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diagnosis and outline of management of localized prostate cancer for non-urologist

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a brief introduction of anatomy of prostate, screening of prostate cancer, measures to improve specificity of PSA screening, risk stratification of prostate cancer, treatment options - active surveillance, radical prostatectomy, radical radiotherapy

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diagnosis and outline of management of localized prostate cancer for non-urologist

  1. 1. LOCALIZED PROSTATE CANCER ​Dr Mayank Mohan Agarwal MBBS, MS, MRCS(Ed), ​DNB, MCh (PGIMER, Chandigarh) VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction (MSKCC, NY; UCLA, LA; WFUBMC, NC)​ Formerly, Associate Professor of Urology (PGIMER, Chandigarh) Formerly, Consultant & Head of Urology (NMCSH, Abu Dhabi) Consultant and Head of Urology (Aster) Dr. Ramesh Cardiac and Multispecialty Hospitals Pvt. Ltd. Guntur (AP), India
  2. 2. Introduction • Anatomy • Diagnosis • Imaging • Risk stratification • Management strategies
  3. 3. Anatomy 4cm 3cm 2cm
  4. 4. Vascular anatomy
  5. 5. Muscular structures
  6. 6. NERVE BUNDLES
  7. 7. CONTINENCE ERECTION LGI FUNCTION LUT FUNCTION
  8. 8. DIAGNOSIS AND IMAGING • DRE • PSA • MULTIPARAMETRIC MRI • TRUS guided prostate biopsy UROLOGIST
  9. 9. Population based PSA screening • Population based RCT n = 182000 0 0.2 0.4 0.6 0.8 1 1.2 50-54 55-59 60-64 65-69 70-74 CAP specific deaths per 1000 person-year screening control Schroder FH et al. N Engl J Med 2009;360:1320-8.
  10. 10. PSA (human Kallikrein peptidase 3) • Serine protease, member of a family of 15 hkp’s • preproPSA  proPSA  PSA  _mg/ml into semen A millionth (_ng/ml) unprocessed Processed in prostate (70-80%) (90-95%) (5-10%) (1-2%) (20-30%)
  11. 11. PSA (human Kallikrein peptidase 3) • Serine protease, member of a family of 15 hkp’s • preproPSA  proPSA  PSA  _mg/ml into semen A millionth (_ng/ml) unprocessed Processed in prostate (70-80%) (90-95%) (5-10%) (1-2%)IN CANCER (<20-30%)
  12. 12. PSA (human Kallikrein peptidase 3) • Organ specific (almost) – breast tissue, breast milk, breast/kidney/adrenal cancer, parotid • Disease non-specific – prostatic hyperplasia, prostatitis, prostate manipulation, prostate cancer
  13. 13. Risk of CAP based on PSA • PSA is a continuous variable • There is actually no “normal” value • “probability” of having CAP proportional to PSA 0 20 40 60 80 100 0.0-0.5 0.6-1.0 1.1-2.0 2.1-3.0 3.1-4.0 4.1-10.0 10.1-20.0 >20.1 % risk of CAP Thompson, I.M., et al. N Engl J Med 2004; 350: 2239.
  14. 14. NCCN 2018
  15. 15. HOW TO IMPROVE SPECIFICITY OF PSA 4-10 • PSA > 3ng/ml – indication for biopsy ~25% PPV • Can we avoid biopsies in some of these patients?
  16. 16. Percent free PSA • “more the merrier” 0 20 40 60 80 100 8 10 11 12 13 14 15 17 perc free PSA sensitivity specificity unprocessed Processed in prostate (70-80%) (90-95%) (5-10%) (1-2%)IN CANCER (<20-30%)
  17. 17. PSA density • PSA per unit volume (PSAD) 0.10 – 0.15 • PSA per unit TZ volume (PSAD-TZ) ?? 0.20 – 0.30 0 20 40 60 80 100 0.1 0.15 0.2 0.3 sensitivity specificity PSAD-TZ 0 20 40 60 80 100 0.075 0.1 0.15 0.2 0.25 sensitivity specificity PSAD
  18. 18. PSA velocity • Various cutoffs sensitivity – specificity balance poor • Valid only in long term follow up (at least 3 values, at least 18m duration) • For PSA 4-10 cutoffs 0.35-0.75 ng/ml/yr have been used with relatively high specificity but low sensitivity Mettlin C. Cancer 1994; 74:1615-20; Lee SC. Korean J Urol 2004;45:747-752
  19. 19. TRUS GUIDED PROSTATE BIOPSY • Proper preparation - Control of sugar - Urine culture (+/_ stool culture to detect MDR / ESBL) - Reduce anticoagulation (max aspirin 75mg/d) - Bowel preparation - Antibiotic prophylaxis • Counseling for complications - Sepsis - Retention - Hematuria • At least 12 cores + lesion guided (if applicable) + more cores for larger prostates
  20. 20. Multiparametric MRI • T1 • T2 • DWI / ADC • CEMRI • spectroscopy PIRADS. American College of Radiology. 2015
  21. 21. Risk stratification Very low low Int. favorable Int. unfavorable Intermediate high low Very high high REGIONAL (N1) METASTATIC (M1)
  22. 22. Risk stratification Factors to consider – 1. TNM staging 2. Gleason scoring 3. PSA 4. PSAD 5. No. of biopsy cores (+) 6. % of a core (+) T1 T2 T3 T4
  23. 23. Risk stratification Factors to consider – 1. TNM staging 2. Gleason scoring 3. PSA 4. PSAD 5. No. of biopsy cores (+) 6. % of a core (+) 1-3 4 5
  24. 24. Risk stratification Factors to consider – 1. TNM staging 2. Gleason scoring 3. PSA < 10 – 20 < 4. PSAD 5. No. of biopsy cores (+) 6. % of a core (+)
  25. 25. Risk stratification Factors to consider – 1. TNM staging 2. Gleason scoring 3. PSA < 10 – 20 < 4. PSAD 5. No. of biopsy cores (+) 6. % of a core (+) Minor factors for ‘fine tuning’
  26. 26. Management strategies for localized cancer Determinants – • Risk-group • Patient’s physiological status  Charlson’s comorbidity index  Life expectancy • Availability and affordability • Patient’s preferences RADICAL PROSTATECTOMY RADICAL RADIOTHERAPY ACTIVE SURVEILLANCE
  27. 27. ACTIVE SURVEILLANCE Diagnosis progression metastasis Death by disease Natural Death Very low low Int. favorable Int. unfavorable Intermediate high low Very high high • Gleason score 6 • PSA <10 • T1 – 2a
  28. 28. ACTIVE SURVEILLANCE • Is not watchful waiting • Actively monitoring disease status throughout • Suitable for very low risk and low risk patients • Monitoring by • PSA velocity • MRI • Re-biopsy Diagnosis progression metastasis Death by disease Natural Death
  29. 29. Radical prostatectomy vs radiotherapy
  30. 30. Radical prostatectomy vs radiotherapy CURE PROS CONS PROS CONS
  31. 31. Radical prostatectomy vs radiotherapy
  32. 32. Radical prostatectomy • Open • Laparoscopic - Without - With robotic assistance Retropubic transperitoneal radical prostatectomy retropubic retroperitoneal radical prostatectomy laparoscopic transperitoneal radical prostatectomy extraperitoneoscopic radical prostatectomy robotic assisted transperitoneal radical prostatectomy robotic assisted extraperitoneoscopic radical prostatectomy intrafascial prostatectomy, transfascial prostatectomy extrafascial prostatectomy partial prostatectomy sexuality preserving prostatectomy open perineal radical prostatectomy robotic perineal radical prostatectomy veil of Aphrodite procedure complete posterior reconstruction complete anterior reconstruction Rocco’s stitch • Most effective local clearance of localized disease • Most accurate biopsy to design further treatment • Incontinence • Erectile dysfunction • LUT dysfunction
  33. 33. Radical Radiotherapy • 3d-CRT • IMRT • With or without IGRT ** - preferred • Non-invasive • Incontinence • Erectile dysfunction • LUT dysfunction • LGI dysfunction
  34. 34. Admissions MIS urology Rectal proceduresOpen surgery Radical prostatectomy vs Radical Radiotherapy • 32465 men with CAP almost 1:1 open RP and RT • 32465 men without CAP comparator Nam et al. Lancet Oncol 2014
  35. 35. Radical prostatectomy vs Radical Radiotherapy • 68665 men with CAP almost 1:2 RP and RT Abdollah et al. Int J Urol 2012
  36. 36. Adjuvant therapy RADICAL PROSTATECTOMY RADICAL RADIOTHERAPY ADT LHRH antagonist LHRH agonist Orchidectomy
  37. 37. THANK YOU

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