Carcinoma of the prostate is the most commonly diagnosed cancer and second leading cause of cancer death in men. Risk increases with age and family history. It often metastasizes to bones and lymph nodes. Diagnosis involves elevated PSA levels, abnormal digital rectal exam, biopsy. Staging uses the TNM system - early stages are limited to the prostate while advanced stages have spread outside the prostate. Gleason scoring evaluates microscopic patterns to determine tumor grade and aggressiveness. Treatment depends on tumor stage, grade and patient health.
A basic approach towards carcinoma of prostate , symptoms, investigations , diagnosis, staging, treatment and follow up along with recent advances in surgeries, vaccines and immunotherapy.
A basic approach towards carcinoma of prostate , symptoms, investigations , diagnosis, staging, treatment and follow up along with recent advances in surgeries, vaccines and immunotherapy.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
It is not for practicing, only general description of prostate cancer.......of my presentation . for explanation study authentic books also .....and webs.
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
It is not for practicing, only general description of prostate cancer.......of my presentation . for explanation study authentic books also .....and webs.
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Carcinoma of the prostate; Incidence, Epidemiology, Aetiology, Clinical features, Workup, and Management.
by Osman Altohamy, A Fifth year Medical Student, Gezira, Sudan
osmansalahe@icloud.com
osmansalahe@hotmail.com
early detection helps ......................................................................................................................................................................................................................................................................................................
A wonderful slide for tumor markers in GI surgery. Cancer biomarkers are often used in monitoring response in cancer.
Tumor marker, biomarkers in common practice.
approach to urosepsis/sepsis/septic shock.
general approach to sepsis, severe sepsis, septic shock according to the latest guidelines. SCG2016/ EGDT2018/EUA2020
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
3. Epidemiology
• Most commonly diagnosed cancer in men
• second leading cause of male cancer death
• Risk increases with age,
• In 80s, slow growing, lower grade, relatively harmless and have little impact on their
survival.
• More common in Australia/Newzealand, in North Americans, African Americans ;less
common in Asians and Hispanic descent than in Whites.
• The overall 5-year survival rate is 99% in the United States.
4. Risk factors
• older age
• positive family history,
• obesity,
• hypertension,
• lack of exercise,
• Alcohol, smoking
• persistently elevated testosterone levels,
5. Genetics
• One first degree relative (father or brother) : twice the risk of the general
population.
• Two first-degree relatives affected have a 5-fold greater risk.
• strong family history : present at a younger age (2.9 years) and with more locally
advanced disease.
• Mutations in BRCA1 and BRCA2 implicated
• P53 mutations more frequently seen in metastatic disease
8. • commonly metastasizes to the
bones and lymph nodes.
• Metastases to the bone are
thought to be at least partially a
result of the prostatic venous
plexus draining into the vertebral
veins.
9. Presentation
EARLY STAGE
• Asymptomatic
LOCALLY ADVANCED DISEASE
• Obstructive or irritative voiding complaints :growth of the tumor into the urethra or
bladder neck or from its direct extension into the trigone of the bladder
frequent urination, nocturia, difficulty starting and maintaining a steady stream,
hematuria, and dysuria (like BEP)
• Retention of urine
• Hematuria
• Hematospermia, difficulty achieving an erection or painful ejaculation.
• Pelvic pain
10. ADVANCED DISEASE (spread to the regional pelvic lymph nodes)
• Edema of the lower extremities
• Pelvic and perineal discomfort
METASTATIC DISEASE
• Bone pain/pathological #
• Spinal cord compression symptoms (tingling, leg weakness, pain, paralysis, and
urinary as well as fecal incontinence)
• Paraperesis
• Para aortic LAP- edema of abdominal wall, genitalia or lower extremities/ mass
abdomen
• Adrenal/ lung/ skin metastasis: SIADH/ Cushing syndrome.
12. Digital rectal examination (DRE)
• Cornerstone of the physical examination/ instrumental in staging
• detect prostate abnormalities, asymmetry, and suspiciously hard nodules
• not considered a definitive test for prostate cancer by itself.
• An abnormal DRE initially uncovers about 20% of all prostate cancers.
13. DRE
• Size: Craniocaudal and transverse dimension
• Consistency / Mobility
• Any firm/ elevated area and its size.
• Rectal mucosa: free/fixed
• Median sulcus: obliterated
Ca prostate- Hard, nodular, asymmetrical, may or may not be raised above the surface
of gland, absent middle lobe and is surrounded by compressible prostatic tissue.
Prostatic induration - BHP nodule/ calculi/ infection/ granulomatous prostatitis
14. Prostate specific antigen(PSA)
• A serine protease
• PSA is organ specific but not proste cancer specific
• Also increases in BPH, prostatitis and other non-malignant conditions.
• only estimates the risk of prostate cancer.
• As an independent variable, PSA is a better predictor of cancer than either DRE or
transrectal ultrasound (TRUS).
• Positive predictive value of a serum PSA between 4 and 10 ng/mL is approx 20–30%.
• For levels in excess of 10 ng/mL, the positive predictive value increases (40-70%)
15. • PSA levels greater than 4 ng/ml is seen in 80% of prostate cancers initial
presentation.
• It is recommended at least 2 abnormal PSA levels or the presence of a palpable
nodule on DRE to justify a biopsy and further investigation
• PCa can occur despite having low serum PSA
PSA>10: suggestive of CaP
PSA>35: advanced CaP
16. :
• Free /Total PSA ratio: .
• If the total PSA is between 4 and 10 ng/ml, a free PSA percentage is considered
valid.
If f/t PSA ratio> 25%, the cancer risk is less than 10%.
If < 10%, the cancer risk is about 50%.
(Free/total PSA is of no clinical use if the total serum PSA is > 10 ng/mL or during follow
up of known PCa.)
17. • PSA Density is the total PSA divided by the prostatic volume as determined by MRI
or ultrasound (US). The PSA density is intended to minimize the effect of benign
prostatic enlargement.
If > than 0.15, it is considered suggestive of malignancy.
• PSA Velocity compares serial, annual PSA serum levels.
-An annual increase > 0.75 ng/ml or > 25% suggests a potential cancer (total PSA 4 to
10 ng/ml).
- If the total PSA is 2.6 to 4 ng/ml, then an annual increase of 0.35 ng/ml would be
considered suspicious.
18. • Prostate cancer is usually suspected on the basis of DRE and/or PSA levels. (DRE+PSA
specificity 87%)
• Definitive diagnosis depends on histopathological verification of adenocarcinoma in
prostate biopsy cores.
19. Prostate Imaging
• Ultrasound and MRI are the main imaging modalities used
for initial prostate cancer detection and diagnosis.
• Transrectal ultrasound (TRUS) "suspicious hypoechoic
area seen," but ultrasound alone is not a reliable
diagnostic test for prostatic malignancy.
• TRUS is best used for directing the needle for prostate
biopsies.
• New sonographic modalities such as sonoelastography,
contrast-enhanced US or high-resolution micro-
ultrasound; either alone or combined used in the so-called
'multiparametric US'
20. Prostate MRI
• Prostatic MRI is becoming a standard imaging modality
for the diagnosis of prostate cancer.
• Identifies and grade suspicious prostate nodules,
extracapsular extension, evaluate the seminal vesicles for
possible tumor involvement and lymph nodes that might
indicate early metastatic disease
• Multiparametric MRI (mpMRI) has good sensitivity for the
detection and localisation of ISUP grade > 2 cancers
• for surgical planning (radical prostatectomy) and for
improved biopsies, in strongly suspected despite a negative
initial TRUS-guided biopsy.
21. • MRI of the prostate may also have a role in active surveillance as an alternative to
periodic or repeated biopsies.
• USG abd/pelvis: obstructive features, HDN,large PVRU, LNs,Liver mets
• Chest Xray: pulmonary metastasis
• Axial skeletal imaging: xray/MRI: osteoblastic secondaries
• CT scan: size, extension, LN involvement, for planning RT, less sensitive, not prefered
22. Testing For Tumor Spread
• Bone scans can detect early metastases to the bones, but the PSA usually needs to
be at least 20 before this is likely to be positive.
• MRI : evaluate extracapsular extension as well as the regional lymph nodes
and seminal vesicles for possible tumor involvement.
• 68-gallium prostate-specific membrane antigen (PSMA) PET/CT scan is a new FDA-
approved test for detecting metastatic prostate cancer
23. Biopsy
• In suspected case(DRE+PSA)
• Conclusive diagnosis
• TRUS guidance to make sure that all areas of the prostate are adequately sampled.
• The most commonly used pattern is to take two specimens from each of three areas
(base, mid-gland, and apex) on both sides. This is called a 12 core sextant
biopsy. The purpose is to better identify the extent and exact location of the tumor.
• Biopsy sites included the
1. midlobe parasagittal plane at the apex,
2. the midgland, and
3. the base bilaterally.
24. Indication of repeat biopsy after previously
negative biopsy
• Rising and/or persistently elevated PSA
• Suspicious DRE
• Atypical small acinar proliferation
• Extensive (multiple biopsy sites, i.e., > 3) high grade prostatic intraepithelial
neoplasia (HGPIN)
• Intraductal carcinoma as a solitary finding, > 90% risk of associated high-grade
prostate carcinoma
• Positive multiparametric MRI findings
25. Histopathology
The Gleason Scoring System
• Originally developed by pathologist
Dr. Donald Gleason in the 1960s
• Based on the microscopic arrangement, architecture or pattern of the glands in the
prostate
• Grade 1 to 5:
- 1 representing an normal microscopic glandular pattern and appearance,
- 5 where no glandular architecture remains, but sheets of abnormal cancer cells.
26. • The predominant pattern(primary pattern) is always the first number, 1 to 5, and
the second number(second pattern) would be any secondary or minor pattern, also
graded 1 to 5.
• lowest risk Gleason score : Gleason 1 + 1 = 2, and
• the worst high-grade pathology: Gleason 5 + 5 = 10.
27. • If only one Gleason grade or pattern is seen, then the Gleason score would consist of
the same Gleason grade repeated and added together as in Gleason 3 + 3 = 6; which
happens to be the most commonly found Gleason score.
1. Low-grade tumors: any Gleason score of 3 + 3 = 6 or less.
2. Intermediate-grade Ca: Gleason score of 3 + 4 = 7.
(This would mean that most of the tumor was Gleason grade 3, but there was a smaller
portion that was the more aggressive Gleason grade 4.)
3. high-grade cancer: A Gleason score of 4 + 3 = 7 or higher
29. Staging
• TNM staging
• T1 and T2 cancers are limited to just the prostate and are considered "localized."
• T3 cancer has spread outside the prostatic capsule but has not reached the rectum
or bladder. Cancer may also have spread to the seminal vesicles (stage T3c), and this
tends to be an ominous sign.
• T4 cancers have spread outside the prostate to adjacent regional structures such as
the bladder. They may also metastasize to the lungs, lymph nodes or liver which
would be identified by their N (nodes) or M (metastasis) scores.
• Stage T4 prostate cancers with distant metastases have an overall 5-year survival rate
of only 29%.
31. Prostate Imaging, Reporting and Data
System (PIRADS)
• Various MRI tissue characteristics ultimately determine the relative cancer risk which
is documented as PIRADS score.
• A PIRADS score of 1 or 2 is highly unlikely to be cancer.
• A PIRADS score of 4 or 5 is highly suspicious for clinically significant disease (Gleason
3 + 4 = 7 and higher).
• PIRADS 3 is equivocal. Histological confirmation with a biopsy is recommended for all
PIRADS 3, 4 and 5 lesions.
32. Biomarker
Prostate Cancer Antigen 3 (PCA3)
is an RNA based genetic test performed from a urine sample obtained immediately
after a prostatic massage.
• PCA3 is a long, non-coding RNA molecule that is overexpressed exclusively in
prostatic malignancies.
•
• If PCA3 is elevated, it suggests the presence of prostate cancer.
• It is more reliable than PSA as it is independent of prostate volume.
• Serial PCA3 testing may also be helpful in monitoring patients with low-grade
prostate cancers on active surveillance
33.
34. Treatment
• Treatment options depend on stage of disease, life expectancy of the patient and
patient preference.
• Prostate cancer, especially low-grade tumors, often grow so slowly that frequently
no treatment is required; particularly in elderly patients and those with
comorbidities that would reasonably limit life expectancy to 10 additional years or
less.
Localised cancer can be treated by radical prostatectomy, radiation therapy and
active monitoring.
Treatment of advanced disease is palliative, and hormone ablation remains the first-
line therapy.
35. Active Surveillance
• Many low-risk cases can now be followed with active surveillance.
• Appropriate for low-grade prostate cancer (Gleason 3+3=6 or less with a
PSA<20) and limited sized cancers.
• It aims to avoid unnecessary treatment in men with clinically localised PCa who do
not require immediate treatment, but at the same time achieve the correct timing
for curative treatment in those who eventually do.
• In active surveillance, patients are usually required to have regular, periodic PSA
testing and at least one additional biopsy 12 to 18 months after the original
diagnosis.
36.
37. • Use of active surveillance for selected, lower risk, intermediate-grade prostate
cancers (Gleason 3 + 4 = 7 with a PSA less than 10) is controversial but seems
reasonable in selected cases.
• MRI of the prostate can also be used to follow these patients and avoids the
discomfort of repeated biopsies.
• The best option depends on the cancer stage, Gleason score, and the PSA level as
well as individual patient preferences, health, comorbidities, quality of life, and age.
38. Localized Disease
• In localized disease,(T1c/T2) definitive therapy if expected to live >10yrs based on
age and co-morbidities.
• Definitive treatment includes
1. radical prostatectomy
2. radiation therapy (external beam and/or brachytherapy radioactive seed
placement)
3. cryotherapy (usually reserved for radiation therapy failures).
39. • For most patients with potentially curable, localized disease, good performance
status, reasonably good QOL and >10-year life expectancy, the choice of treatment
should be an informed patient decision made after discussions including both
urology (surgery) and radiation therapy.
• Discuss side effects such as erectile dysfunction and urinary incontinence,
complications, cost, possible lack of ultimate survival benefit and questionable
quality of life improvement over doing nothing.
40. Surgery
Radical Prostatectomy
• definitive cure for localized prostate cancer
• a significant improvement in overall survival
• suitable for localised disease and with a life expectancy of>10 years
• These benefits over other definitive, curative therapies are not evident before 10
years after treatment for localized disease and are most pronounced in men younger
than 65 years at the time of diagnosis.
• Not appropriate if the tumor is fixed to surrounding structures or there are distant
metastases.
• Nerve sparing RP
41. • open-, laparoscopic- or robot-
assisted (RARP).
• entire prostate gland between
the urethra and bladder, and
resection of both seminal
vesicles, along with b/l Pelvic LNs
42. Lymph Node Dissections (PLND)
• Not done in low-risk patient
• may remove undetectable micrometastases and
therefore potentially improve survival.
• In the past, a pelvic lymph node dissection was
sufficient, but it is now known that metastases will
often go directly to the common iliac, paraaortic,
perirectal or presacral nodes, so a more extended
dissection is recommended; particularly in higher
risk disease
• limited PLND : confined to the external iliac and obturator fossa areas
• extended PLND: external iliac, hypogastric and obturator nodes and other including
the pre sacral and pre sciatic nodes.
Rees, Thomas et al. “Is extended pelvic lymph node dissection for prostate cancer the only recommended option? A
systematic over-view of the literature.” Turkish journal of urology vol. 42,4 (2016):
43. Complications of radical prostatectomy
• Bleeding.
• Urinary tract infection.
• Urinary incontinence.
• Erectile dysfunction (impotence)
• Narrowing (stricture) of the urethra or bladder neck.
• Formation of cysts containing lymph (lymphocele)
• Injury to the rectum (rare)
44. Salvage Radiation Therapy After
Radical Prostatectomy
• The serum PSA should become and remain undetectable after successful radical
prostatectomy surgery.
• If not or if there are positive margins after surgery, salvage radiation therapy should
be considered
• Typically, salvage radiation therapy is 60 to 70 Gy, which is substantially less than for
primary definitive radiation therapy.
• Salvage radiation therapy may also be recommended if the PSA becomes detectable
at a later date, indicating possible residual disease that was present but previously
undetectable could now be growing in the immediate area of the prostatic bed
45. Radiation therapy
• The goal of radiation therapy is to provide a lethal dose of radiation to the
tumor without harming the surrounding normal tissue of the bladder and
rectum.
• As Adjuvant (margin positive after RP) or Primary therapy in Locally advanced
• After radiation therapy, the PSA is expected to decrease for about 18 months.
• Treatment failure is usually noted by a rise in PSA level of 2 ng/ml or more
above the baseline level before initiation of radiation therapy
46. • External Beam Radiation Therapy(XRT)
• Dose of 75-80 Gy results in lower recurrence and
higher local cancer control
• Brachytherapy (Radioactive Implants):
• temporary-high dose Iridium 192
• Permanent-lose dose, seed implants- I125,Cs131
• Radiation therapy tends to have much fewer side
effects (about 50% less) than radical prostatectomy
surgery with very similar overall survival.
47. Treatment Selection: Radiation
Therapy versus Radical Prostatectomy
• The best available data suggest no significant difference in overall survival in most
cases of potentially curable, localized, prostate cancer treated with either external
beam radiation therapy, stereotactic radiotherapy, brachytherapy (radioactive seed
implants), or radical prostatectomy surgery.
• (Wang Z et al. The efficacy and safety of radical prostatectomy and radiotherapy in high-risk
prostate cancer: a systematic review and meta-analysis. World J Surg Oncol.
2020;18(1):42. Published 2020 Feb 24)
48. Focal Ablation Therapy for Localized
Prostate Cancer
• for selected patients with localized disease.
• Focal ablative therapy can use microwave, cryotherapy, laser, high intensity focused
ultrasound, etc., to precisely treat a localized malignant prostatic lesion.
• Optimal patients :a single, isolated Gleason 7 (3 + 4 or 4 + 3) lesion and no evidence
of extraprostatic or more widespread disease on MRI or prostatic biopsies.
• Focal Laser Ablation uses laser fibers to heat and destroys prostatic cancer nodules
based on MRI imaging using MRI-Fusion guided targeting
• Cryotherapy
49. Cryotherapy
• Cryotherapy can be the primary surgical therapy for prostate cancer,
• But most useful as a salvage surgical treatment after radiation therapy has failed
• Control tumors resistant to all other therapies which will still be susceptible to
ablation by alternating freeze-thaw cycles that disrupt cell membranes resulting in
tissue destruction.
• Freezing...Coagulative necrosis
• T1-2N0M0, GS<7, who have not undergone TURP
• Since cryotherapy cannot treat nodal involvement, lymph node dissections may be
needed.[
50. Hormone Therapy
• In 1941, Urologist Charles Huggins MD from the
University of Chicago discovered that androgen
deprivation (castration) would cause prostate
glands to atrophy and prostate cancer to
regress.
• Prostate cells (normal and malignant)
are physiologically dependent on
androgens to grow, function and
proliferate
• Dihydrotestosterone (DHT) is a
metabolite of testosterone,is more
potent androgen
• Testosterone doesn’t ‘cause’ prostate
cancer but promotes and encourages
growth.
51. • the first line treatment for advanced/metastatic prostate Ca.
• For asymptomatic men, immediate ADT will delay progression to
the symptomatic stage and avoid/decrease the risk of cancer
related complications such as a spinal cord compression or
pathological fracture.
52. Androgen deprivation therapy (ADT)
• Androgen deprivation can help to induce apoptosis (cell death) or
at the very least prevent further growth.
1. Surgical or medical ‘castration’- stops the production of
testosterone
2. Anti-androgen therapy- inhibits the action of testosterone
preventing its interaction with the receptors on the prostate
cancer cells
53. Testosterone-lowering therapy
• LHRH agonists (first line): Depot Inj;busereline, gosereline, leuproreline, triptoreline
• LHRH antagonists e.g. abarelix, degarelix
• Estrogen-DES
• Surgical castration-B/L orchidectomy;
Anti-androgens
• steroidal, e.g. cyproterone acetate (CPA), megestrol acetate and
medroxyprogesterone acetate;
• non-steroidal e.g. nilutamide, flutamide and bicalutamide.
Castration <20ng/ml
54. • Initial therapy with leuprolide, goserelin (LHRH) agonists should be preceded by
anti-androgen therapy, such as bicalutamide when the PSA >10 ng/ml to prevent any
clinical response to the temporary testosterone surge (flare phenomnon) that typically
accompanies initiation of hormonal therapy with these agents.
• Hormonal therapy has been found to improve survival when combined with radiation
therapy but not with radical prostatectomy for intermediate (Gleason 3 + 4 = 7) and
higher grade disease.
55. • The hormonal therapy is usually continued for at least one year and optimally for at
least two years after radiation.
• Side effects : hot flashes, reduced libido, and loss of bone density resulting in
osteopenia or osteoporosis.
• Intermittent hormone therapy is another option in selected cases to minimize the
side effects of sustained, very low testosterone levels.
56. Castrate Resistant Tumor (CRPC)
• CRPC is present when PSA rises after medical castration (LHRH suppressor) or
surgical castration ( orchiectomy), despite having a serum testosterone< 50 ng/dl
(i.e the cancer grows despite castration).
• "hormone refractory" or "androgen independent"; however, the preferred term is
castration resistant
57. Medical Oncology
Aggressive Prostate Cancer
• defined as either locally advanced(T3/T4), higher Gleason score (Gleason 4 + 5 = 9 or
higher) or rapid PSA doubling time of two years or less.
• Early use of chemotherapy has been shown to be helpful in many patients
presenting with aggressive or advanced, localized disease.
58. Chemotherapy
• typically consists of docetaxel in addition to modified hormonal therapy.
• Docetaxel is the standard initial chemotherapy agent used to treat CRPC with a
median survival benefit of 2 to 3 months.
• Docetaxel plus prednisone now the first line standard (delivered every 3 weeks for
up to 10 cycles)
• The early use of docetaxel in hormone naive patients with high volume or high grade
localized disease appears to be beneficial based on increased survival noted in
several studies (STAMPEDE, CHAARTED, RTOG 0521 and GETUG 12).
• Second-Line chemotherapy treatment is cabazitaxel.
• Other: Mitoxantrone
59. • Enzalutamide, abiraterone, and apalutamide are newer, hormonally based drug
treatments that often work even when initial hormonal therapy has failed.
60. Prostate cancer vaccine
Sipuleucel-T
• Is an autologous, dendritic cell-based vaccine that targets prostatic acid
phosphatase.
• survival benefit for men with metastatic, castrate-resistant prostate cancer (CRPC)
• quite expensive and provides only a relatively limited improvement in life
expectancy.
61. Summary of treatment for Ca prostate
1) Low risk disease
• For men in their 70s, conservative treatment
• Radical surgical treatment considered in younger (<70years) man , although even in this group,
some men will elect to pursue a conservative course when counselled about risks versus
benefits.
2) Intermediate risk disease
• In younger, fitter men (<70years), this may be treated by radical prostatectomy or radiotherapy.
• Active monitoring remains an option, particularly for more elderly patients towards the lower
end of the risk spectrum.
• In the elderly patient with out-flow obstruction, transurethral resection with or without
hormone therapy is indicated.
62. Summary …..
3) High risk disease.
• Early androgen ablation is favoured if close follow-up is not possible.
• For the sexually active,a careful conservative approach with the adoption of androgen
ablation when symptoms arise is reasonable.
• Androgen ablation coupled with radiotherapy, perhaps with surgery as part of a
multimodal approach, is standard treatment for younger men with T3 disease.
4) Metastatic disease
• Once metastases have developed, the outlook is poor.
• For patients with symptoms: androgen ablation will provide symptomatic relief in over
two-thirds of patients.
• For patients with asymptomatic metastases, the timing of treatment is less clear.
Systemic chemotherapy with docetaxel should be considered in younger, fitter men
64. Screening
• the 'systematic examination of
asymptomatic men (at risk)' and
is usually initiated by health
authorities
• reduction in mortality due to
PCa
• disadvantage- overdiagnosis,
overtreatment
65. References
• European Association Guideline (Prostate Carcinoma) 2019
• Bailey & Love's Short Practice of Surgery 27th Edition
• Smith and Tanagho: General Urology 19th edition
• Leslie SW et al. Prostate Cancer. [Updated 2020 Jun 27]. In: StatPearls
Editor's Notes
Lung cancer is first leading cause of death.[48][49] Incidence rates have been increasing although the death rate has been decreasing since 1992 when PSA testing became widely available.
Genetic background, ethnicity, and family history are all known to contribute to prostate cancer risk.
Hereditary Ca Prostate (9%) defined as three or more affected relatives or at least two relatives who have developed early-onset PCa (< 55 years)
• LN: Obturator & internal Iliac LN
In real life, these histological extremes are almost never seen.
This indicates possible conversion to a more aggressive cancer and definitive treatment can then be offered appropriately while the vast majority are safely spared the costs, inconvenience, side effects, and complications of curative therapy.
Robotically or laparoscopically.
Intraprostatic injections of indocyanine green (ICG) has been used to visualise prostate-related LNs during lymphadenectomy.
During prostatectomy, preservation of the neurovascular bundles with parasympathetic nerve branches of the pelvic plexus may spare erectile function
. He was awarded the Nobel Prize for Medicine in 1966 for this discovery which is the
estrogens e.g. Diethylstilboestrol (DES) LHRH agonists e.g. busereline, gosereline, leuproreline, triptoreline LHRH antagonists e.g. abarelix, degarelix
LHRH agonist: downregulation in long term
Castration levels of testosterone have historically been considered <50 ng/dL, but newer data suggest that optimal results are obtained when testosterone levels are maintained at less than 20 ng/dL
Annual screening if PSA is >2.5ng/ml, family history of prostate cancer, increasing age or African descent If low risk, every 2 years