This document discusses prostate cancer, including: - It is the most common cancer in men in North America and the second leading cause of cancer death in men. - Risk factors include advancing age, family history, and African ancestry. Screening includes a PSA test and digital rectal exam. Biopsy is used for diagnosis. - Treatment options depend on tumor stage and grade. Early stage options include radical prostatectomy, radiotherapy, brachytherapy, active surveillance, or observation. Later stage options involve more aggressive treatments. Complications can include incontinence and erectile dysfunction.

2. Most common non-cutaneous
malignancy in men in North America
2nd most common cause of cancer-
related deaths in men
1 in 7 men will be diagnosed WITH PR_ CA
Lifetime risk of being diagnosed with
prostate cancer is 18/100 but risk of
dying of prostate cancer is only 3/100

3. Risk factors
Established
Advancing age
Presence of androgens
Family history 1st d.relative
African ancestry

4. RISK FACTORS
Potential
High dietary fat
Obesity
Inherited mutations (BRCA1 or
BRCA2 genes)
Vitamin D or E deficiency
Selenium deficiency?

5. Early stages usually asymptomatic
Most cases detected by serum PSA
screening
Palpable nodule or firmness on DRE
Advanced stages
Urinary retention/renal failure
Bone pain
Anemia
Weight loss, fatigue
Spinal cord compression

6. Screening for Prostate Cancer
US Preventive Services Task Force
Recommendation Statement
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710

7. Screening for prostate cancer
– USPSTF
• Adequate evidence from randomized clinical trials shows
that PSA-based screening programs in men aged 55 to 69
years may prevent approximately 1.3 deaths from prostate
cancer over approximately 13 years per 1000 men
screened.
• Screening programs may also prevent approximately 3
cases of metastatic prostate cancer per 1000 men
screened.
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710

8. Screening for prostate cancer
– USPSTF
• Potential harms of screening include frequent
false-positive results and psychological harms.
• Harms of prostate cancer treatment include
erectile dysfunction, urinary incontinence, and
bowel symptoms.
• About 1 in 5 men who undergo radical
prostatectomy develop long-term urinary
incontinence, and 2 in 3 men will experience
long-term erectile dysfunction.
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710

9. Screening for prostate cancer
– USPSTF
• Adequate evidence shows that the harms of
screening in men older than 70 years are at least
moderate and greater than in younger men
because of increased risk of false-positive results,
diagnostic harms from biopsies, and harms from
treatment.
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710

10. Screening for prostate cancer
– USPSTF
• The USPSTF concludes with moderate certainty that the
net benefit of PSA-based screening for prostate cancer in
men aged 55 to 69 years is small for some men.
• How each man weighs specific benefits and harms will
determine whether the overall net benefit is small.
• The USPSTF concludes with moderate certainty that the
potential benefits of PSA-based screening for prostate
cancer in men 70 years and older do not outweigh the
expected harms.
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710

11. Cribado: cáncer de próstata
Ministerio de Salud de Colombia
Si se realiza tamización de oportunidad debe hacerse con
antígeno específico de próstata y tacto rectal en una frecuencia
no inferior a 5 años y previa explicación de los potenciales
riesgos y beneficios para el paciente, promoviendo una toma de
decisiones concertada.
En los pacientes en quienes se registre un primer nivel de
antígeno prostático alterado acorde con la edad, en presencia de
tacto rectal normal, se recomienda la repetición de la prueba en
el curso de los siguientes seis meses.”

13. Fusión TMPRSS2-ERG
• En hasta 80% de los cánceres de próstata
• ERG es un factor de transcripción
– Proliferación
– Fenotipo resistente a la castración
• TMPRSS2 es un gen que responde al AR
– Es una serina proteasa
• Es una diana molecular potencial
– El silenciamiento ERG con RNAi disminuye
proliferación

14. Prostate cáncer diagnosis
Indications for transrectal ultrasound (TRUS)
guided biopsy
Palpable nodule on DRE
Elevated serum PSA
Biopsy involves 10-18 needle cores taken mostly
from the peripheral zone of the prostate
Transrectal ultrasound alone/CT scan/MRI not
sensitive enough to make the Diagnosis

15. Enfoque diagnóstico – Cáncer de Próstata
Enfoque
diagnóstico –
cáncer de
próstata
Síntomas
urinarios o
PSA anormal
Evaluación
rectal digital
(DRE) / PSA
(si falta)
DRE: Normal
PSA: Normal
PSA de 2, o
menos
PSA de 2+
Velocidad PSA
0.75+/año
TRUB
Repetir 1-3
años
DRE: Anormal
o
PSA: Anormal
TRUB
PSA 10, o menos
+ PSA libre 15%
o menos
Repetir en 6
meses
TRUB: Biopsia transrectal eco-dirigida
PSA: Antígeno específico de próstata
No
Si
No
PSA 10+

16. - histology:
- Gleason scores

17. Prostate cáncer pathology
Adenocarcinoma
Gleason “grade” is from 1-5
based on glandular
architecture
Gleason score is the total
primary grade (1-5) +
secondary grade (1-5) = 2-10
 4-6/10=well-differentiated
 7/10=moderately differentiated
 >8/10=poorly differentiated

18. Gleason 6
www.cancernetwork.com - Cesar A Moran, 07.02.2014

19. Gleason 7
www.cancernetwork.com - Cesar A Moran, 07.02.2014

20. Gleason 8
www.cancernetwork.com - Cesar A Moran, 07.02.2014

21. Gleason 9
www.cancernetwork.com - Cesar A Moran, 07.02.2014

22. PATHOLOGY GROUPINGS IN PROSTATE
CANCER
• GROUP 1
– Gleason score 3+3, or less.
• GROUP 2
– Gleason score 3+4
• GROUP 3
– Gleason score 4+3
• GROUP 4
– Gleason total score 8
• GROUP 5
– Gleason total score 9 or 10

23. Prostate cáncer staging
Can spread to adjacent organs (seminal
vesicles, bladder), lymph nodes, bone
Most bone mets are osteoblastic
Prior to initiating treatment consider
Bone scan (PSA>10, Gleason Score >7)
CT scan pelvis/abdomen (PSA >10, Gleason
Score >7))
These tests are typically not required in
asymptomatic men with low risk prostate
cancer

24. Maniobras de estadificación
• Consideraciones
– Tumores MUY tempranos pueden no necesitar estudios
adicionales para metástasis a distancia
• T1c/T2a; PSA de 10, o menos; Gleason 6, o menos.
• RM de próstata con antena rectal – para planeación terapia
– Tumores MUY avanzados pueden ser investigados con:
• Gammagrafía ósea / TAC de tórax, abdomen y pelvis
– Tumores POTENCIALMENTE avanzados pueden beneficiarse de:
• RM corporal total
• El PET-CT es ineficaz en cáncer de próstata
– Tumores candidatos a terapia local (Prostatectomía /
Braquiterapia) o candidatos a Radioterapia
• RM Multiparamétrica de próstata con antena rectal

25. Práctica usual
• Gammagrafía ósea
• TAC de tórax contrastado
• RM de pelvis / Próstata con antena rectal
• PSA

26. Carcinoma de Próstata
TNM
• T1 - Tumor primario no aparente clínicamente ni visible por imágenes.
T1a - Hallazgo incidental que compromete <= 5% del tejido resecado.
T1b - Hallazgo incidental que compromete > 5% del tejido resecado.
T1c - Diagnóstico obtenido por biopsia ciega inducida por un PSA
elevado.
• T2 - Tumor confinado a la próstata.
T2a - Compromete la mitad o menos de un lóbulo.
T2b - Compremete más de la mitad de un lóbulo.
T2c – Compromiso de ambos lóbulos prostáticos
• T3 - Tumor que se extiende más allá de la cápsula prostática.
T3a - Extensión extracapsular.
T3b - Invade la vesícula seminal.
• T4 - Fijado a otras estructuras distinto a las vesículas seminales.
• N1 - Ganglios linfáticos comprometidos.
• M1 - Metástasis a distancia.
M1a - Ganglios linfáticos no regionales.
M1b – Huesos.
M1c - Otros sitios.

27. Grado T1a T1b T1c T2a T2b T2c T3a T3b T4 N1 M1 PSA
1 I I I I IIa IIa IIIb IIIb IIIb IVa IVb <10
1 IIa IIa IIa IIa IIa IIa IIIb IIIb IIIb IVa IVb 10-20
2 IIb IIb IIb IIb IIb IIb IIIb IIIb IIIb IVa IVb <20
3 IIc IIc IIc IIc IIc IIc IIIb IIIb IIIb IVa IVb <20
4 IIc IIc IIc IIc IIc IIc IIIb IIIb IIIb IVa IVb <20
1-4 IIIa IIIa IIIa IIIa IIIa IIIa IIIb IIIb IIIb IVa IVb ≥20
1-4 IIIb IIIb IIIb IVa IVb Any
5 IIIc IIIc IIIc IIIc IIIc IIIc IIIc IIIc IIIc IVa IVb Any
Any Any Any Any Any Any Any Any Any Any IVa IVb Any
Prostate cancer staging system

28. Very low risk (must fulfill all)
T1c
Grade Group 1
PSA less than 10
Less than 4 core+, with less
than 50 per-cent cancer in
each
Psa density less than 0.15

29. low risk (must fulfill all)
T1-T2a
Grade Group 1
PSA less than 10

30. Favorable intermediate
T2b-T2c or
Grade Group 2 or
PSA 10-20 and
positive biopsy cores less 50
per-cent

31. unfavorable intermediate
T2b-T2c or
Grade Group 2 or group 3 or
PSA 10-20

32. high
T3a or
Grade Group 4 or group 5 or
PSA greater than 20

33. VERY high
T3b-t4 or
Grade group 5 or
More than 4 cores with grade
group 4 or 5

35. Prostate cáncer treatment
Considerations
Patient’s age
Co-morbid health conditions
Tumor stage
Tumor grade (Gleason score)
Often a patient choice
Surgery and

36. Early stage Prostate cáncer
treatment
Early stage Cancer
1. Radical Prostatectomy
2. External Beam Radiotherapy
3. Radioactive Seeds (Brachytherapy)
4. Active Surveillance
5. Observation – Watchful Waiting

37. Early stage Prostate cáncer
treatment: radical prostatectomy
Radical Prostatectomy
Complete surgical removal of entire prostate,
seminal vesicles
Considered a good treatment for men <70
years of age with clinically organ confined
cancer who are healthy
Open or laparoscopic/robotic approaches

38. Early stage Prostate cáncer
treatment: radical prostatectomy

39. radical prostatectomy:
complications
<10% risk of blood transfusion
Wound infection
Rectal injury (<1%)
Urinary incontinence (~10%)
Erectile dysfunction (variable but common)
Anesthetic related

40. Prosate cancer treatment:
radiotherapy
Radiotherapy Options
External Beam
Brachytherapy (seed implant)
Concept of maximizing dose to the tumor and
minimizing collateral damage
Curative options for patients at high risk for
morbidity from radical prostatectomy
Age, medical co-morbidities
Patient preference

41. Prosate cancer treatment:
radiotherapy

42. Radiotherapy: complications
External Beam Radiation Therapy
Hematuria
Radiation proctitis
Loose, bloody stools
Urinary retention
Strictures (urethra and ureter)
Erectile dysfunction
Secondary malignancies
Bladder, rectal, hematological

43. Proctitis Actínica

44. Prostate cancer therapy:
brachytherapy

45. Brachytherapy: complications
Urethral strictures
Seed migration
Urinary retention
Erectile dysfunction
Irritative voiding symptoms

46. Active surveillance
Observing low grade tumors in men <70 yrs and >10 yr
life expectancy
Delay definitive treatment until it is necessary and
cancer is still curable
Goal is to delay potential treatment-related morbidity
Monitor DRE, PSA, and periodic repeat biopsy
Ideal candidate:
 PSA < 10
 Normal DRE
 Gleason <7 (low grade)
 Only 1-3 / 12 biopsy cores positive

47. Watchful waiting
Observing low grade tumors in men
>70 yrs or <10 yrs life expectancy
Institute hormonal therapy when
patient becomes symptomatic
No curative intent

48. Todos:
T1c (detectado por PSA)
Grupo 1 (Gleason 3 + 3)
PSA<10
<3 cores positivos
≤50% de tumor por core
Densidad de PSA <0.15
Vigilancia activa
Todos:
T1-T2a (Compromiso <50% de un lóbulo)
Grupo 1 (Gleason 3 + 3)
PSA<10
Vigilancia activa
Cualquiera:
T2b-T2c (>50% de un lado o bilateral)
Grupo 2 (Gleason 3 + 4), 3 (Glason 4 + 3)
PSA 10-20
Tratamiento
Ultrabajo
Bajo
Intermedio
CaPróstata

49. Cualquiera
T2b-T2c (>50% de un lado o bilateral)
Grupo 2 (Gleason 3 + 4), 3 (Glason 4 + 3)
PSA 10-20
Favorable
Intermedio
CaPróstata
1 solo core afectado
y grupo 1 o 2, y <50%
de tejido afectado
Desfavorable
>1 core afectado, o
grupo 3, o >50% de
tejido afectado
Radioterapia Radioterapia + bloqueo
androgénico corto

50. Alguno
T3a
Grupo 4 o 5 (Gleason 8-10)
PSA>20
RT + ADT
Alguno:
T3b-T4
Gleason primario 5
>4 cores con Grupo 4 o 5
RT + ADT
Alto
Ultra-alto
CaPróstata

51. Alguno:
T3b-T4
Gleason primario 5
>4 cores con Grupo 4 o 5
Ultra-alto
CaPróstata
Radioterapia +
bloqueo androgénico
largo (1.5-3 años)

52. Treatment options by risk
1/2
Risk Group
Very-low risk
Active surveillance
External-Beam Radiotherapy
Radical prostatectomy +/- RPLND
Observation
Low risk
Active surveillance
External-Beam Radiotherapy
Radical prostatectomy +/- RPLND
Observation
Favorable intermediate
Active surveillance
External-Beam Radiotherapy
Radical prostatectomy +/- RPLND
Observation
RPLND: Retroperitoneal Lymph-Node Dissection

53. Treatment options by risk
2/2
Risk Group
Unfavorable intermediate risk
External-Beam Radiotherapy + ADT (4 mo)
Radical prostatectomy +/- RPLND
Observation
High risk
External-Beam Radiotherapy + ADT (18 mo)
Radical prostatectomy + RPLND
Very High risk
External-Beam Radiotherapy + ADT (18 mo)
Radical prostatectomy +/- RPLND
RPLND: Retroperitoneal Lymph-Node Dissection

54. Position statement: Non metastastic prostate cancer
Mauricio Lema - 2014
Watchful waiting and Active
Surveillance are NOT without
side-effects. Recommendations
need to be INDIVIDUALIZED
RP or RT or Active Surveillance (AS) or Watchful Waiting
(WW), or Brachytherapy (BT)*
Localized Low-Risk
T1c-T2a
PSA 10, or less
Gleason 6, o less
AS: Prostate US/PSA q3 Mo; Biopsy if
indicated. Treatment if progression.
WW: PSA q6 Mo, treatment if indicated
65 yo, or less: RT, RP or AS
Adverse features
PSA velocity 2+/year
50%+ positive findings in biopsy
Perineural invasion
Adverse features: active
treatment (RT, RP or BT)
*BT if feasible
Low risk
Small tumors
Adequate anatomy

55. Position statement: Non metastastic prostate cancer
Mauricio Lema - 2014
Radiation (RT) + LH-RH/Antiandrogen x6-24 Mo+ Mo
Locally-Advanced
(T3/T4)
Localized High-
Risk
T2c
PSA 20+
Gleason 8+
RT + LH-RH/Antiandrogen x4 Mo or RP
Localized
Intermediate-Risk
T2b
PSA 10-20
Gleason 7
Antiandrogen for at least 1 Mo
Antiandrogen for at least 1 Mo
“Would NOT use hormonal therapy in patients with known
coronary artery disease, unless benefit clearly outweigh risk”
RT + LH-RH/Antiandrogen x6-24 Mo or Radical
prostatectomy (RP)
Antiandrogen for at least 1 Mo
RP or RT or Active Surveillance (AS) or
Watchful Waiting (WW), or Brachytherapy
Localized Low-Risk
T1c-T2a
PSA 10, or less
Gleason 6, o less
AS: Prostate US/PSA q3 Mo; Biopsy if
indicated. Treatment if progression.
WW: PSA q6 Mo, treatment if indicated

56. Advanced or metastatic prostate
cancer
Not curable disease
Goals shift to disease control
Development of cancer cells unresponsive
to androgen deprivation
Typically occurs slowly over time, although
it can occur rapidly

57. Treatment strategies for
metastatic prostate cancer
Androgen Deprivation (Hormonal Rx)
Orchidectomy
LHRH analogues
Antiandrogens
Supportive therapies
Analgesics
Steroids
Bisphosphonates/Vitamin
D/Calcium for bone health
Chemotherapy
 Taxotere, Docetaxel
Last line of treatment