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Ca prostate
- 2. GUIDELINES FOR MANAGEMENT Dr ANKITASINGH PATEL MBBS,MD(KGMU) CONSULTANT Apex Hospital Cancer Institute TRAINING AND FELLOWSHIP Fortis Research Institute ,New Delhi Tata Memorial Hospital,MUMBAI Mob. 8765845035,9305421547 Email: dr.ankitapatel.onco@gmail.com
- 3. INCIDENCE Prostate cancer(PCa) is the second most common cause of cancer and the sixth leading cause of cancer death among men worldwide. RISK FACTORS: Age ,Race , Family history/age of onset , Diet / fat , Cadmium, cigarette
- 4. PROSTATE CANCER Tumor distribution %of glandular tissue in prostate % of cancers in zone 10% 25% 65% 5-10% 70%20% Oesterling J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1322-1386. Transition zone Central zone Peripheral zone
- 7. Lung Bone Liver Epidural space PROSTATE CANCERDistant metastatic spread
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- 10. AGE NORMAL (ng/Ml) 40-490-2.5 50-59 3.5 60-69 4.5 70-79 6.5 AGE SPECIFIC PSA CUTOFF
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- 14. GLEASON SCORE PRIMARYGRADE – Most predominant pattern. SECONDARY GRADE – Highest grade in all the samples. When these two grades are added together, the total is called the Gleason score. EXAMPLE if the biopsy samples show that: most of the cancer seen is grade 3 the highest grade of any other cancer seen is grade 4, then the Gleason score will be 7 (3+4). A Gleason score of 4+3 shows that the cancer is slightly more aggressive than a score of 3+4, as there is more grade 4 cancer.
- 15. Pathology Classification >95%------------------adenocarcinoma 5%------------------ - 90%--------------TCC - 10%--------------neuroendocrine (small cell) CA --------------sarcomas
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- 17. Androgen Deprivation Therapy degarelix(Firmagon) •enzalutamide(MDV3100) • ketoconazole •Abiraterone (Zytiga) •Goserlin (Zoladex) •Histerlin (Vantas) • leuprolide (Lupron) • triptorelin (Trelstar). HYPOTHALAMUS PITUITARY TESTES S PROSTATE / TUMOR megestrol bicalutamide flutamid ilutamide
- 19. American Society Prostate CancerScreening Guidelines Average risk: annually beginning age 50 years with 10+ year life expectancy Age 45 if high risk: High risk includes African-American men or those with first-degree relative with prostate cancer <65 years of age Age 40 if very high risk: Very high risk includes multiple family members with prostate cancer at early age If testing performed, PSA with or without DRE 2009 guidelines reaffirmed in 2013
- 20. PSA Cutpoints for Biopsy Recommendations PSA RANGERECOMMENDATION 0-3.9ng/mL “normal “ range; biopsy not generally recommended 4-9 ng/mL Biopsy recommended ; probability of detecting cancer ranges from 25% to 30%. >10 ng/mL Biopsy recommended ; high probability of detecting cancer (>=50%)
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- 22. PROSTATE CANCER SUSPECTED(PSA/Screening) COMPLETEHISTORY AND PHYSICAL EXAMINATION INCLUDING DRE TRUS GUIDED BIOPSY Life expectancy <=5 yrs and Asymptomatic No further workup or treatment until symptomatic except in high or very high risk group. Life expectancy >5 yrs OR symptomatic Risk classification WORK UP depends on Risk Classification BONE SCAN IF 1. T1 and PSA>20 2. T2 and PSA>10 3. Gleason score >=8 4. T3,T4 5. Symptomatic 1. T3,T4 2. T1-T2 and normogram indicated probability of lymph node involvment>10% Pelvic CT or MRI or PETCT
- 23. VERY LOW RISKGROUP EXPECTED SURVIVAL INITIAL THERAPY ADJUVANT THERAPY ACTIVE SURVEILLANCE •PSA 6 monthly and SOS •DRE 12 monthly and SOS •repeat prostate biopgy 12 monthly and SOS >=20yrs EBRT OR Brachytherapy Radical Prostatectomy(RP)+PLND if predicted probability of LN mets is >=2% Roach formula LN metastasis (%) = 2/3 PSA + 10× (Gleason-6) ADVERSE FEATURES (Detectable PSA,positive margin,seminal vesicle invasion,ECE) EBRT LYMPH NODE METASTASIS ADT+EBRT 10-20YRS ACTIVE SURVEILLANCE <10 YRS OBSERVATION •T1c •Gleason score<=6 •PSA<10 ng/ML •Fewer than 3 prostate biopsy cores positive,<=50% cancer in each core
- 24. LOW RISK EXPECTED SURVIVALINITIAL THERAPY ADJUVANT THERAPY >=10YRS ACTIVE SURVEILLANCE EBRT OR Brachytherapy RADICAL PROSTATECTOMY(RP)+PLN D if predicted probability of LN mets is >=2% ADVERSE FEATURES (Detectable PSA, positive margin, seminal vesicle invasion, ECE) EBRT LYMPH NODE METASTASIS ADT+EBRT <10YRS OBSERVATION •T1-T2a •Gleason score<=6 •PSA<10 ng/ML
- 25. INTERMEDIATE RISK EXPECTED SURVIVALINITIAL THERAPY ADJUVANT THERAPY >=10 Year RADICAL PROSTATECTOMY(RP)+P LND if predicted probability of LN mets is >=2% ADVERSE FEATURES (Detectable PSA, positive margin, seminal vesicle invasion, ECE) EBRT LYMPH NODE METASTASIS ADT+EBRT EBRT +- ADT(4-6 month) OR Brachytherapy alone <10 yr EBRT +- ADT(4-6 month) OR Brachytherapy alone Observation •T2b-T2c or •Gleason score 7 or •PSA 10-20ng/mL
- 26. HIGH RISK INITIAL THERAPYADJUVANT THERAPY EBRT + ADT (2-3 YRS) or EBRT + + brachytherapy +ADT (2-3 YRS) or RP +PLND ADVERSE FEATURES (Detectable PSA, positive margin, seminal vesicle invasion, ECE) EBRT LYMPH NODE METASTASIS ADT+EBRT •T3a or •Gleason score 8-10 or •PSA>20 ng/mL
- 27. VERY HIGH GRADE INITIALTHERAPY ADJUVANT THERAPY EBRT + ADT (2-3 YRS) or EBRT + + brachytherapy +ADT (2-3 YRS) or RP +PLND ADVERSE FEATURES (Detectable PSA, positive margin, seminal vesicle invasion, ECE) EBRT LYMPH NODE METASTASIS ADT+EBRT ADT in select patient •T3b-T4 or •Primary Gleason pattern 5 or •>4 cores with Gleason score 8-10
- 28. METASTATIC Any T ,N1 ADT or EBRT +ADT(2-3 YRS) Any T , Any N , M1 ADT + EBRT to site of metastasis ,if in weight bearing bones , or symptomatic •Any T,N1 or •Any T,Any N , M1
- 29. MONITERING AFTER INITIAL MANAGEMENT PSA every 6-12 months for 5 yr , then every year. DRE every year, but may be omitted if PSA undetectable N1 ,M1 - Physical examination +PSA every 3-6 month POST RP Failure of PSA to fall to undetectable levels (PSA PERSISTENCE) RADICAL PROSTATECTOMY BIOCHEMICAL FAILUREUndetectable PSA after RP with a subsequent detectable PSA that increases on 2 or more determination (PSA RECURRENCE) POST EBRT Biochemical failure (PSA increase by 2ng/mL or more above nadir) Or Positive DRE RADIATION THERAPY RECURRENCE
- 30. RADICAL PROSTATECTOMY BIOCHEMICAL FAILURE PSADT +-CT/MRI TRUS +- Bone Scan +-PET CT +-Prostate bed biopsy (especially if imaging suggests local recurrence) Studies negative for distant metastasis EBRT +- ADT OR Observation Studies positive for distant metastasis ADT + EBRT to site of metastasis ,if in weight bearing bones , or symptomatic
- 31. RADIATION THERAPY RECURRENCE Candidate for LOCAL THERAPY •PSADT •TRUS Biopsy •Bone Scan •PET CT/CT/MRI •+Prostate MRI TRUS Biopsy + metastatic - •Observation or •RP or •Cryosurgery or •Brachytherapy •ADVANCED DISEASE TRUS Biopsy - metastatic - •Observation or •ADT or •Clinical trial or •More aggressive workup for local recurrence ADVANCED DISEASE metastatic + •ADVANCED DISEASE Not a candidate for LOCAL THERAPY ADT Or observation ADVANCED DISEASE
- 32. ADVANCED DISEASE :SYSTEMIC THERAPY •Orchidectomyor PROGRESSION •LHRH agonist +- antiandrogen >= 7 days to prevent testosterone flare or •Castration •LHRH agonist + antiandrogen or •Resistant •LHRH antagonist or •Prostate •Observation(for M0 disease) or •Cancer •Continous ADT and Docetaxel 75mg/m2 w/o prednisolone for 6 cycles( for castration sensitive high volume M1 only)
- 33. Definition of CastrationResistant Prostate Cancer Serum testosterone <50 ng/Ml And one or more of the following: • Rising PSA from nadir on androgen deprivation therapy(ADT) • Radiographic progression on ADT. • Clinical progression
- 34. APPROVED THERAPY FORCRPC NAME DRUG TYPE APPROVAL INDICATION Docetaxel (Taxotere)+Prednisolone Chemotherapy FDA,EMA First line Denosumab(Xygeva) Targeted therapy( RANKL) FDA Prevention of SREs in patients with bone metastasis Cabazitaxel (Jevtana+ Prednisolone Chemotherapy FDA,EMA Second line Sipuleucel-T (Provenge) Immunotherapy FDA First line asymptomatic or minimally symptomatic mCRPC Abiraterone acetate(Zytiga) Targetederapy(an ti-androgen) FDA,EMA First and second line Enzalatumide (Xtandi) Targeted THerapy(anti- androgen) FDA Second line advanced mCRPC
- 35. PROGNOSIS Stage 5-year relativesurvival rate local nearly 100% regional nearly 100% distant 28%
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