.com - Cesar A Moran, 07.02.2014

16. PATHOLOGY GROUPINGS IN PROSTATE
CANCER
• GROUP 1
– Gleason score 3+3, or less.
• GROUP 2
– Gleason score 3+4
• GROUP 3
– Gleason score 4+3
• GROUP 4
– Gleason total score 8
• GROUP 5
– Gleason total score 9 or 10

17. Prostate cáncer staging
Can spread to adjacent organs (seminal
vesicles, bladder), lymph nodes, bone
Most bone mets are osteoblastic
Prior to initiating treatment consider
Bone scan (PSA>10, Gleason Score >7)
CT scan pelvis/abdomen (PSA >10, Gleason
Score >7))
These tests are typically not required in
asymptomatic men with low risk prostate
cancer

18. Maniobras de estadificación
• Consideraciones
– Tumores MUY tempranos pueden no necesitar estudios
adicionales para metástasis a distancia
• T1c/T2a; PSA de 10, o menos; Gleason 6, o menos.
• RM de próstata con antena rectal – para planeación terapia
– Tumores MUY avanzados pueden ser investigados con:
• Gammagrafía ósea / TAC de tórax, abdomen y pelvis
– Tumores POTENCIALMENTE avanzados pueden beneficiarse de:
• RM corporal total
• El PET-CT es ineficaz en cáncer de próstata
– Tumores candidatos a terapia local (Prostatectomía /
Braquiterapia) o candidatos a Radioterapia
• RM Multiparamétrica de próstata con antena rectal

19. Práctica usual
• Gammagrafía ósea
• TAC de tórax contrastado
• RM de pelvis / Próstata con antena rectal
• PSA

20. Carcinoma de Próstata
TNM
• T1 - Tumor primario no aparente clínicamente ni visible por imágenes.
T1a - Hallazgo incidental que compromete <= 5% del tejido resecado.
T1b - Hallazgo incidental que compromete > 5% del tejido resecado.
T1c - Diagnóstico obtenido por biopsia ciega inducida por un PSA
elevado.
• T2 - Tumor confinado a la próstata.
T2a - Compromete la mitad o menos de un lóbulo.
T2b - Compremete más de la mitad de un lóbulo.
T2c – Compromiso de ambos lóbulos prostáticos
• T3 - Tumor que se extiende más allá de la cápsula prostática.
T3a - Extensión extracapsular.
T3b - Invade la vesícula seminal.
• T4 - Fijado a otras estructuras distinto a las vesículas seminales.
• N1 - Ganglios linfáticos comprometidos.
• M1 - Metástasis a distancia.
M1a - Ganglios linfáticos no regionales.
M1b – Huesos.
M1c - Otros sitios.

21. Grado T1a T1b T1c T2a T2b T2c T3a T3b T4 N1 M1 PSA
1 I I I I IIa IIa IIIb IIIb IIIb IVa IVb <10
1 IIa IIa IIa IIa IIa IIa IIIb IIIb IIIb IVa IVb 10-20
2 IIb IIb IIb IIb IIb IIb IIIb IIIb IIIb IVa IVb <20
3 IIc IIc IIc IIc IIc IIc IIIb IIIb IIIb IVa IVb <20
4 IIc IIc IIc IIc IIc IIc IIIb IIIb IIIb IVa IVb <20
1-4 IIIa IIIa IIIa IIIa IIIa IIIa IIIb IIIb IIIb IVa IVb ≥20
1-4 IIIb IIIb IIIb IVa IVb Any
5 IIIc IIIc IIIc IIIc IIIc IIIc IIIc IIIc IIIc IVa IVb Any
Any Any Any Any Any Any Any Any Any Any IVa IVb Any
Prostate cancer staging system

22. Very low risk (must fulfill all)
T1c
Grade Group 1
PSA less than 10
Less than 4 core+, with less
than 50 per-cent cancer in
each
Psa density less than 0.15

23. low risk (must fulfill all)
T1-T2a
Grade Group 1
PSA less than 10

24. Favorable intermediate
T2b-T2c or
Grade Group 2 or
PSA 10-20 and
positive biopsy cores less 50
per-cent

25. unfavorable intermediate
T2b-T2c or
Grade Group 2 or group 3 or
PSA 10-20

26. high
T3a or
Grade Group 4 or group 5 or
PSA greater than 20

27. VERY high
T3b-t4 or
Grade group 5 or
More than 4 cores with grade
group 4 or 5

29. Prostate cáncer treatment
Considerations
Patient’s age
Co-morbid health conditions
Tumor stage
Tumor grade (Gleason score)
Often a patient choice
Surgery and

30. Early stage Prostate cáncer
treatment
Early stage Cancer
1. Radical Prostatectomy
2. External Beam Radiotherapy
3. Radioactive Seeds (Brachytherapy)
4. Active Surveillance
5. Observation – Watchful Waiting

31. Early stage Prostate cáncer
treatment: radical prostatectomy
Radical Prostatectomy
Complete surgical removal of entire prostate,
seminal vesicles
Considered a good treatment for men <70
years of age with clinically organ confined
cancer who are healthy
Open or laparoscopic/robotic approaches

32. Early stage Prostate cáncer
treatment: radical prostatectomy

33. radical prostatectomy:
complications
<10% risk of blood transfusion
Wound infection
Rectal injury (<1%)
Urinary incontinence (~10%)
Erectile dysfunction (variable but common)
Anesthetic related

34. Prosate cancer treatment:
radiotherapy
Radiotherapy Options
External Beam
Brachytherapy (seed implant)
Concept of maximizing dose to the tumor and
minimizing collateral damage
Curative options for patients at high risk for
morbidity from radical prostatectomy
Age, medical co-morbidities
Patient preference

35. Prosate cancer treatment:
radiotherapy

36. Radiotherapy: complications
External Beam Radiation Therapy
Hematuria
Radiation proctitis
Loose, bloody stools
Urinary retention
Strictures (urethra and ureter)
Erectile dysfunction
Secondary malignancies
Bladder, rectal, hematological

37. Proctitis Actínica

38. Prostate cancer therapy:
brachytherapy

39. Brachytherapy: complications
Urethral strictures
Seed migration
Urinary retention
Erectile dysfunction
Irritative voiding symptoms

40. Active surveillance
Observing low grade tumors in men <70 yrs and >10 yr
life expectancy
Delay definitive treatment until it is necessary and
cancer is still curable
Goal is to delay potential treatment-related morbidity
Monitor DRE, PSA, and periodic repeat biopsy
Ideal candidate:
 PSA < 10
 Normal DRE
 Gleason <7 (low grade)
 Only 1-3 / 12 biopsy cores positive

41. Watchful waiting
Observing low grade tumors in men
>70 yrs or <10 yrs life expectancy
Institute hormonal therapy when
patient becomes symptomatic
No curative intent

42. Todos:
T1c (detectado por PSA)
Grupo 1 (Gleason 3 + 3)
PSA<10
<3 cores positivos
≤50% de tumor por core
Densidad de PSA <0.15
Vigilancia activa
Todos:
T1-T2a (Compromiso <50% de un lóbulo)
Grupo 1 (Gleason 3 + 3)
PSA<10
Vigilancia activa
Cualquiera:
T2b-T2c (>50% de un lado o bilateral)
Grupo 2 (Gleason 3 + 4), 3 (Glason 4 + 3)
PSA 10-20
Tratamiento
Ultrabajo
Bajo
Intermedio
CaPróstata

43. Cualquiera
T2b-T2c (>50% de un lado o bilateral)
Grupo 2 (Gleason 3 + 4), 3 (Glason 4 + 3)
PSA 10-20
Favorable
Intermedio
CaPróstata
1 solo core afectado
y grupo 1 o 2, y <50%
de tejido afectado
Desfavorable
>1 core afectado, o
grupo 3, o >50% de
tejido afectado
Radioterapia Radioterapia + bloqueo
androgénico corto

44. Alguno
T3a
Grupo 4 o 5 (Gleason 8-10)
PSA>20
RT + ADT
Alguno:
T3b-T4
Gleason primario 5
>4 cores con Grupo 4 o 5
RT + ADT
Alto
Ultra-alto
CaPróstata

45. Alguno:
T3b-T4
Gleason primario 5
>4 cores con Grupo 4 o 5
Ultra-alto
CaPróstata
Radioterapia +
bloqueo androgénico
largo (1.5-3 años)

46. Treatment options by risk
1/2
Risk Group
Very-low risk
Active surveillance
External-Beam Radiotherapy
Radical prostatectomy +/- RPLND
Observation
Low risk
Active surveillance
External-Beam Radiotherapy
Radical prostatectomy +/- RPLND
Observation
Favorable intermediate
Active surveillance
External-Beam Radiotherapy
Radical prostatectomy +/- RPLND
Observation
RPLND: Retroperitoneal Lymph-Node Dissection

47. Treatment options by risk
2/2
Risk Group
Unfavorable intermediate risk
External-Beam Radiotherapy + ADT (4 mo)
Radical prostatectomy +/- RPLND
Observation
High risk
External-Beam Radiotherapy + ADT (18 mo)
Radical prostatectomy + RPLND
Very High risk
External-Beam Radiotherapy + ADT (18 mo)
Radical prostatectomy +/- RPLND
RPLND: Retroperitoneal Lymph-Node Dissection

48. Advanced or metastatic prostate
cancer
Not curable disease
Goals shift to disease control
Development of cancer cells unresponsive
to androgen deprivation
Typically occurs slowly over time, although
it can occur rapidly

49. Treatment strategies for
metastatic prostate cancer
Androgen Deprivation (Hormonal Rx)
Orchidectomy
LHRH analogues
Antiandrogens
Supportive therapies
Analgesics
Steroids
Bisphosphonates/Vitamin
D/Calcium for bone health
Chemotherapy
 Taxotere, Docetaxel
Last line of treatment