This document discusses prostate cancer and germ cell tumors. It provides information on prostate cancer incidence and mortality, screening recommendations, prevention studies using 5-alpha reductase inhibitors, pathology grading, staging, risk assessment, treatment options for localized disease including active surveillance and radical prostatectomy, treatment of recurrent disease including androgen deprivation therapy, and treatment of metastatic prostate cancer with androgen deprivation therapy. It also briefly discusses current treatment recommendations for testicular cancer including seminomas and non-seminomatous germ cell tumors.
This document summarizes prostate cancer detection, prognosis, treatment options, and future directions. It discusses standard therapies including surgery, radiation, hormone therapy, chemotherapy, and bone-targeted therapy. Emerging immunotherapies and clinical trials of new agents such as abiraterone and MDV3100 are also reviewed. The disease continuum moves from localized to advanced disease, and treatments aim to target different stages from non-metastatic to castration-resistant prostate cancer.
The document discusses prostate cancer and benign prostatic hyperplasia (BPH). It covers the incidence, risk factors, pathology, clinical findings, diagnosis and evaluations, as well as treatments for both conditions. For prostate cancer, it addresses staging and grading. It describes treatments for localized disease and recurrent disease after treatment. For BPH, it discusses symptoms, signs, tests, differential diagnosis, and medical and surgical treatment options.
Current Diagnosis And Management Of Prostate Cancerfondas vakalis
1) Prostate cancer risk factors include increasing age, family history, and lifestyle factors like smoking and high fat diets.
2) Screening methods include digital rectal exam and PSA testing, though screening recommendations vary.
3) Treatment options depend on cancer severity and include watchful waiting, surgery, radiation, hormone therapy, and cryotherapy. Long-term side effects can include incontinence and impotence.
Presentation is highlighting the integration of different modalities in the management of locally advanced and metastatic prostate cancer pointing to the proven values of adding chemotherapy. A special note has been made to oligometastatic disease.
Advances in risk assessment, differential diagnosis between aggressive and non-aggressive tumors, and the development of novel/optimized treatment for advanced disease are discussed.
This slide deck is made available for patients/caregivers. It is not a substitute for seeking medical help. Please check original sources listed in the deck and consult your physician for the latest information and advice.
Prostate cancer is the most commonly diagnosed cancer and second leading cause of cancer death among men over 65 in Western countries. Risk factors include increasing age, family history, and diet. Histopathological grading uses the Gleason grading system to determine tumor differentiation and prognosis. Treatment options depend on disease stage and include local therapies like surgery and radiation for early disease, hormone therapy for advanced or metastatic disease, and chemotherapy for hormone-refractory prostate cancer.
This document provides an overview of prostate cancer, including who is affected, risk factors, detection methods like PSA testing and biopsy, staging using the Gleason score and TNM system, and treatment options like surgery, radiation therapy, active surveillance, and androgen blockade. It discusses outcomes for different treatments and challenges in managing prostate cancer recurrence after initial therapy.
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
This document summarizes prostate cancer detection, prognosis, treatment options, and future directions. It discusses standard therapies including surgery, radiation, hormone therapy, chemotherapy, and bone-targeted therapy. Emerging immunotherapies and clinical trials of new agents such as abiraterone and MDV3100 are also reviewed. The disease continuum moves from localized to advanced disease, and treatments aim to target different stages from non-metastatic to castration-resistant prostate cancer.
The document discusses prostate cancer and benign prostatic hyperplasia (BPH). It covers the incidence, risk factors, pathology, clinical findings, diagnosis and evaluations, as well as treatments for both conditions. For prostate cancer, it addresses staging and grading. It describes treatments for localized disease and recurrent disease after treatment. For BPH, it discusses symptoms, signs, tests, differential diagnosis, and medical and surgical treatment options.
Current Diagnosis And Management Of Prostate Cancerfondas vakalis
1) Prostate cancer risk factors include increasing age, family history, and lifestyle factors like smoking and high fat diets.
2) Screening methods include digital rectal exam and PSA testing, though screening recommendations vary.
3) Treatment options depend on cancer severity and include watchful waiting, surgery, radiation, hormone therapy, and cryotherapy. Long-term side effects can include incontinence and impotence.
Presentation is highlighting the integration of different modalities in the management of locally advanced and metastatic prostate cancer pointing to the proven values of adding chemotherapy. A special note has been made to oligometastatic disease.
Advances in risk assessment, differential diagnosis between aggressive and non-aggressive tumors, and the development of novel/optimized treatment for advanced disease are discussed.
This slide deck is made available for patients/caregivers. It is not a substitute for seeking medical help. Please check original sources listed in the deck and consult your physician for the latest information and advice.
Prostate cancer is the most commonly diagnosed cancer and second leading cause of cancer death among men over 65 in Western countries. Risk factors include increasing age, family history, and diet. Histopathological grading uses the Gleason grading system to determine tumor differentiation and prognosis. Treatment options depend on disease stage and include local therapies like surgery and radiation for early disease, hormone therapy for advanced or metastatic disease, and chemotherapy for hormone-refractory prostate cancer.
This document provides an overview of prostate cancer, including who is affected, risk factors, detection methods like PSA testing and biopsy, staging using the Gleason score and TNM system, and treatment options like surgery, radiation therapy, active surveillance, and androgen blockade. It discusses outcomes for different treatments and challenges in managing prostate cancer recurrence after initial therapy.
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
This document discusses factors to consider when determining treatment for prostate cancer, including the biology and extent of the cancer, patient health status and life expectancy. It outlines prostate cancer risk groups based on staging and tumor characteristics, and how newer genomic testing can better classify risk. Combining clinical and genomic data separates risk groups and more accurately predicts outcomes like metastasis and mortality risks over 10 years. Genomics may reclassify some patients originally in intermediate risk groups to lower or higher risk, influencing treatment decisions.
The document discusses carcinoma of the prostate, including:
1. It provides information on prostate anatomy and the distribution and risk factors of prostate cancer.
2. Early detection is important as survival rates are 99% for localized cancer but only 31% once it has spread; screening involves digital rectal exams and PSA tests beginning at age 40-50.
3. Treatment options depend on the stage and grade of cancer, and include watchful waiting, surgery, radiation therapy, and hormone therapy.
The prostate is a gland that produces seminal fluid. Prostate cancer is the second most common cancer in men. The prostate has four zones - peripheral, transition, central and anterior fibromuscular. Prostate cancer usually arises in the peripheral zone and is typically an adenocarcinoma. Diagnosis involves a digital rectal exam, prostate-specific antigen testing, transrectal ultrasound of the prostate and biopsy. Staging involves evaluating if the cancer is organ-confined or has spread locally or metastasized. Treatment options depend on risk stratification and may include active surveillance, surgery, radiation therapy or hormone therapy.
Chemoprevention aims to prevent prostate cancer using pharmaceutical agents. Some key points about chemoprevention of prostate cancer include:
- Finasteride and dutasteride, 5-alpha reductase inhibitors, have been shown to reduce the risk of prostate cancer, especially low-grade cancer, but may increase the risk of higher grade cancers.
- Selenium and vitamin E supplements have been studied but did not show a clear benefit and in some cases increased risk.
- Dietary factors like lycopene from tomatoes and phytoestrogens from soy products are thought to possibly reduce prostate cancer risk but evidence is limited.
- Larger randomized controlled trials of pharmaceutical agents like the PCPT and REDU
Localized prostate cancer is the most common cancer in men in Western countries. For patients with high risk localized prostate cancer, the current recommended treatment is androgen deprivation therapy combined with radiotherapy. Several large randomized controlled trials have shown this combination prolongs progression-free and overall survival compared to androgen deprivation alone. Additional treatment options for high risk localized prostate cancer currently being investigated include radical prostatectomy and chemotherapy with docetaxel. Erectile dysfunction is a common side effect of treatment that can be addressed with oral phosphodiesterase inhibitors or intracavernosal injections.
Carcinoma of the prostate (CaP) is the most common cancer in American men and the second leading cause of cancer death. Most cases originate in the peripheral zone of the prostate. Risk factors include increasing age, African American race, family history, and high dietary fat intake. CaP is typically an adenocarcinoma and is graded using the Gleason system. Local spread can occur through the seminal vesicles, bladder, and rectum. Distant spread is usually to bones, lymph nodes, and lungs. Treatment depends on grade and stage, and may include surgery, radiation therapy, hormone therapy, or watchful waiting.
Mills-Peninsula Health Services 2013 Cancer Symposium presentation - Brad Ekstrand, MD/PhD, California Cancer Care Mills-Peninsula Health Services San Mateo, CA
The document discusses prostate cancer including its anatomy, epidemiology, diagnosis, staging, treatment and outcomes. Key points include:
- Prostate cancer is the most commonly diagnosed cancer in men. Risk factors include age, family history, and ethnicity. Screening includes PSA testing and biopsy.
- Treatment depends on risk classification based on PSA, Gleason score, and stage. Options include active surveillance, surgery, radiation therapy and hormone therapy.
- Studies show dose escalation radiation therapy and use of IMRT/3D conformal radiation improve biochemical control rates with acceptable toxicity compared to conventional radiation. Adjuvant hormone therapy with radiation improves outcomes for intermediate-high risk disease.
This seminar discussed screening for carcinoma of the prostate. It was chaired by Prof. C. S. Ratkal and co-chaired by Dr. M. Shivalingaiah. Dr. Prakash H. S. presented on various screening modalities including digital rectal examination (DRE), prostate-specific antigen (PSA) testing, prostate biopsy, and imaging. PSA testing combined with DRE is the most useful first-line screening approach. While screening can detect early-stage cancers, it also risks overdiagnosis and overtreatment of indolent tumors. The benefits and limitations of prostate cancer screening continue to be debated.
Overview and Pharmacotherapy of Prostate Cancer (based on NCCN 2012 guideline...hyunik116
This presentation was the prostate cancer lecture for the oncology therapeutics course (31:725:560) that was presented to the class of 2014 PharmD students at the Ernest Mario School of Pharmacy.
I really enjoyed researching and preparing this lecture for the students, and hope you also will find at least something useful in this presentation.
This document provides an overview and updates on prostate cancer pharmacotherapies. It discusses the anatomy and physiology of the prostate, risk factors for prostate cancer like diet and genetics, screening methods including PSA tests and digital rectal exams, diagnostic workup involving imaging and biopsies, tumor staging using Gleason scores and TNM classification, and treatment strategies at different stages including radiation, surgery, and hormone therapies. Controversies around PSA screening and increasing legal risks for failure to diagnose are also reviewed.
This document discusses prostate cancer awareness and provides information about prevention, symptoms, treatment options and stages. It notes that prostate cancer is the second leading cause of cancer death in American men and that early detection is vital for survival. It describes exams like the digital rectal exam and PSA testing that are used to detect prostate cancer early before symptoms appear. If cancer is found, it explains treatment options depending on the stage, like watchful waiting, surgery, radiation and hormone therapy. It stresses the importance of education and consulting doctors to make informed healthcare decisions.
This document discusses the approach to localized prostate cancer. It begins by outlining the various treatment options available after diagnosis. It then defines localized prostate cancer and discusses how widespread PSA screening has led to earlier detection and improved survival rates. Risk stratification methods like the D'Amico and EAU systems are introduced. Counseling patients involves shared decision making considering cancer severity, life expectancy, expected functional outcomes, and risks. Treatment methods like active surveillance, surgery, radiation, and androgen deprivation are covered at a high level. Follow up for active surveillance involves periodic PSA, DRE, and biopsy to monitor for cancer progression.
Prostate cancer is the most common cancer in men after lung cancer. It often grows slowly and can go undetected for years. The prostate is a gland located behind the penis that produces seminal fluid. Risk factors for prostate cancer include age, race, family history, diet, and hormones. Tests for early detection include a PSA test, digital rectal exam, and transrectal ultrasound. Treatment depends on the stage of cancer and may involve surgery, radiation therapy, hormone therapy, or chemotherapy, with potential side effects like fatigue, urinary problems, and sexual issues.
This document summarizes statistics on prostate cancer incidence and mortality rates in the United States from 1975 to 2009. It also discusses results from several major clinical trials comparing prostate cancer screening to no screening, and radical prostatectomy to observation for localized prostate cancer. The key findings are:
1) Prostate cancer incidence peaked in 1992 but mortality rates have been declining since the 1990s.
2) Large screening trials show screening increases prostate cancer diagnosis but does not reliably decrease prostate cancer mortality.
3) The PIVOT trial found that among men with localized prostate cancer, radical prostatectomy resulted in a 2.9% lower rate of death from any cause and a 2.6% lower rate of death from prostate
CARCINOMA PROSTATE- Dr Manoj Kumar B, PGIPGIMER, AIIMS
The document discusses carcinoma of the prostate, including its anatomy, epidemiology, etiology, natural history, clinical manifestations, diagnostic workup, imaging, and management. It provides detailed information on prostate anatomy, risk factors for prostate cancer, methods of evaluation including PSA levels, biopsy, and various imaging modalities like ultrasound, CT, and MRI.
Management of prostate cancer involves assessing risk levels based on PSA, Gleason score, and percentage of positive biopsy cores. Treatment options include active surveillance for low risk prostate cancer with potential delayed treatment if cancer progresses. Radical prostatectomy is the gold standard for localized prostate cancer and provides the possibility of cure with minimal side effects when performed by an experienced surgeon. While providing excellent cancer control, radical prostatectomy carries risks of erectile dysfunction and urinary incontinence.
This document discusses stage IV prostate cancer and advanced or metastatic prostate cancer. It defines stage IV based on the TNM classification system and notes that approximately 10-20% of newly diagnosed prostate cancer cases involve locally advanced disease. For metastatic prostate cancer, median survival ranges from 9 to 24 months depending on whether metastases are asymptomatic or symptomatic. Main treatments discussed include androgen deprivation therapy and chemotherapy. The document also covers management of bone metastases, hormone-refractory prostate cancer, newer hormone therapies like abiraterone and enzalutamide, immunotherapy with sipuleucel-T, chemotherapy options including docetaxel and cabazitaxel, radiopharmaceuticals like radium-223, and bone-mod
Bone-targeted therapy can play an important role in preventing fractures for patients with prostate cancer undergoing androgen deprivation therapy (ADT). ADT significantly increases the risk of fractures by causing rapid bone loss. Several therapies including bisphosphonates like zoledronic acid and alendronate, as well as denosumab, have been shown to reduce bone loss and increase bone mineral density when given to men on ADT, thereby decreasing their fracture risk. Large clinical trials are still needed to demonstrate whether these therapies can actually reduce fracture rates.
This document discusses factors to consider when determining treatment for prostate cancer, including the biology and extent of the cancer, patient health status and life expectancy. It outlines prostate cancer risk groups based on staging and tumor characteristics, and how newer genomic testing can better classify risk. Combining clinical and genomic data separates risk groups and more accurately predicts outcomes like metastasis and mortality risks over 10 years. Genomics may reclassify some patients originally in intermediate risk groups to lower or higher risk, influencing treatment decisions.
The document discusses carcinoma of the prostate, including:
1. It provides information on prostate anatomy and the distribution and risk factors of prostate cancer.
2. Early detection is important as survival rates are 99% for localized cancer but only 31% once it has spread; screening involves digital rectal exams and PSA tests beginning at age 40-50.
3. Treatment options depend on the stage and grade of cancer, and include watchful waiting, surgery, radiation therapy, and hormone therapy.
The prostate is a gland that produces seminal fluid. Prostate cancer is the second most common cancer in men. The prostate has four zones - peripheral, transition, central and anterior fibromuscular. Prostate cancer usually arises in the peripheral zone and is typically an adenocarcinoma. Diagnosis involves a digital rectal exam, prostate-specific antigen testing, transrectal ultrasound of the prostate and biopsy. Staging involves evaluating if the cancer is organ-confined or has spread locally or metastasized. Treatment options depend on risk stratification and may include active surveillance, surgery, radiation therapy or hormone therapy.
Chemoprevention aims to prevent prostate cancer using pharmaceutical agents. Some key points about chemoprevention of prostate cancer include:
- Finasteride and dutasteride, 5-alpha reductase inhibitors, have been shown to reduce the risk of prostate cancer, especially low-grade cancer, but may increase the risk of higher grade cancers.
- Selenium and vitamin E supplements have been studied but did not show a clear benefit and in some cases increased risk.
- Dietary factors like lycopene from tomatoes and phytoestrogens from soy products are thought to possibly reduce prostate cancer risk but evidence is limited.
- Larger randomized controlled trials of pharmaceutical agents like the PCPT and REDU
Localized prostate cancer is the most common cancer in men in Western countries. For patients with high risk localized prostate cancer, the current recommended treatment is androgen deprivation therapy combined with radiotherapy. Several large randomized controlled trials have shown this combination prolongs progression-free and overall survival compared to androgen deprivation alone. Additional treatment options for high risk localized prostate cancer currently being investigated include radical prostatectomy and chemotherapy with docetaxel. Erectile dysfunction is a common side effect of treatment that can be addressed with oral phosphodiesterase inhibitors or intracavernosal injections.
Carcinoma of the prostate (CaP) is the most common cancer in American men and the second leading cause of cancer death. Most cases originate in the peripheral zone of the prostate. Risk factors include increasing age, African American race, family history, and high dietary fat intake. CaP is typically an adenocarcinoma and is graded using the Gleason system. Local spread can occur through the seminal vesicles, bladder, and rectum. Distant spread is usually to bones, lymph nodes, and lungs. Treatment depends on grade and stage, and may include surgery, radiation therapy, hormone therapy, or watchful waiting.
Mills-Peninsula Health Services 2013 Cancer Symposium presentation - Brad Ekstrand, MD/PhD, California Cancer Care Mills-Peninsula Health Services San Mateo, CA
The document discusses prostate cancer including its anatomy, epidemiology, diagnosis, staging, treatment and outcomes. Key points include:
- Prostate cancer is the most commonly diagnosed cancer in men. Risk factors include age, family history, and ethnicity. Screening includes PSA testing and biopsy.
- Treatment depends on risk classification based on PSA, Gleason score, and stage. Options include active surveillance, surgery, radiation therapy and hormone therapy.
- Studies show dose escalation radiation therapy and use of IMRT/3D conformal radiation improve biochemical control rates with acceptable toxicity compared to conventional radiation. Adjuvant hormone therapy with radiation improves outcomes for intermediate-high risk disease.
This seminar discussed screening for carcinoma of the prostate. It was chaired by Prof. C. S. Ratkal and co-chaired by Dr. M. Shivalingaiah. Dr. Prakash H. S. presented on various screening modalities including digital rectal examination (DRE), prostate-specific antigen (PSA) testing, prostate biopsy, and imaging. PSA testing combined with DRE is the most useful first-line screening approach. While screening can detect early-stage cancers, it also risks overdiagnosis and overtreatment of indolent tumors. The benefits and limitations of prostate cancer screening continue to be debated.
Overview and Pharmacotherapy of Prostate Cancer (based on NCCN 2012 guideline...hyunik116
This presentation was the prostate cancer lecture for the oncology therapeutics course (31:725:560) that was presented to the class of 2014 PharmD students at the Ernest Mario School of Pharmacy.
I really enjoyed researching and preparing this lecture for the students, and hope you also will find at least something useful in this presentation.
This document provides an overview and updates on prostate cancer pharmacotherapies. It discusses the anatomy and physiology of the prostate, risk factors for prostate cancer like diet and genetics, screening methods including PSA tests and digital rectal exams, diagnostic workup involving imaging and biopsies, tumor staging using Gleason scores and TNM classification, and treatment strategies at different stages including radiation, surgery, and hormone therapies. Controversies around PSA screening and increasing legal risks for failure to diagnose are also reviewed.
This document discusses prostate cancer awareness and provides information about prevention, symptoms, treatment options and stages. It notes that prostate cancer is the second leading cause of cancer death in American men and that early detection is vital for survival. It describes exams like the digital rectal exam and PSA testing that are used to detect prostate cancer early before symptoms appear. If cancer is found, it explains treatment options depending on the stage, like watchful waiting, surgery, radiation and hormone therapy. It stresses the importance of education and consulting doctors to make informed healthcare decisions.
This document discusses the approach to localized prostate cancer. It begins by outlining the various treatment options available after diagnosis. It then defines localized prostate cancer and discusses how widespread PSA screening has led to earlier detection and improved survival rates. Risk stratification methods like the D'Amico and EAU systems are introduced. Counseling patients involves shared decision making considering cancer severity, life expectancy, expected functional outcomes, and risks. Treatment methods like active surveillance, surgery, radiation, and androgen deprivation are covered at a high level. Follow up for active surveillance involves periodic PSA, DRE, and biopsy to monitor for cancer progression.
Prostate cancer is the most common cancer in men after lung cancer. It often grows slowly and can go undetected for years. The prostate is a gland located behind the penis that produces seminal fluid. Risk factors for prostate cancer include age, race, family history, diet, and hormones. Tests for early detection include a PSA test, digital rectal exam, and transrectal ultrasound. Treatment depends on the stage of cancer and may involve surgery, radiation therapy, hormone therapy, or chemotherapy, with potential side effects like fatigue, urinary problems, and sexual issues.
This document summarizes statistics on prostate cancer incidence and mortality rates in the United States from 1975 to 2009. It also discusses results from several major clinical trials comparing prostate cancer screening to no screening, and radical prostatectomy to observation for localized prostate cancer. The key findings are:
1) Prostate cancer incidence peaked in 1992 but mortality rates have been declining since the 1990s.
2) Large screening trials show screening increases prostate cancer diagnosis but does not reliably decrease prostate cancer mortality.
3) The PIVOT trial found that among men with localized prostate cancer, radical prostatectomy resulted in a 2.9% lower rate of death from any cause and a 2.6% lower rate of death from prostate
CARCINOMA PROSTATE- Dr Manoj Kumar B, PGIPGIMER, AIIMS
The document discusses carcinoma of the prostate, including its anatomy, epidemiology, etiology, natural history, clinical manifestations, diagnostic workup, imaging, and management. It provides detailed information on prostate anatomy, risk factors for prostate cancer, methods of evaluation including PSA levels, biopsy, and various imaging modalities like ultrasound, CT, and MRI.
Management of prostate cancer involves assessing risk levels based on PSA, Gleason score, and percentage of positive biopsy cores. Treatment options include active surveillance for low risk prostate cancer with potential delayed treatment if cancer progresses. Radical prostatectomy is the gold standard for localized prostate cancer and provides the possibility of cure with minimal side effects when performed by an experienced surgeon. While providing excellent cancer control, radical prostatectomy carries risks of erectile dysfunction and urinary incontinence.
This document discusses stage IV prostate cancer and advanced or metastatic prostate cancer. It defines stage IV based on the TNM classification system and notes that approximately 10-20% of newly diagnosed prostate cancer cases involve locally advanced disease. For metastatic prostate cancer, median survival ranges from 9 to 24 months depending on whether metastases are asymptomatic or symptomatic. Main treatments discussed include androgen deprivation therapy and chemotherapy. The document also covers management of bone metastases, hormone-refractory prostate cancer, newer hormone therapies like abiraterone and enzalutamide, immunotherapy with sipuleucel-T, chemotherapy options including docetaxel and cabazitaxel, radiopharmaceuticals like radium-223, and bone-mod
Bone-targeted therapy can play an important role in preventing fractures for patients with prostate cancer undergoing androgen deprivation therapy (ADT). ADT significantly increases the risk of fractures by causing rapid bone loss. Several therapies including bisphosphonates like zoledronic acid and alendronate, as well as denosumab, have been shown to reduce bone loss and increase bone mineral density when given to men on ADT, thereby decreasing their fracture risk. Large clinical trials are still needed to demonstrate whether these therapies can actually reduce fracture rates.
Prostate cancer detection, UroLifts, HaematuriaMarc Laniado
This document discusses innovations in prostate disease management, including focal therapy options for prostate cancer and the UroLift procedure for treating benign prostatic hyperplasia (BPH). It summarizes guidelines for investigating hematuria and evaluating prostate cancer risk. It also compares treatment options for localized prostate cancer and BPH, noting UroLift offers symptom relief while preserving sexual function unlike other BPH treatments. Clinical data shows UroLift improves urinary symptoms and quality of life compared to TURP, with faster recovery and no effect on ejaculation.
This study examined genetic variants in DNA repair genes and their association with prostate cancer risk in a population-based case-control study conducted in China. The study genotyped 191 prostate cancer cases and 305 controls for five single nucleotide polymorphisms (SNPs) in DNA repair genes. Statistical analysis found that variants in the XRCC1 and MGMT genes were associated with increased prostate cancer risk, and that these associations were modified by factors like abdominal obesity, insulin resistance, and diet. The study provides evidence that DNA repair capacity may influence prostate cancer risk. Larger confirmation studies in other populations are still needed.
This document discusses metastatic castrate-resistant prostate cancer (CRPC) and its management at LASUTH Urology Unit. CRPC occurs when prostate cancer progresses despite testosterone suppression through androgen deprivation therapy. While initial responses to androgen deprivation are common, cancer inevitably becomes resistant. Mechanisms of resistance include hypersensitive androgen receptor pathways, outlaw pathways activated by other ligands, and bypass pathways not dependent on the androgen receptor. The epidemiology, criteria for defining progression, mechanisms of resistance, current management approaches, and LASUTH's experience with CRPC are outlined.
1) Castrate-resistant prostate cancer (CRPC) has become increasingly treatable over the past decade with the approval of several new drugs including docetaxel, sipuleucel-T, cabazitaxel, denosumab, and abiraterone.
2) Clinical trials have shown that docetaxel improves survival when used to treat metastatic CRPC and cabazitaxel improves survival in CRPC progressing after docetaxel.
3) Denosumab has been shown to delay skeletal-related events in men with bone metastases from prostate cancer compared to zoledronic acid. Abiraterone has also improved survival in CRPC progressing after chemotherapy.
1. Targeted therapies and chemotherapy have improved survival rates for patients with metastatic colorectal cancer by increasing the resectability of liver metastases and prolonging progression-free and overall survival.
2. Studies show that preoperative chemotherapy can increase resection rates for initially unresectable liver metastases from 10-30% to over 40% and improve long-term survival outcomes compared to surgery alone.
3. Ongoing clinical trials are further exploring the benefits of targeted agents in combination with chemotherapy administered preoperatively to potentially convert more patients to resectable status.
This document provides an overview of the treatment of dementia. It discusses the definition and classification of dementia, as well as the staging and types of dementia. It then describes the pathophysiology and management of dementia, including both pharmacologic and non-pharmacologic approaches. Regarding pharmacologic management, it outlines three broad categories of treatment: symptomatic treatment of memory disturbance, disease-modifying treatments, and symptomatic treatment of behavioral disturbances. Specific drugs discussed in detail include cholinesterase inhibitors such as donepezil, rivastigmine, and tacrine.
Analysis On Global Drugs for Prostate Cancer Market Research, Demands & Produ...Pallavi Pawar
The global Drugs for Prostate Cancer market the target of analysis of the research report recently added to the expansive database in QYResearchReports.com. The extremely descriptive and insightful document chalks out a thorough and all-inclusive analytical perspective of the global Drugs for Prostate Cancer market, covering all key categories and their segments, along with the factors that have the potential of being influential on the market in the near future. The report thus presents a 360-degree analysis of the current state of the global Drugs for Prostate Cancer market to the reader.
The market has been excavated from a ground-up fashion, where rudimentary data and key, industry-specific definitions of the global Drugs for Prostate Cancer market’s elements are described in the overview. The report moves ahead to the complete analysis of global Drugs for Prostate Cancer market, sticking to aspects such as classifications, industry chain structure, applications, policies, industry overview, and recent developments.
Molecular biology of Prostate cancer. There are three major pathways - the androgen receptor pathway, PI3K/Akt pathway, and Rb pathway. Other factors include TMPRSS2-ETS fusion, TGF-b1, PTEN loss, and aberrant E-cadherin expression. Risk factors include age, ethnicity, genetic mutations like BRCA1/2, and environmental exposures. Prostate cancer can metastasize, with bone and lymph nodes being common sites. Diagnosis involves tests like DRE, PSA, biopsy, and imaging. Hormone therapy targets the androgen receptor and includes surgical or medical castration as well as antiandrogens, but resistance eventually develops
This document discusses the management of advanced prostate carcinoma in a 65-year-old politician. It outlines the epidemiology, risk factors, pathogenesis, pathology, staging, grading, investigations, and treatment options. The patient has locally advanced or metastatic disease. Treatment aims to be palliative and multidisciplinary, focusing on hormonal manipulation through antiandrogens and LHRH agonists. The prognosis is poor, with progression to hormone resistance typically within 12-18 months and median survival of 2-3 years. Future trends include targeted therapies such as androgen synthesis inhibitors and PSMA-targeted antibodies.
Dr Ho Siew Hong delivered a public lecture on differentiating prostate cancer from non cancer enlargement of the prostate during the Prostate Awareness Month 2008
Poster Presentation Title: A Phase 1 clinical trial of a therapeutic prostate cancer vaccine containing PSA/IL-2/GM-CSF in PSA defined biochemical recurrent prostate cancer patients
Meeting: CRI-CIMT-EATI-AACR: Inaugural International Cancer Immunotherapy Conference: Translating Science Into Survival
Immunotherapy for cancer has had two main approaches that have lead to clinical applications. The first is stimulating immune responses to tumor cells with cytokines or cellular immunotherapy and the second is blocking tumor immune evasion and the associated inhibition of T-cell activation with antibodies to the CTLA-4 receptor, PD-1 receptor or PD-L1. At OncBioMune, we have taken a different approach and have developed therapeutic cancer vaccines that are a combination of tumor antigens (whole cells or proteins) with biological adjuvants (the cytokines IL-2 and GM-CSF). This study is a Phase 1a/1b clinical trial of a PSA/IL-2/GM-CSF vaccine in recurrent prostate cancer in hormone-naïve and hormone-independent patients. Major inclusion criteria include adenocarcinoma of the prostate, rising serum PSA and no measurable disease. Phase 1a examines the rate of dose limiting adverse events (DLAEs) in an initial course of 6 vaccinations (“induction vaccination”). The Phase 1b examines the rate of DLAEs with a continued coarse of an additional 6 vaccinations (“maintenance vaccine”). All patients will receive intradermal injections of the PSA/IL-2/GM-CSF vaccine at weeks 1, 2, 3, 7, 11, and 15. In an additional 28 patients the six maintenance vaccines will alternate IL-2 and the complete vaccine (PSA/IL-2/GM-CSF) at weeks 23, 27, 31, 35, 39 and 43. To date, twelve of twenty patients in the Phase 1a portion of the trial have received at least one vaccine injection and ten patients have received all 6 vaccines. Seven of the ten patients that have received 3 vaccines had increased responses to PSA in a lymphocyte blastogenesis assay and five of the nine patients had an increase in their response after 6 vaccines. None of the patients vaccinated in the Phase 1a portion have had a DLAE and enrollment continues in the Phase 1a.
The document discusses the anatomy and physiology of the prostate gland, including its location, lobes, and zones where cancer is most common. It then covers the causes, symptoms, incidence, and risk factors of prostate cancer. Several diagnostic examinations are outlined, including digital rectal examination, ultrasound, biopsy, and tests to determine tumor staging and lymph node involvement. Treatment planning techniques like simulation, localization, and dosimetry are described. Common treatment modalities are radiation therapy using external beam radiotherapy techniques like four field technique, and side effects of treatment are mentioned.
An informative and, dare I say, entertaining view of prostate cancerTamara Paton
I put this presentation together for my husband, a family doctor who presents to small community groups.
This marks my first attempt at following the Slide:ology approach.
This document provides an overview of prostate cancer, including the anatomy and histology of the prostate gland, risk factors for prostate cancer such as age and family history, common symptoms and sites of metastasis, methods of grading and staging prostate cancer, investigations used in diagnosis, and management options. The pathophysiology involves genetic mutations and hormonal influences on prostate cell growth. Treatment may include radical prostatectomy, radiation therapy, surveillance, or a combination of therapies.
Brachytherapy is a type of prostate cancer treatment that involves the computer-assisted implantation of radioactive seeds directly into the prostate. The document discusses the history and development of brachytherapy since the 1960s. It provides details on patient selection and presents results from early and recent studies showing high 5 and 10-year survival and biochemical relapse-free survival rates following permanent brachytherapy.
Prostate cancer is the most common cancer in men and the second leading cause of cancer death. It occurs when cells in the prostate gland grow abnormally. There are often no early symptoms but some men experience urinary issues or discomfort. Treatment options include surgery, chemotherapy, cryotherapy, hormonal therapy, and watchful waiting. Screening tools include digital rectal exams, transrectal ultrasound, and PSA tests.
This document discusses radiation therapy options after prostate cancer surgery. Post-operative (adjuvant) radiation therapy may be recommended if the pathology report finds adverse features like positive margins or extracapsular extension, as it can reduce cancer recurrence. Salvage radiation is an option if the prostate-specific antigen (PSA) level begins rising after surgery, and works best with low PSA levels and higher radiation doses. Studies show adjuvant and salvage radiation can improve survival rates versus surgery alone or observation for patients with high-risk features. Newer radiation techniques like image-guided IMRT may lower side effects and boost cure rates compared to earlier methods.
This document discusses the management of intermediate and high risk prostate cancer. It begins by providing background on prostate cancer epidemiology and risk stratification. It then covers various treatment options including observation, active surveillance, radical prostatectomy, radiotherapy, and androgen deprivation therapy. Several studies comparing the efficacy of radiotherapy alone versus radiotherapy with short or long-term ADT are summarized. For intermediate risk prostate cancer, the document recommends 4-6 months of ADT with radiotherapy based on trial results. For high risk prostate cancer, 2-3 years of ADT with radiotherapy is recommended.
Prostate cancer is the second most common cancer in men worldwide. While early detection and treatment of localized prostate cancer can lead to many years of survival, the disease often progresses to an advanced or metastatic stage where it becomes resistant to hormonal therapies and has limited treatment options. New drugs like abiraterone and enzalutamide that target androgen signaling pathways have improved survival for men with metastatic castration-resistant prostate cancer, but optimal treatment sequencing remains unclear as the disease continues to evolve.
MANAGEMENT 0F SEMINOMA CURRENT STATUS AND FUTURE DIRECTIONS.pdfadhilaamariyil
1) Seminoma is the most common germ cell tumor in young males. The standard treatment for stage I seminoma is either surveillance, radiotherapy, or chemotherapy.
2) For stage IIA/B seminoma, treatment options are radiotherapy or 3-4 cycles of chemotherapy. Radiotherapy provides better outcomes for stage IIA.
3) Advanced or metastatic seminoma (stage IIC/III) is treated with chemotherapy, with 5-year survival rates of 95% for good prognosis patients and 87% for intermediate prognosis.
This case study discusses treatment options for a 45-year-old man with low risk prostate cancer based on an elevated PSA. Screening is recommended due to his family history of prostate cancer in his father. Further testing reveals a small, low grade tumor. He is a candidate for active surveillance, brachytherapy, or radical prostatectomy. Active surveillance is preferred given his age and low risk profile to avoid overtreatment. Brachytherapy is also an option and has advantages over external beam radiation in reducing dose to surrounding organs. Close monitoring is needed as most low risk prostate cancer patients will not require immediate treatment.
This document summarizes a journal club discussion on a clinical trial comparing active monitoring, surgery, and radiotherapy for treating clinically localized prostate cancer. The trial included over 2,600 men randomized to one of the three treatment groups or choosing their own treatment. Results found no difference in prostate cancer deaths between groups after 10 years. Exploratory analyses combining randomized and non-randomized cohorts found a lower risk of cancer death with radical treatment versus active monitoring. However, radical treatments were associated with higher rates of urinary incontinence, erectile dysfunction, and bowel issues compared to active monitoring. Limitations included potential for bias in the analyses and unknown long-term outcomes beyond 10 years.
This document discusses the use of radiosurgery, specifically CyberKnife, for gastrointestinal (GI) tumours. It provides an overview of common GI cancers such as liver, pancreatic and colorectal cancers. It then discusses various treatment options for these cancers including surgery, chemotherapy, radiotherapy, radiosurgery, stereotactic body radiation therapy and targeted therapies. It focuses on the use of CyberKnife for treatment of liver tumours such as hepatocellular carcinoma and liver metastases. Key benefits of CyberKnife highlighted are its precision, ability to track tumour motion, and delivery of high radiation doses in a short course of treatment.
1) Post-operative radiotherapy (PORT) can reduce the risk of prostate cancer recurrence after radical prostatectomy for patients with adverse features like positive surgical margins or extracapsular extension.
2) Large randomized trials have shown that adjuvant radiotherapy (ART) within 6 months of surgery improves outcomes compared to observation or early salvage radiotherapy initiated at first signs of recurrence.
3) Salvage radiotherapy is an option for patients with rising PSA after surgery but no metastases, and can improve biochemical progression-free survival and cancer-specific survival when initiated promptly at low PSA levels.
The document discusses screening and active surveillance for prostate cancer. It summarizes that screening with PSA testing can reduce prostate cancer mortality by 20% but also leads to overdiagnosis of indolent cancers. Active surveillance is presented as an alternative to immediate treatment for selected low-risk prostate cancer patients with criteria such as Gleason score ≤6, PSA<10ng/ml, and limited cancer in biopsy cores. Studies found that 29-50% of patients identified by screening as low-risk were found to have more aggressive cancer upon undergoing radical prostatectomy.
The document provides information on developing clinical guidelines for prostate cancer screening using PSA testing. It includes requirements for effective screening programs, characteristics of the PSA test, results from two large randomized controlled trials (PLCO and ERSPC) on PSA screening, and considerations for formulating a screening guideline. A third summary discusses estimates of lead time and overdiagnosis from prostate cancer screening from three mathematical models, with lead times ranging from 5-7 years and overdiagnosis estimated at 23-42% of screen-detected cancers.
Localized Prostate Cancer in Puerto Ricoflasco_org
This document summarizes localized prostate cancer screening and treatment options in Puerto Rico. It discusses screening guidelines and biomarkers like PSA, PCA3, and multiparametric MRI. Treatment options covered include active surveillance, surgery (open, robotic, cryotherapy), and radiation therapy (brachytherapy, external beam). Robotic prostatectomy results in less blood loss and shorter catheter time compared to open surgery. Adjuvant radiation after prostatectomy may improve outcomes for men with adverse features like positive margins or extraprostatic extension.
This document summarizes guidelines for diagnosis and treatment of prostate cancer. It discusses various staging tests including digital rectal exam, PSA levels, and biopsy. For localized disease, active surveillance is recommended for very low risk while radical prostatectomy or radiotherapy are options for low to intermediate risk. For high risk disease, radiotherapy dose escalation to 74-80 Gy is recommended. Brachytherapy or external beam radiotherapy with brachytherapy boost are discussed. Androgen deprivation therapy is indicated for high risk, locally advanced or metastatic disease.
Post treatment surveillance for Genitourinary CancersAjeet Gandhi
Clinicians should monitor localized prostate cancer patients post therapy with PSA screening and inform them of their individual risk of recurrence. Survivorship programs should address symptom management and connect patients to support resources.
For patients with rising PSA after treatment, clinicians should interpret levels in light of other clinical factors and consider imaging like MRI to identify local recurrence and determine eligibility for salvage therapy. Biopsy of recurrent lesions may be warranted in select cases.
Post-treatment surveillance for testicular cancer should be individualized based on stage and histology, utilizing history, physicals, imaging and tumor markers selectively rather than routinely. Long-term monitoring for potential late effects is also important
Prostate cancer updates were presented. Key points include:
1) The Gleason score is used to assess tumor aggressiveness and has shifted to include higher scores over time.
2) Screening results do not support widespread mass screening, but early detection may be offered to informed men with baseline PSA testing at age 40 and screening intervals of 8 years if initial PSA is low.
3) For localized disease, treatment options include active surveillance, radical prostatectomy, or radiation therapy depending on risk level and life expectancy. Deferred treatment may be appropriate for many cases.
1. The document discusses the debate around prostate cancer screening in elderly men over age 65, with arguments on both sides.
2. Screening may detect cancers early that would not have progressed or caused harm in a man's lifetime given his life expectancy. However, screening also risks overdiagnosis and overtreatment of biologically unimportant cancers.
3. Guidelines in the US do not recommend routine screening for low-risk, elderly patients due to the scientific uncertainties around the balance of benefits and harms. Patient-clinician discussion is important to make informed, individual decisions.
This document summarizes information about lung cancer screening. It discusses results from large randomized controlled trials like the National Lung Screening Trial and the NELSON trial which found that low-dose CT screening can reduce lung cancer mortality compared to chest x-ray screening in high-risk individuals. The document also reviews lung cancer epidemiology, staging, management guidelines based on nodule size and characteristics, and results from other lung cancer screening studies globally.
This document discusses a trial investigating the role of local radiation therapy for metastatic prostate cancer. The main findings were:
1. No overall survival benefit was seen with radiation therapy, but survival improved in patients with low metastatic burden.
2. Failure-free survival improved with radiation therapy overall and in the low metastatic burden group.
3. Adverse effects from radiation therapy were modest.
The trial provides evidence that radiation therapy to the prostate improves outcomes for men with metastatic prostate cancer who have a low metastatic burden and does not negatively impact side effects.
This document summarizes information about prostate cancer, including statistics on incidence and mortality rates in the United States. It discusses various screening and treatment options for prostate cancer. Key points include: lifetime risk of developing prostate cancer is 16.2% for men; screening with PSA and digital rectal exam has not been proven to reduce mortality; watchful waiting or active surveillance are appropriate for very low or low risk prostate cancer depending on life expectancy; radical prostatectomy and radiation therapy offer similar cure rates for early stage disease but have different side effect profiles.
1. The document discusses whether prostate cancer screening should be recommended for elderly men over age 65 given the high prevalence of prostate cancer but also the slow growing nature in many cases and short life expectancy.
2. While screening can detect cancer early, it also risks overdiagnosing biologically unimportant cancers and subjects men to potential harms of treatment without clear benefits due to their age.
3. Guidelines in the US have differing recommendations regarding screening older men, reflecting the ongoing debate around the balance of risks and benefits in this population.
This document discusses the management of oligometastatic breast cancer. It begins by providing historical context on the evolution of understanding and treatment of breast cancer. It then defines oligometastatic breast cancer as limited metastases that may be amenable to local treatment. The document reviews evidence that local ablative therapy combined with systemic therapy can improve outcomes for select patients. It also discusses several studies that provide randomized evidence supporting the use of stereotactic ablative radiotherapy to treat limited metastatic sites. In conclusion, the document emphasizes that careful patient selection is important to identify those most likely to benefit from localized treatment of oligometastatic disease.
Similar to Intern talk prostate and testis cancer 2015 (20)
This document provides a summary of articles across various medical specialties discussed in the April 2015 edition of the UTSW Journal Watch. In the Hepatology section, an article is summarized that finds corticosteroids may be safely used in patients with severe alcoholic hepatitis who present with an upper GI bleed after bleeding is controlled. In Pulmonary/Critical Care, a summary is provided of a trial finding no difference in mortality between early goal-directed therapy and usual care for treating septic shock. The study suggests protocols for goals of care are less important than early antibiotics and fluids. In Nephrology, a meta-analysis summary indicates preoperative use of renin-angiotensin system inhibitors may be linked to
The CT chest scan showed mosaic attenuation with air-trapping as well as an increase in size of a non-calcified lingular nodule and other scattered nodules.
This document summarizes guidelines for screening and treatment related to gynecologic health in menopausal women. It discusses recommendations and risks for cervical and breast cancer screening, as well as guidelines for and risks of hormone replacement therapy. It also reports on non-hormonal options for treating post-menopausal symptoms like hot flashes. The document provides this information through a series of clinical vignettes and recommendations based on evidence from sources like the USPSTF.
This document provides guidance on identifying and managing clinically significant depression for internists. It outlines how to take a thorough history to assess for depression, safety risks, substance use, bipolarity and psychosis. Common mimics of depression like delirium, substance withdrawal and medical condition-related depression are reviewed. First-line antidepressant medications are SSRIs, SNRIs, bupropion and mirtazapine. The document describes strategies for patients who do not improve on initial treatment, such as switching or augmenting medications. Non-pharmacological approaches like exercise and social support are also encouraged.
This document discusses the evaluation and treatment of low back pain. It notes that low back pain is very common, affecting 90% of people and costing $40 billion annually. For acute low back pain, the short answer is to leave patients alone and for chronic pain, recommend back classes and functional rehabilitation. Red flags to evaluate for include cancer, infection, or neurological deficits. The goal is to distinguish the 95% with simple back pain from the 5% with serious underlying issues. Conservative treatment is usually sufficient, with opioids not recommended for chronic pain due to lack of evidence of long-term benefit and risk of harm.
This document discusses the evaluation and treatment of low back pain. It notes that low back pain is very common, affecting 90% of people and costing $40 billion annually. For acute low back pain, the short answer is to leave patients alone and for chronic pain, recommend back classes and functional rehabilitation. Red flags to evaluate for include cancer, infection, or neurological deficits. The goal is to distinguish the 95% with simple back pain from the 5% with a serious underlying problem. Conservative treatment including education, exercise, and over-the-counter medications is usually sufficient. Opioids are not recommended for chronic back pain due to lack of evidence of long-term benefit and risk of harm.
This document summarizes a presentation on atypical hemolytic uremic syndrome (aHUS). The key points are:
1) Atypical HUS is caused by dysregulation of the alternative complement pathway leading to thrombotic microangiopathy. There is often an underlying genetic predisposition that is triggered by stressors like pregnancy.
2) Treatment with plasma therapy and transplantation previously had limited success due to recurrent disease.
3) The monoclonal antibody eculizumab, a C5 inhibitor, is highly effective at treating and preventing recurrence of aHUS. However, the high cost of the medication presents barriers to treatment.
Mr. Lung is a 78-year-old man scheduled for a 4-hour L3-5 laminectomy and fusion who has severe COPD, diabetes, hypertension, and a 40 pack-year smoking history. He takes medications for his COPD and other conditions and is functionally independent but dyspneic with exertion. Preoperative evaluation shows he is at increased risk for postoperative pulmonary complications according to several risk prediction models. Recommendations are made for postoperative lung expansion techniques and monitoring to help mitigate his risks.
Based on the evidence presented in the document, the appropriate recommendation for Mrs. K would be a lifestyle intervention with a goal of 7% weight loss (Option B). The DPP trial demonstrated that lifestyle intervention, aimed at 7% weight loss through diet and exercise, reduced the risk of developing diabetes by 58% over 3 years compared to placebo. This lifestyle intervention was more effective than metformin alone in preventing diabetes.
1. The Diabetes Prevention Program (DPP) found that an intensive lifestyle intervention aimed at 7% weight loss was more effective than metformin or placebo at preventing diabetes in patients with prediabetes over 3 years, with a 58% reduction in relative risk.
2. For Mrs. K, an intensive lifestyle intervention targeting at least 7% weight loss would be the recommended first-line evidence-based approach based on the DPP findings.
3. After 1 year of lifestyle changes, Mrs. K had achieved 6% weight loss and normal fasting glucose and A1C levels, indicating response to treatment. However, 12 months later with 10 pounds regained, her glucose levels have
Community-acquired pneumonia (CAP) is a leading cause of death and hospitalization in the United States. Guidelines recommend using severity of illness scores like CURB-65 to determine appropriate site of care and empiric antibiotic therapy including β-lactams with macrolides or fluoroquinolones. Studies show guideline-concordant therapy improves outcomes. Procalcitonin levels may help determine duration of antibiotics, with lower levels associated with shorter treatment. Overall, clinicians should aim for 5-7 days of effective antibiotics guided by clinical and procalcitonin findings to optimize CAP treatment.
This document summarizes information on altitude physiology and acute illnesses that can occur at high altitude. It discusses how oxygen levels decrease with increasing altitude, leading to tissue hypoxia. It describes the body's acclimatization process through various pulmonary, cardiovascular, cerebrovascular, and hematologic adaptations. The most common high altitude illnesses are acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. The document provides details on risk factors, symptoms, treatments, and prevention strategies for each of these illnesses. It emphasizes the importance of gradual ascent and allowing time for acclimatization to reduce risks.
This document discusses complications that can arise in patients with cirrhosis, including portal hypertension, ascites, hepatic encephalopathy, and hepatorenal syndrome. It provides details on the pathophysiology, clinical presentation, diagnosis, and treatment of these complications. Specifically, it focuses on portal hypertension and the development of varices, describing the risks of variceal bleeding and approaches to prevention and management. It also covers ascites extensively, explaining how and why it develops in cirrhosis and its treatment with diuretics and sodium restriction.
This document provides an overview of various food intoxications, covering bacteria such as Staphylococcus aureus, Bacillus cereus, Clostridium perfringens, and toxins including ciguatera, scombroid, tetrodotoxin, and domoic acid from contaminated shellfish. It describes the organisms and toxins involved, foods commonly associated with poisoning, symptoms, mechanisms of toxicity, and treatments for each type of food intoxication.
This document summarizes key information about peptic ulcer disease and Helicobacter pylori (H. pylori). It discusses how H. pylori eradication benefits active gastric ulcer, past duodenal ulcer, and gastric MALT lymphoma. Proton pump inhibitors, sucralfate, and misoprostol are effective in decreasing NSAID-induced ulcers. H. pylori infection is associated with gastric adenocarcinoma through a sequence of events. Triple therapy is the preferred first line treatment for H. pylori, while quadruple therapy is used for retreatment. Risk of NSAID-induced ulcers increases with corticosteroid use, anticoagulant use,
March 192015talkforresidents final03232015 (1)katejohnpunag
This document provides an update on viral hepatitis and discusses two case studies. It begins by describing a 71-year-old male presenting with jaundice who is diagnosed with acute hepatitis A infection based on a reactive HAV IgM test. It then reviews hepatitis A virus and the diagnosis and management of acute hepatitis A. The second case discusses a 26-year-old male diagnosed with chronic hepatitis B infection based on positive HBsAg, anti-HBc IgM, and HBV DNA tests. The document concludes by discussing chronic hepatitis B infection and approved treatments.
This summary reviews a journal club discussion on two phase 3 clinical trials evaluating the efficacy and safety of nintedanib in patients with idiopathic pulmonary fibrosis (IPF). The trials found that nintedanib significantly reduced the rate of decline in forced vital capacity (FVC) over 52 weeks compared to placebo. There was no consistent effect on time to first acute exacerbation or change in symptoms. Common side effects included diarrhea. While the study design was valid, questions remain regarding the clinical significance of the outcomes and relevance of factors like smoking status.
This document discusses the increasing use of therapeutic monoclonal antibodies in internal medicine. It provides examples of monoclonal antibodies used in various specialties like hematology/oncology, rheumatology, gastroenterology, and cardiology. The document outlines the historical development of monoclonal antibody technology from the 1890s to modern advances in recombinant DNA and transgenic mice that have allowed for humanized monoclonal antibodies. It notes both the benefits monoclonal antibodies have provided but also the issues of diminishing response, high costs, and sometimes unanticipated safety risks. The document concludes by predicting more monoclonal antibody approvals and emphasizes the need for rigorous evaluation of safety, efficacy and cost-effectiveness as with other medical therapies.
This document summarizes various approaches for managing type 1 diabetes, including the bionic pancreas, islet transplantation, and stem cell therapy. It notes that the bionic pancreas can help improve glucose control but has limitations like being invasive and not physiological. Islet transplantation via the Edmonton protocol can cure diabetes, but challenges remain in expanding the donor supply and improving techniques. Stem cell therapy shows promise if stem cells can be encapsulated to both differentiate into insulin-producing cells and avoid immune rejection. Overall, a cure exists on the horizon, but further progress is still needed to overcome immune issues and increase donor availability.
HFPEF is defined as clinical signs of congestive heart failure with a preserved left ventricular ejection fraction over 50%. It accounts for about half of all heart failure cases and is associated with significant mortality. The pathophysiology involves abnormal ventricular stiffness from an upward and leftward shift in the end diastolic pressure-volume relationship. This results in poor exercise tolerance and fatigue. While the exact causes are unclear, comorbidities like hypertension, diabetes and obesity likely play a key role. No treatments shown to improve outcomes for heart failure with reduced ejection fraction have been effective for HFPEF.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
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Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
1. Prostate cancer and germ cell tumors
(testicular cancer)
Kevin Courtney, MD, PhD
Assistant Professor of Internal Medicine
Division of Hematology/Oncology
UT Southwestern Medical Center
3. Educational Objectives
• To understand the mechanisms underlying the development
and progression of prostate cancer (prostatic
adenocarcinoma)
• To become familiar with current treatment options for
localized and metastatic prostate cancer and their biologic
rationale
• To become familiar with current treatment recommendations
for testicular cancer
– Seminomas
– Non-seminomatous germ cell tumors (NSGCT)
5. Prostate Cancer: Incidence and Mortality
• American Cancer Society 2015 US estimates:
• 220,800 new cases of prostate cancer - #1 (excluding
squamous or basal cell skin cancer) for men and women
combined – 85% localized disease
• 27,540 deaths - # 2 for men, # 5 for men and women
combined – metastatic disease
• Lifetime probability: 1 in 7
• Focus of presentation: prostatic adenocarcinoma (setting
aside adenocarcinoma with neuroendocrine features and
small cell carcinoma of the prostate)
Siegel RL, et al. “Cancer Statistics, 2015.” CA: A Cancer Journal for Clinicians (2015) 65:5-29.
6. Prostate Cancer Screening
• Prostate Cancer Risk Factors:
– Family History, especially 1st degree relative, relatives diagnosed at age < 65
– Black ancestry
– Age
• Large Screening Studies:
– Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer screening trial
(US) (Andriole GL, et al. (2009) NEJM, 360:1310-19; Andriole GL, et al. (2012) JNCI, 104:125-32.)
• 76,685 men aged 55-74 randomized to annual PSA x 6 years + DRE x 4 years vs. control
• 7% with FH of CaP, 4% African American
• 11% vs 10% incidence of CaP at 13 years (RR 1.12, 95% CI [1.07,1.17])
• 0.4% prostate cancer – specific mortality in each group (RR 1.09, 95% CI [0.87,1.36])
• NB: ~ 50% in control group underwent PSA testing in 6th year of screening
– European Randomized Study of Screening for Prostate Cancer (ERSPC)
(Schroder FH, et al. (2009) NEJM, 360:1320-28; Schroder FH, et al. (2012) NEJM, 366:981-90)
• 182,160 men in 7 countries randomized to PSA without DRE every 4 years (every 2 years in
Sweden)
• ~ 10% vs. 6% cumulative CaP incidence at 11 years in screening vs. control group (RR 1.63, 95%
CI [1.57,1.69])
• ~ 0.4% vs. 0.5% prostate cancer mortality at 11 years, RR 0.79, 95% CI [0.68,0.91])
• ~ 20% annual rate of PSA screening in the control group
• Need to diagnose 37 additional men through screening for 1 fewer prostate cancer deaths after
11 years of follow up for men aged 55-69
Hayes JH and MJ Barry (2014) JAMA, 311:1143-49.
8. Prostate cancer prevention studies with 5a-reductase
inhibitors
• 5a-reductase converts testosterone to the
more potent androgen
dihydrotestosterone (DHT)
• Three isoforms of 5a-reductase
• Finasteride inhibits type 1
• Dutasteride inhibits types 1 & 2
Nacusi LP and DJ Tindall. (2011) Nat Rev Urol 8:378-84.
9. Prostate cancer prevention studies with 5a-reductase
inhibitors
• Prostate Cancer Prevention Trial (PCPT) (Thompson IM, et al. (2003) NEJM, 349:215-24;
Thompson IM, et al. (2013) NEJM, 369:603-10)
– 18,880 men with PSA < 3.0 ng/mL and normal DRE randomized to finasteride 5 mg daily vs placebo
– Decreased prostate cancer incidence with finasteride (10.5% vs 14.9%) with up to 18 years of follow
up (RR 0.70; 95% CI [0.65,0.76], p<0.001)
– Increased % of Gleason 7-10 tumors with finasteride (3.5 vs 3.0%, RR 1.17, 95% CI [1.00, 1.37],
p=0.05)
– 15-year survival 78.0% vs 78.2% (HR 1.02, 95% CI [0.97,10.8], p=0.46)
• Reduction by dutasteride of prostate cancer events (REDUCE) Trial (Andriole GL, et al.
(2010) NEJM, 362:1192-202)
– 6,729 men ages 50-75 with PSA 2.5-10.0 ng/mL and negative prostate biopsy within 6 months of
enrollment randomized to dutasteride 0.5 mg daily vs placebo
– TRUS-guided prostate biopsy (10 core) at 2 and 4 years
– Relative risk reduction for prostate cancer of 22.8% (95% CI [15.2,29.8], p<0.001)
– No statistically significant difference in Gleason 7-10 tumors over 4 years, but during years 3-4, 12
dutasteride –treated vs 1 placebo-treated subjects were found to have Gleason 7-10 cancer
(p=0.003)
• No American Urologic Association (AUA) or American Society of Clinical Oncology
(ASCO) clinical practice guidelines for use of 5a-reductase inhibitors (Nacusi LP and DJ
Tindall. (2011) Nat Rev Urol 8:378-84)
10. Prostate cancer pathology: Gleason
grading
• Gleason score 2-4
essentially a thing
of the past
• > 12 Cores
Epstein JI, J Urol, 2010.
11. TNM staging system for prostate cancer
• Clinical
• T0 – no evidence of primary tumor
• T1 – Undetectable by palaption or imaging
– T1a – incidental histologic finding in < 5% of tissue resected
– T1b – incidental histologic finding in > 5% of tissue resected
– T1c – Tumor identified by needled biopsy (e.g. due to elevated PSA)
• T2 – Tumor confined within the prostate
– T2a - < ½ of 1 lobe
– T2b - > ½ of 1 lobe, not both lobes
– T2c – both lobes
• T3 – Tumor extends through the prostatic capsule
– T3a – Extracapsular extension
– T3b – Seminal vesicle invasion
• T4 – Tumor is fixed or invades adjacent structures other than SVs
• Pathologic (pT)
• pT2 – Organ confined
• pT3 – Extraprostatic extension
• pT4 – Invasion of bladder, rectum
AJCC Cancer Staging Manual, 7th Ed (2010).
12. TNM Staging System for prostate cancer
• Regional Lymph Nodes (N)
• Clinical
• NX – Not assessed
• N0 – No regional lymph nodes metastasis
• N1 – Metastasis in regional lymph nodes
• Pathologic
• pNX – Not sampled
• pN0 – None positive
• pN1 – Metastases in regional node(s)
• Distant Metastasis (M)
• M0 – None
• M1 – Distant metastasis
– M1a – Non-regional lymph node(s)
– M1b – Bone
– M1c – Other sites
AJCC Cancer Staging Manual, 7th Ed (2010).
13. Anatomic Stage / Prognostic Groups
Group T N M PSA Gleason
I T1a-c N0 M0 < 10 < 6
T2a N0 M0 < 10 < 6
T1-2a N0 M0 X X
IIA T1a-c N0 M0 < 20 7
T1a-c N0 M0 > 10 < 20 < 6
T2a N0 M0 < 20 < 7
T2b N0 M0 < 20 < 7
T2b N0 M0 X X
IIB T2c N0 M0 Any Any
T1-2 N0 M0 > 20 Any
T1-2 N0 M0 Any > 8
III T3a-b N0 M0 Any Any
IV T4 N0 M0 Any Any
Any N1 M0 Any Any
Any Any M1 Any Any
AJCC Cancer Staging Manual, 7th Ed (2010)
14. Prostate cancer staging work up
• If life expectancy < 5 years, reasonable to wait until symptoms
develop prior to treating unless high-risk disease where risk of
complications such as hydronephrosis or metastasis are
expected within 5 years
• If life expectancy > 5 years, stage and risk stratify
– Bone scan if T1 and PSA > 20 or T2 and PSA > 10 or Gleason > 8 or T3,
T4 or symptomatic
– Pelvic CT or MRI if T3, T4 or T1-T2 and probability of LN involvement >
20% by nomogram
– I scan if PSA > 7 and planning definitive treatment
• http://www.mskcc.org/cancer-care/adult/prostate/prediction-tools
NCCN Guidelines Version 3.2012
16. Prostate cancer recurrence risk
VERY LOW LOW INTERMEDIATE HIGH VERY HIGH
PSA < 10 ng/mL < 10 20-Oct > 20
and
Gleason score < 6 < 6 7 10-Aug
and
Clinical T stage < T1c T1-T2a T2b-T2c T3a T3b-T4
and
< 3 + cores
and
< 50% cancer / core
and
PSA density < 0.15
ng/mL/g
NCCN Guidelines Version 3.2012
17. Treatment Options
• Active surveillance (NB: different from observation)
• Radical prostatectomy (RP) – “open” retropubic vs robotic-assisted
laparoscopic RP
• Cryotherapy (insufficient longitudinal data for my taste)
• HIFU (not FDA approved)
• Radiation Therapy
– Brachytherapy (seeds)
– External beam – electrons
– External beam – protons
– Stereotactic radiotherapy (not yet)
• Androgen deprivation therapy and / or androgen receptor inhibitor
therapy
• Multimodality therapy
18. Very Low and Low Risk
• Active Surveillance
– PSA at least q 6 months
– DRE at least q 12 months
– Repeat biopsy at 6-18 months and at intervals thereafter
• Brachytherapy
– Contraindicated if high AUA score, prior TURP, large median lobes (where
prostate converges on bladder neck), large prostate
– Brachytherapy survival data for only about 15 years
– 125-Iodine, 103-Palladium
• EBRT
– IMRT (photons) vs protons: the “no exit dose” advantage of protons is lost
when treating deep tissue like prostate, which requires opposing beams
• Radical prostatectomy +/- PLND (yes if probability of LN
involvement > 2%)
NCCN Guidelines Version 3.2012
19. Radical Prostatectomy (RP) vs “Watchful Waiting” (WW): SPCG-4
• Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4)
• 10/89-02/99: 695 men with newly diagnosed prostate cancer stage T1b
(12%), T1c (11%), or T2 (76%) randomized to watchful waiting (348 WW)
or radical prostatectomy ( 347 RP) – prior to the era of PSA testing
• Primary endpoints: death from any cause, death from prostate cancer, risk
of metastases
• Median f/u 13.2 years
• Incidence of death at 18 years: 56.1% (RP) vs 68.9% (WW): RR 0.71 (95%
CI, 0.59 to 0.86, P<0.001)
• Number needed to treat to prevent 1 death at 18 years of f/u: 8
• Incidence of death from prostate cancer at 18 years: 17.7% (RP) vs 28.7%
(WW): RR 0.56 ((5% CI, 0.41 to 0.77, P=0.001)
Bill-Axelson A et al, (2014) NEJM, 370:932-42.
20. RP vs observation: PIVOT
• Prostate Cancer Intervention Versus Observation Trial (PIVOT):A Randomized
Trial Comparing Radical Prostatectomy Versus Palliative Expectant
Management for the Treatment of Clinically Localized Prostate Cancer
(NCT00007644)
• 731 patients, < 75 years old, clinically localized prostate cancer (stage T1-
T2NxM0, any grade, PSA < 50 ng/mL) enrolled between 1994-2010 – initiated
in the era of PSA testing
• Median age 67
• 75% detected by screening
• Median PSA 7.8
• Median f/u 10 years
• No significant difference in overall mortality (primary endpoint) or prostate
cancer-specific mortality through > 12 years of f/u
• Subset of patients with PSA > 10: RP associated with improved all-cause
mortality (P = 0.04 for interaction)
Wilt TJ, et al. (2012) NEJM, 367:203-13.
21. Intermediate risk
• Androgen suppression if life expectancy < 10 years
• EBRT +/- neoadjuvant/concommitant/adjuvant ADT (4-6
months) +/- brachytherapy
• RP +/- PLND (if predicted probability of LN involvement > 2%)
NCCN Guidelines Version 3.2012
22. High risk prostate cancer
• RP + PLND (with reasonable probability of adjuvant or salvage
RT +/- ADT)
• EBRT + 2-3 years ADT (6 months in select cases)
NCCN Guidelines Version 3.2012
26. Endocrine Axis in Prostate Cancer
Hypothalamus
Pituitary
Adrenals
Testes
Prostate
ACTH
LHRH (pulsatile)
LH
T
T DHT
AR
X
X
X
27. Methods of androgen deprivation therapy (ADT)
• Orchiectomy
• LHRH agonist / antagonist
• Estrogen (cardiovascular and
thromboembolic toxicity)
• Antiandrogen
• CYP17 inhibition in the adrenal gland
• Combined androgen blockade (CAB)
• 5a-reductase inhibition to impair
conversion of T to DHT (as part of
CAB)
Hypothalamus
Pituitary
Adrenals
Testes
Prostate
ACTH
LHRH (pulsatile)
LH
T
T DHT
AR
X
X
X
28. Androgen deprivation therapy (ADT) to treat
metastatic prostate cancer
• ADT leads to objective responses in 80-90% of men
(castration-sensitive prostate cancer)
• Highly variable duration of efficacy
• Median time to prostate cancer progression with ADT: 2-3
years
29. Castration-sensitive metastatic prostate cancer
• ADT (GnRH agonist + initial anti-androgen to offset transient
androgen surge OR GnRH antagonist or orchiectomy) – until
June 2014 was the standard of care for all patients
• In emergent setting, orchiectomy or ketoconazole 400 mg po
tid + hydrocortisone (30 mg qam, 10 mg qpm) and confirm
testosterone < 50 ng/mL prior to initiating GnRH agonist
therapy
• No convincing evidence for survival benefit for combined
androgen blockade with GnRH agonist + first-generation anti-
androgens
30. ADT side effects
• Hot flashes
• Loss of Libido
• Decreased sexual performance
• Gynecomastia
• Weight gain
• Decreased muscle mass
• Accelerated osteoporosis
• Increased DM
• Altered lipid profile
• Increased CV risk
31. ADT and osteoporosis
• Bisphosphonates (oral or iv) have been demonstrated to prevent bone loss
associated with ADT (pamidronate, zoledronic acid, alendronate)
• Denosumab: a fully human monoclonal antibody against receptor activator of
nuclear factor-κB ligand (RANKL)
• Patients receiving > 12 months ADT for non-metastatic prostate cancer with high
risk for osteoporosis (age > 70 or low baseline bone mineral density or h/o
osteoporotic fracture)
• 734 patient per arm randomized to placebo or denosumab 60 mg sq q 6 mos
Smith MR et al, NEJM, 2009.
32. Combining castration therapy with other treatments in
castration-sensitive prostate cancer
• ADT – until June 2014 was the standard of care for all patients
with metastatic castration-sensitive prostate cancer
• Earlier study with docetaxel failed to show significant survival
benefit for patients with castration-sensitive metastatic
prostate cancer – most with “low volume” disease (Gravis G, et al.
(2013) The Lancet Oncology; 14:149-58.)
• Data in support of combining ADT with 6 cycles of docetaxel +
prednisone presented at ASCO Annual Meeting 2014:
ChemoHormonal Therapy Versus Androgen Ablation
Randomized Trial for Extensive Disease in Prostate Cancer
(CHAARTED)
33. Castration-sensitive metastatic prostate cancer:
CHAARTED study comparing ADT to ADT + docetaxel (D)
with prednisone
• 1:1 randomization to ADT alone or ADT + D dosed
75mg/m2 every 3 weeks for 6 cycles within 4 month of
starting ADT
• Primary Endpoint: Overall Survival
• 790 men: ADT N=393; ADT + D: N=397
• High Volume Disease: 64% on ADT and 67% on ADT + D
• 1 death due to ADT + D, 0 deaths from ADT alone
Sweeney C, et al. (2014) J Clin Oncol 32:5s, (suppl; abstr LBA2).
34. Primary endpoint: Overall survival
Presented By Christopher Sweeney at 2014 ASCO Annual Meeting
Adding docetaxel to ADT improves survival in men with
metastatic castration-sensitive prostate cancer
35. OS by extent of metastatic disease at start of ADT
Presented By Christopher Sweeney at 2014 ASCO Annual Meeting
Adding docetaxel to ADT improves survival in men with
metastatic castration-sensitive prostate cancer
36. Castration-resistant prostate cancer
• Majority of patients with metastatic prostate cancer
experience disease progression within 2-3 years despite
surgical or chemical castration
• CRPC is principally responsible for prostate cancer mortality: <
20% of patients with CRPC survive beyond 3 years
• “Castration resistant” “Androgen independent”
37. Mechanisms of prostate cancer progression and
castration resistance: targets for therapy
• Persistent androgen signaling despite castration therapy
• Microtubule polymerization
• Immune escape
• Interactions with bone microenvironment
39. Sites of inhibition of androgen biosynthesis and
androgen-mediated signaling
• Castration therapy: depletes the 90-95% of circulating T
produced by testes
• 25% of circulating DHT produced by testes – the more
relevant androgen for mCRPC
• Adrenal glands and prostate cancer cells produce androgens
40. Inhibition of CYP17 (17a-hydroxylase / 17,20-lyase) to
impair androgen synthesis: abiraterone acetate
• Abiraterone acetate: Irreversible inhibitor of CYP17 (17a-hydroxylase /
17,20-lyase)
• Predominant toxicities from mineralocorticoid excess due to loss of
negative feedback on ACTH: hypertension, hypokalemia, edema
• Prednisone 5 mg twice daily co-administered with abiraterone acetate
1000 mg daily to suppress symptoms of secondary hyperaldosteronism
Acquired de novo androgen synthesis by the testis and extra-gonadal sources in mCRPC
Figure from Reid AHM, et al. (2009) Nat Clin Pract Urol;5:610-20
41. Abiraterone acetate improves overall survival (OS) for
men with mCRPC
• I. Post-docetaxel trial: Randomized, placebo-controlled phase III study
compared abiraterone acetate 1000 mg daily + prednisone 5 mg bid to
placebo + prednisone 5 mg bid 2:1 (779 vs 398) for treatment of men with
mCRPC who had received prior docetaxel chemotherapy
• Primary endpoint: OS
• Improved OS of 14.8 vs 10.9 mos (HR 0.65, P < 0.001) with median f/u of
12.8 mos
• II. Pre-docetaxel trial: Randomized, double-blind, phase III study of
abiraterone 1000 mg daily + prednisone 5 mg bid vs placebo + prednisone
in men with metastatic CRPC
• 546 vs 542 subjects
• Co-Primary endpoints:
– Radiographic PFS
– OS
• Median PFS 16.5 vs 8.3 months, HR 0.53, P<0.001
• Median OS 35.3 mos vs 30.1 mos, HR 0.79
de Bono JS, et al. NEJM 2011; 364:1995-2005.
Ryan CJ, et al. NEJM 2013; 368:138-148
43. Androgen receptor signaling
Friedlander TW and Ryan CJ. Urol Clin N Am 2012; 39:453-464.
The presence of testosterone (T) or dihydrotestosterone (DHT) causes dissociation of HSP, dimerization, and
phosphorylation (P) of the AR and translocation to the nucleus where the AR binds to an ARE,causing
recruitment of DNA transcriptional machinery and gene transcription. (Adapted from Li J, Al-Azzawi F.
Mechanism of androgen receptor action. Maturitas 2009;63:142–8; with permission.)
44. Nonsteroidal AR Antagonists
- Block agonist access to the AR ligand-binding domain
-Three 1st generation anti-androgens used in standard practice
-Bicalutamide > Nilutamide > Flutamide
-All have relatively poor binding affinity for AR compared to
endogenous agonists T and DHT
-Partial agonist activity
-Some patients will temporarily benefit from anti-androgen
withdrawal
-No established overall survival benefit for patients with mCRPC
45. Antagonists of androgen receptor function:
enzalutamide
• Enzalutamide is an AR signaling inhibitor
• Derived from chemical screen targeting AR-overexpressing
prostate cancer model
• Impairs AR nuclear translocation, DNA binding, and co-
activator recruitment
• Increased affinity for AR vs bicalutamide
• Pure AR antagonist
Tran C, et al. Science 2009; 324:787-790
Scher HI, et al. NEJM 2012; 367:1187-1197
46. Antagonists of androgen receptor function:
enzalutamide
• AFFIRM: phase III RCT of men with mCRPC following docetaxel
• Enzalutamide 160 mg daily (800) vs placebo (399)
• Median OS: 18.4 vs 13.6 mos (HR 0.63, P<0.001)
• PREVAIL: phase III study vs placebo in chemotherapy –naïve
patients: OS and rPFS were co-primary endpoints
• 1,717 men were randomized 1:1 to enzalutamide vs placebo
• 81% reduction in rPFS (65% vs 14%, HR 0.19, P<0.001) and
29% reduction in risk of death (72% vs 63% survival, HR 0.71,
95% CI 0.60-0.84, P<0.001) with enzalutamide treatment
Scher HI, et al. NEJM 2012; 367:1187-1197.
Beer TM, et al. NEJM 2014; 371:424-433.
47. Microtubule stabilization as a rational therapeutic
target in prostate cancer
• Prostate cancer cells:
long doubling times, low
fraction of dividing cells
– is chemotherapy
relevant?
• Microtubules: dynamic
polymers of a- and b-
tubulin heterodimers
• Essential for regulation
of chromosomal
segregation
• Role in AR nuclear
translocation
• Inhibition can increase
nuclear accumulation of
AR-suppressor FOXO1
• Inhibition by taxanes can
decrease AR expression
Mistry SJ and WK Oh. (2013) Mol Cancer Ther; 12:555-66.
48. Microtubule stabilizers: docetaxel
• TAX 327: Phase III study of 1006 men with mCRPC received prednisone 5
mg bid and randomized to docetaxel 75 mg/m2 q 3 weeks vs 30 mg/m2
weekly for 5/6 weeks vs mitoxantrone 12 mg/m2 q 3 weeks
• Medians OS: 18.9 mos vs 17.4 mos vs 16.5 mos (HRf 0.76, p = 0.009 for q 3
week docetaxel)
• Increased PSA response rate, decreased pain, and improved QoL with
docetaxel
• SWOG 99-16: Phase III study of men randomized to 21-day cycles of 280
mg estramustine (estradiol-linked nitrogen-mustard) tid days 1-5 and 60
mg/m2 docetaxel on day 2 and 60 mg dexamethasone in 3 divided doses
pre-docetaxel vs. mitoxantrone 12 mg/m2 day 1 plus prednisone 5 mg bid
• Median OS 17.5 vs 15.6 mos, HR 0.80, P=0.02
• Improved median TTP and PSA response rate with docetaxel
Tannock IF et al., NEJM 2004; 351:1502.
49. Microtubule stabilizers: cabazitaxel
• Cabazitaxel: docetaxel derivative with decreased affinity for P-glycoprotein
efflux pump and improved ability to cross blood-brain barrier
• TROPIC phase III study: 755 men with mCRPC following docetaxel
treatment treated with prednisone 10 mg daily and randomized to 25
mg/m2 cabazitaxel q 3 weeks vs mitoxantrone 12 mg/m2 q 3 weeks
• Median OS: 15.1 mos vs 12.7 mos, HR 0.70 (95% CI 0.59-0.83, p<0.001)
• 82% in cabazitaxel group with grade > 3 neutropenia, 6% grade > 3
diarrhea, 8% febrile neutropenia
• Growth factor support required
• FDA mandated non-inferiority study of 20 mg/m2 vs 25 mg/m2
• FDA mandated 20 mg/m2 or 25 mg/m2 vs docetaxel
de Bono JS, et al. Lancet 2010; 376:1147
50. Immunotherapy for CRPC
• Immune escape is a hallmark of
cancer
• Increased activity of
immunosuppressive T regulatory
cells (Treg), myeloid-derived
suppressor cells (MDSC)
• Upregulation of T-cell inhibitory
checkpoint pathways (CTLA-4,
PD-1)
• Impaired tumor antigen
presentation by antigen
presenting cells (APCs)
• Prostate-cancer specific antigens
are non-essential: attractive
therapeutic targets
Sipuleucel-T
Prostate cancer
cell
PSA PAP
T cell
Dendritic
cell
CTLA-4
51. Sipuleucel-T for metastatic CRPC
• Active cellular immunotherapy approved for treatment of
asymptomatic or minimally symptomatic men with mCRPC
• CD45+ APCs collected by leukapheresis and pulsed with fusion
construct of prostatic acid phosphatase (PAP) and
granulocyte-macrophage colony-stimulating factor (GM-CSF)
called PA2024
• 3 leukapheresis procedures each separated by 2 weeks, with
reinfusion of sipuleucel-T 3 days after each leukapheresis
Sonpadve G and Kantoff PW. Urol Clin N Am 2012; 39:465-481.
Kantoff PW, et al. NEJM 2010; 363:411-422.
52. Sipuleucel-T for metastatic CRPC
• Two “identically designed” phase III, double-blind, placebo-
controlled trials (D9901, D9902A) of 225 patients (147 sipuleucel-T
vs 78 placebo) failed to demonstrate improvement in the primary
endpoint (TTP), but showed apparent improvement (D9901) and
trend toward improvement (D9902A) in median OS
• IMPACT: phase III trial of men with asymptomatic or minimally
symptomatic metastatic CRPC with primary endpoint of OS
• Randomized 2:1 (n = 512) to sipuleucel-T vs APCs not pulsed with
PA2024
• Improved median OS 25.8 vs 21.7 mos, HR 0.77; P = 0.2
• No delay in first TTP
• Few PSA declines or objective responses
Small EJ, et al. JCO 2006; 24:3089-3094
Higano CS, et al. Cancer 2009; 115:3670-3679
Kantoff PW, et al. NEJM 2010; 363:411-422
53. Promising immunotherapies under investigation
• Phase III study of ipilimumab (anti-
CTLA-4) in men with previously
treated CRPC showed no
improvement in OS, but improved
PFS; ongoing study in
chemotherapy-naïve patients
• Ongoing PROSTVAC-VF TRICOM
phase III study: poxvirus-based
vaccine therapy where
recombinant vaccinia and fowlpox
vectors express PSA and
costimulatory molecules (TRICOM)
Sonpadve G and Kantoff PW. Urol Clin N Am 2012; 39:465-81.
Suzman DL and Antonarakis ES. Ther Adv Med Oncol 2014; 6:167-79.
Prostate cancer
cell
PSA
T cell
CTLA-4
PROSTVAC-VF TRICOM
Ipilimumab
54. Prostate cancer bone tropism and bone-targeted
therapies
• ~ 90% of patients with metastatic
prostate cancer develop bone
metastases
• Zoldedronic acid (bisphosphonate)
and denosumab (RANKL inhibitor)
approved in mCRPC to reduce SREs
• Strontium-89 and samarium-153
lexidronam (beta-emitters) approved
to provide palliation for painful bone
metastases
Pal SK, Lewis B, and Sartor O. (2012) Urol Clin N Am; 39:583-91.
Keller ET, et al. (2001) Cancer Metast Rev; 333-49.
Model of cross-talk between
prostate cancer and bone
microenvironment: a “vicious
cycle” where CaP cells stimulate
osteoclasts to break down bone,
releasing growth factors that
support proliferation of CaP, which
releases factors supporting
osteoblast proliferation/survival.
55. Radium-223 dichloride preferentially targets osteoblastic
metastases
• Bone-targeted a-emitter
• Effective at inducing DNA double-strand breaks
• Emission over a short (microns) path-length vs. b-radiation (millimeters)
• Calcium mimic with preferential uptake in osteoblastic metastases vs. normal bone
Imaging Radium-223
Cheetham PJ and DP Petrylak (2012) Oncology; epub.
Pandit-Taskar N, et al. (2014) J Nucl Med; 55:268-74.
56. Bone-targeted therapies: radium-223 chloride
• ALSYMPCA:
• Randomized phase III study of patients with mCRPC
previously treated with, unfit for, or refusing docetaxel
• Symptomatic CRPC with > 2 bone lesions with no visceral
metastases or bulky (>3 cm) lymph nodes
• 921 patients randomized 2:1 to Ra-223 vs placebo
• 6 injections 50 kBq/kg IV q 4 wks vs placebo
• Median OS: 14.9 vs 11.3 mos, HR 0.70, 95% CI 0.58-0.83,
P<0.001
• Prolonged time to 1st SRE: 15.6 vs 9.8 mos, HR 0.66, 95% CI
0.52-0.83, P<0.001
• Low rates of Ra-223-associated myelosuppression
Parker C, et al. NEJM 2013; 369:213-223.
57. Agent Action Year Primary Endpoint
Estramustine Nitrogen mustard-estradiol conjugate 1981 Disease responses
Strontium-89 Radiopharmaceutical 1993 Pain palliation
Mitoxantrone + prednisone Type II topoisomerase inhibitor 1996 Pain palliation
Samarium-153 Radiopharmceutical 1997 Pain palliation
Zoledronic acid Bisphosphonate 2002 Reduced SRE
Docetaxel + prednisone Microtubule stabilizer 2004 Overall Survival
Sipuleucel-T Cell-based immunotherapy 2010 Overall Survival
Cabazitaxel + prednisone Microtubule stabilizer 2010 Overall Survival
Denosumab mAb to RANKL 2010 Reduced SRE
Abiraterone + prednisone CYP17 inhibitor 2011, 2012* Overall Survival
Enzalutamide AR antagonist 2012, 2014* Overall Survival
Radium-223 Radiopharmaceutical 2013 Overall Survival
Currently approved therapies for metastatic CRPC
SRE, skeletal-related event; mAb, monoclonal antibody; RANKL, receptor of nuclear factor kappa-B ligand; * dates are for FDA
approval for treatment of patients post- and pre-docetaxel, respectively
Modified from Pal SK, Lewis B, and Sartor O. Urol Clin N Am 2012; 39:583-591.
58. Mechanisms of resistance to current therapies:
potential therapeutic targets?
• AR mutations, overexpression, and splice variants
• Glucocorticoid receptor (GR) upregulation
• 3bHSD mutation
• Alternative signaling pathways (eg: PI3K / AR crosstalk;
Met/VEGFR)
59. Areas of ongoing investigation
• Optimal sequencing of available therapies?
• Combination therapies?
• Earlier interventions targeting potential future mechanisms of
resistance?
60. My approach to treatment of metastatic prostatic
adenocarcinoma
Castration-sensitive:
Start with GnRH-agonist or antagonist (orchiectomy or ketoconazole +
hydrocortisone if emergent castration required) if low-volume disease and discuss
findings of CHAARTED study
Start with ADT + 6 cycles of docetaxel w/prednisone if high-volume disease
Castration-resistant:
Sipuleucel-T if asymptomatic / minimally symptomatic: monitor clinical and
radiographic response (pre- or post-docetaxel, but appears to be of greatest
efficacy early
Abiraterone plus prednisone (pre- or post-docetaxel)
Enzalutamide (pre- or post-docetaxel)
Radium-223 if symptomatic bone-only metastatic disease (pre- or post-docetaxel)
Docetaxel plus prednisone (earlier if symptomatic)
Cabazitaxel plus prednisone with growth factor support
Clinical trials warrant consideration at any point from time of diagnosis
61. Germ Cell Tumors (Testicular
Cancer)
Acknowledgement: Christopher Sweeney, MBBS,
Associate Professor of Medicine, Harvard Medical
School ,
Clinical Director, The Lank Center for Genitourinary
Oncology, Dana-Farber Cancer Institute
62. Testicular Cancer: Incidence and Mortality
• American Cancer Society 2015 US estimates:
• 8,430 new cases of testis cancer
• 380 testis cancer deaths
• > 90% of patients with germ cell tumors are cured
• 70-80% of patients with advanced tumors treated with
chemotherapy are cured
Siegel RL, et al. “Cancer Statistics, 2015.” CA: A Cancer Journal for Clinicians (2015) 65:5-29.
65. Seminoma
• Tumor markers:
– Can make beta human chorionic gonadotropin (bHCG) and lactate
dehydrogenase (LDH)
– Cannot make alpha-fetoprotein (AFP)
• No teratoma component
• Significant role for radiation
• Less role for surgery than NSGCT
66. NSGCT
• Histologies
– Embryonal carcinoma
– Yolk sac tumor
– Teratoma
• Chemotherapy insensitive (surgery)
• Mature or immature
• Can de-differentiate (sarcoma, carcinomas)
– Choriocarcinoma
– Seminoma
• Tumor markers
– can make AFP, LDH, and bHCG (or none)
67. Seminoma vs NSGCT
Seminoma
• More likely to be localized
at presentation
• Very radiosensitive
• Tumor markers less useful
• More indolent and longer
natural history
– Longer median time to
relapse
– More common late relapses
NSGCT
• More likely to have
metastasized at
presentation
• Not radiosensitive
• Tumor markers useful
indicator of viable tumor
• More likely hematogenous
spread
68. Risk factors
• Cryptorchidism
• History of GCT
• Intratubular germ cell neoplasia
• Family history – specific genetic factors unknown
• HIV infection – much higher risk for seminoma
• Klinefelter syndrome (mediastinal GCT)
• Down syndrome
• Androgen insensitivity syndromes and mixed gonadal
dysgenesis
69. Patterns of GCT lymphatic spread
• Primary drainage of testis: to embryological origin in the
retroperitoneum
• Tumors of right testicle
– Interaortocaval lymph nodes
– Precaval and preaortic lymph nodes
– Contralateral spread more common
• Tumors of left testicle
– Para-aortic and pre-aoritc nodes
– Interaortocaval nodes
• Aberrant spread: cryptorchidism, inguinal surgery, biopsy
70. Tumor markers
• AFP
– T1/2 5 days if no cancer post-orchiectomy
– Log reduction after each cycle of chemotherapy
– False +: liver, familial
• bHCG
– T1/2 24 hours if no cancer post-orchiectomy
– Log reduction after each cycle of chemotherapy
– False +: LH (cross reacts), marijuana, pituitary secretion
• LDH
– Multiple enzymes
– Correlates with tumor burden / proliferation rate
– Other causes (non-specific)
71. Work up of suspicious testicular mass
• H&P: painless solid testicular mass is pathognomomic
• Labs: Tumor markers (AFP, bHCG, LDH), chemistry
profile
• CXR
• Testicular ultrasound
• Discuss sperm banking
• Radical inguinal orchiectomy
• Consider inguinal biopsy if
– Suspicious US for intratesticular abnormalities
– Cryptorchid testis
– Marked atrophy
72. Post-orchiectomy workup
• CT abdomen/pelvis
• CT chest if + CT A/P or abnormal CXR
• Repeat tumor markers (TNM staging based on post-
orchiectomy values)
• Brain MRI if clinically indicated
• Bone scan if clinically indicated
• Discuss sperm banking
• PFTs if BEP chemotherapy planned
73. Risk classification for advanced germ cell
tumors
Seminoma
• Good risk: any primary site,
no non-pulmonary visceral
metastases, any bHCG or
LDH
• Intermediate risk: non-
pulmonary visceral
metastases
NSGCT
• Good risk: testicular or
retroperitoneal primary, no
non-pulmonary visceral
mets, and low tumor
marker levels
• Intermediate risk: same as
good risk but intermediate
tumor marker levels
• High risk: mediastinal
primary or non-pulmonary
visceral mets or high tumor
marker levels
75. Treatment: seminoma stage I (localized disease)
• Stage IA (pT1N0M0S0), IB (pT2-4N0M0S0)
– Surveillance (pT1-pT3) or
– Carboplatin x 1 or 2 cycles or
– Radiation therapy
• Stage IS (no mets, persistent + markers)
– Radiation therapy
76. Treatment: seminoma stage II (regional lymph
node involvement)
• Stage IIA
– RT (preferred) or Chemotherapy for multiple + LNs
(BEP x 3, EP x 4)
• Stage IIB
– Chemotherapy (preferred; BEP x 3, EP x 4) or RT in
select non-bulky cases
• Stage IIC - chemotherapy
– Good risk: BEP x 3 or EP x 4
– Intermediate risk: BEP x 4
77. Treatment: seminoma stage III – distant
metastasis
• Stage III – chemotherapy
– Good risk: BEP x 3 or EP x 4
– Intermediate risk: BEP x 4
78. Treatment: localized NSGCT
• Stage IA
– Surveillance or
– Nerve-sparing RPLND
• Stage IB
– Nerve-sparing RPLND or
– Chemotherapy (BEP x 1 or 2 cycles) or
– Surveillance (T2 only)
• Stage IS
– Chemotherapy (BEP x 3 or EP x 4)
79. Treatment of metastatic NSGCT: risk-
stratification more relevant than stage*
• Stage IIA
– Negative tumor markers: RPLND or BEP x 3 or EP x 4
– Positive tumor markers: chemotherapy*
• Stage IIB
– Negative markers: BEP x 3 or EP x 4 or RPLND
– Positive tumor markers: chemotherapy
• Stage IIC, IIIA, IIIB, IIIC
– Chemotherapy* (EP x 3 or BEP x 4 or VIP x4
depending on both disease risk and disease stage)