Prostate cancer is the most common cancer in men. It arises from the prostate gland and is dependent on androgens like testosterone for growth. Risk factors include increased age, family history, and race. Screening involves a digital rectal exam and PSA blood test. Biopsy confirms diagnosis. Staging uses the TNM system and Gleason score. Treatment options include active surveillance for low risk disease, surgery, radiation, hormone therapy, chemotherapy, and palliation depending on age, risk level, and whether the cancer has spread. The goal is cure of localized disease or palliation of symptoms from advanced disease.

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