basic evaluation, pathology, management of prostate cancer

1. PROSTATE CANCER
Dr Winston Makanga, M.B.Ch.B, M.MEd (Surg)
Consultant General and Laparoscopic Surgeon

2. Objectives of the lecture
• Surgical anatomy
• Physiology and functions
• Epidemiology
• Etiology
• Work-up (screening, diagnosis, staging)
• Treatment

3. Surgical anatomy 1

4. Surgical anatomy 2

5. Physiology and function
• Testosterone is trophic to the prostate
• DHT is the active form after conversion by 5 alpha
reductase
• LH production by pituitary responds to pulsatile release of
GnRH
• Function = production of seminal fluid, hormone
production and sphincteric function

6. Epidemiology

7. Etiology
• High body mass index
• Physical activity
• Smoking
• African-American race
• Positive family history

8. Pathology
• Microscopic: adenocarcinoma
• Types
• Latent disease found on autopsy
• Incidental disease on TURP/open prostatectomy
• Localized cancer
• Locally advanced
• Metastatic disease
• Spread
• Local to seminal vesicles, trigone, membranous urethra, ureters
• Metastatic: by blood to lumbar vertebrae/pelvis/ribs
• Lymphatic: internal and external iliac nodes, para-aortic, mediastinal

9. Presentation
• Mostly asymptomatic (screening or opportunistic PSA testing)
• LUTS
• BOO, pain, hematuria, renal failure
• Symptoms due to metastatic disease
• DRE: nodule, hard, irregular, fixed rectal mucosa, sulcus obliteration

10. Investigation
• General blood tests
• CBC, UEC, LFTs
• PSA
• Trucut biopsy
• Radiology
• CXR, Lumbar and pelvic XR
• Ultrasound - TRUS
• MRI
• Bone scan

11. Gleason’s score Most prevalent
gland types
Second most
common gland
type
1 1
2 2
3 3
4 4
5 5
High risk disease >7 (4+3)

12. Staging
• Clinical vs Pathological staging; Based on TNM
• Nodes: N1 – N2 – N3 (<2-5> cm)
• Met: M0 and M1 (abc)

13. Treatment options
• Active surveillance
• Radical prostatectomy
• Androgen suppression therapy
• Chemotherapy
• Radiotherapy
• Palliation

14. Active surveillance
• For low risk disease
• Low PSA
• Small focus
• <Gleason 6 on histology
• Involves:
• 3 monthly DRE and PSA
• Repeat trucut if/when needed
• Avoid use of Alpha reductase inhibitors to treat LUTS
• ~ 30% will require radical treatment in ~3-5 years

15. Surgery
• Ideally for T1, T2 and ?T3a
• Radical prostatectomy offers potential cure
• Open (perineal/retropubic) vs laparoscopic vs robotic
• Highly dependent on case load, life expectancy, performance status and lifestyle
• Likely complications:
• Erectile dysfunction
• Incontinence
• Hemorrhage

16. Radiotherapy
• External beam or internal – brachytherapy (T1,T2)
• Can be offered for localized disease
• OS similar to radical prostatectomy
• Complications
• Radiation Cystitis &/or proctitis
• urinary frequency, urgency
• urge incontinence
• Diarrhea

17. Androgen deprivation therapy ADT
• Used in advanced disease or poor performance status
• As adjuvant therapy in locally advanced disease
• Lessens risk of metastatic advancement
• Controls local and general symptoms
• Combine GnRH agonist with androgen receptor blockers ARB at initiation
• Prevents flare up of mets at initiation of therapy
• Combined androgen blockade for locally advanced disease = long term
GnRH agonist + ARB*
• Abiraterone may be an option in castrate resistance
* Time to CRPC is ~ 5-15 years in CAB

18. Chemotherapy
• In castrate resistant ca prostate
• Main option = taxanes (docetaxel)
• Early introduction may have better outcome
• Response is generally poor

19. Palliation
• Radiotherapy for focal mets (pain and risk of fracture)
• Orchidectomy for imminent risk of cord compression in poor status
• Channel TURP for BOO
• Manage castration induced osteoporosis with Vit D, calcium and
bisphosphonates (Alendronate….)

20. Overview of treatment
Age Low risk Intermediate High risk Metastatic
>70 Watchful waiting Palliate BOO
Androgen suppression
Palliate BOO
Androgen suppression
Palliate BOO
Androgen suppression
Focal radiotherapy
<70 Active surveillance Radical prostatectomy
Radiotherapy
Androgen suppression
Radical prostatectomy
Radiotherapy
Androgen suppression
Chemotherapy
Focal radiotherapy
Palliate BOO

21. Thank you