This document discusses evaluation and management of prostate-specific antigen (PSA) recurrence after radical prostatectomy for localized prostate cancer. It defines PSA recurrence as a rising PSA level after surgery without clinical or radiographic evidence of disease. A PSA level of 0.2 ng/mL or higher is commonly used to define recurrence. Factors like preoperative PSA, Gleason score, and pathological stage can predict recurrence risk. While tests cannot reliably determine the site of recurrence at low PSA levels, treatment may involve observation, salvage radiation for presumed local recurrence, or hormone therapy for presumed metastases. The document outlines guidelines for these treatments and concludes that patients can be stratified into low, intermediate, and high risk groups
Presentación realizada por el Dr. Juan Carlos Vázquez García, R1 de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
Presentación realizada por el Dr. Juan Carlos Vázquez García, R1 de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
Presentación realizada por el Dr. Cesar Augusto Herrera Méndez, R1 de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
Presentación realizada por el Dr. Cesar Augusto Herrera Méndez, R1 de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
Presentación realizada por el Dr. Juan Carlos Vázquez García, R1 de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
Presentación realizada por el Dr. Cesar Augusto Herrera Méndez, R1 de la especialidad de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
Dr. Federico Navarrete. Módulo Tórax.
R2 Imagenología Diagnóstica
Tema relevante en el estudio de pacientes con Cirrosis.
Basado en artículo de Radiographics.
Presentación realizada por el Dr. Juan Carlos Vázquez García, R1 de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
Presentación realizada por el Dr. Cesar Augusto Herrera Méndez, R1 de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
Dres. Héctor Domínguez Hernández y Victor Hugo Cruz
Residentes de Imagenología
Dan Inicio al módulo de musculoesquelético.
Anatomía básica de tobillo por ultrasonido.
Presentación realizada por el Dr. Juan Carlos Vázquez García, R1 de Imagenología Diagnostica y Terapéutica del Hospital Regional de Alta Especialidad de la Península de Yucatán.
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.
Radical prostatectomy in high serum psa values a surgical expertise againstVijay Elipay
This presentation is prepared for a medical debate for one of my clients, as such I couldn't disclose his name. However, I thought it might be useful to other medicos who might be looking for it or relevant to it, the same way slideshare helped me find some useful presentations earlier.
- Vijay
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
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
MANAGEMENT OF BIOCHEMICAL RECURRENCE AFTER RADICAL PROSTATECTOMY & RADIATION THERAPY
1. GAURAV NAHAR
DNB UROLOGY(STD.)
MMHRC, MADURAI
Evaluation and Management
of Prostate-specific Antigen
Recurrence After Radical
Prostatectomy for Localized
Prostate Cancer
2. INTRODUCTION
Radical prostatectomy(RP)- the primary curative
procedure for the treatment of localized prostate
cancer.
Approximately one third of all patients still
demonstrate disease recurrence after surgery.
For the majority, first sign of recurrent disease is a
rising PSA level without either clinical or
radiographic evidence of disease—the so-called ‘PSA
recurrence’ or ‘biochemical failure’.
3. Rising PSA levels after RP may be due to 1. a local
recurrence in the prostatic bed, 2. occult distant
metastases or 3. a combination of both.
Quite difficult to identify recurrent lesions accurately
at an early stage of PSA recurrence.
Local recurrence may be cured using salvage
external-beam radiotherapy, whereas distant
metastases require systemic hormonal therapy.
4. Majority of patients with PSA recurrence after RP-
relatively young and healthy; hence treatment for
PSA recurrence should aim not only to improve
survival but also to preserve the quality of life.
5. PSA is a glycoprotein produced primarily by
epithelial cells lining the acini and ducts of prostate
gland.
Serum PSA levels are normally very low.
Elevated serum PSA level-d/t disruption of normal
prostatic architecture- an important marker of many
prostate diseases- BPH, prostatitis, and prostate
cancer.
6.
7.
8.
9. Treatment options
T1/T2 disease
• The standard approaches for men with organ-
confined T1/T2 prostate cancer are
– radical prostatectomy (RP)
– external beam radiation therapy (EBRT),
– brachytherapy, and
– active surveillance
Choice of therapy is largely a matter of patient
preference.
No evidence that cure rate is different with RP,
EBRT, or brachytherapy when patients are stratified
based upon prognostic characteristics.
10. Intermediate- or high-risk T1/T2 prostate cancer
For these patients definitive treatment rather than
active surveillance
Intermediate-risk disease- EBRT, brachytherapy, or
RP
High-risk disease- ADT plus EBRT or RP plus
adjuvant EBRT
11. Advantages of main treatment for early prostate
cancer: EBRT
Effective long term control with high dose Rx
Low risk of urinary incontinence
Wide range of ages
When combined with hormonal therapy, offers a
chance of cure in high-risk of disease
Treatments can eradicate extension of tumor beyond
the margins of prostate
12. Advantages of main treatment for early prostate
cancer: Brachytherapy
Cancer control rate equal to surgery and EBRT for
organ-confined tumor
Quicker than EBRT (one treatment)
Available for cure in a wide range of ages and in
those with comorbidities
13. Advantages of main treatment for early
prostate cancer: Radical Prostatectomy
Effective long-term cancer control
Prediction of prognosis can be more precise based on
pathologic features in specimen
Pelvic lymph node dissection is possible through the
same incision
PSA failure easy to predict
14. Advantages of main treatment for early
prostate cancer: Active Observation
Reduces overtreatment
Avoids or postpones treatment-associated
complications
Has no effect on work or social activities
15. Contraindications to main treatment options for
early prostate cancer
RP: High operative risk, ‘medical age’ of 70 or more,
neurogenic bladder, morbid fear of surgery
Active observation: High grade tumors, pt
preference, expected survival of 10 or more years.
16. DEFINITION OF PSA RECURRENCE
AFTER RP
PSA usually reaches an undetectable level within 21–
30 days after radical prostatectomy.
Persistently detectable or subsequent rising serum
PSA levels (typical limit of detection is 0.05 ng/ml)
after RP indicate either residual prostate cancer or
recurrence.
17. AUA Guideline Update Panel recommended using a
cut point ≥ 0.2 ng/mL, with a second confirmatory
level ≥ 0.2 ng/mL, to define surgical failure.
Memorial Sloan-Kettering Cancer Center (MSKCC)
demonstrated best cut point to predict the
probability of metastatic progression was > 0.4
ng/mL, followed by another rise.
18. EAU guidelines on prostate cancer: serum PSA
level of >0.2 ng/ml- residual or recurrent disease &
major risk of progression when the PSA level
reaches 0.4 ng/ml.
Prostate-Specific Antigen Working Group
recommendation: PSA value ≥ 0.4 ng/mL, 8 weeks
or more after RP and rises on a subsequent
measurement.
Eight weeks is ample time to allow PSA levels to
clear, given a half-life of 2 to 3 days.
19. EAU guidelines for follow-up of prostate cancer after
treatment with curative intent, PSA measurement +
DRE at 3, 6 and 12 months after treatment, then
every 6 months until 3 years, and thereafter
annually.
45% developed recurrence in first 2 years after RP,
76% within first 5 years, and the remaining 23% >5
years after surgery. Hence a prolonged PSA follow-
up is necessary after RP.
20. No definite consensus regarding PSA cut-off point
for defining PSA recurrence after RP, a PSA level of
0.2 ng/ml on conventional assays is the most
acceptable cut-off point for PSA recurrence based on
a clinical point of view.
21. PSA RECURRENCE AFTER RADIATION
THERAPY
Biochemical failure after radiation therapy (ASTRO)
as three consecutive PSA rises, optimally separated
by 3 months between measurements, beginning at
least 2 years after the start of radiation therapy.
Time of failure is midpoint between the nadir and
the first confirmed rise, or any rise significant
enough to trigger therapy.
22. ASTRO Phoenix Criteria recommend that
biochemical failure be defined as a PSA rise of 2
ng/mL above the post-treatment nadir, whether or
not the patient received hormonal therapy in
conjunction with radiation therapy.
The date at which that level was reached would be
the date of relapse.
23. FACTORS PREDICTING PSA
RECURRENCE AFTER RP
Local extent of disease on a DRE (T stage), serum PSA
level and Gleason score from prostate biopsy
specimens- all are important factors for predicting
pathological stage (pT stage) for clinically localized
prostate cancer.
Partin Tables combine clinical stage, Gleason score,
preop PSA level to predict pathologic stage:
1. Organ confined
2. Extracapsular (extraprostatic) extension
3. Seminal Vesicle invasion
4. Lymph node mets
25. Using Partin tables, information regarding the
probability of various pathological stages, such as
organ-confined disease, extraprostatic extension,
and seminal vesicle or lymph node involvement, is
provided pre-operatively.
Such pathological stages can serve as an excellent
surrogate for outcome after RP.
26. For majority of patients, biochemical relapse occurs
far earlier than the development of radiographically
evident findings or findings on physical examination
or by biopsy.
Low pretreatment PSA levels, lower-grade tumors,
low clinical or pathologic staging, late time from
definitive local therapy to PSA relapse, and long
PSADTs generally indicate a low likelihood of
developing distant radiographically apparent
metastases.
27. Serum PSA level between 10 and 20 ng/ml-
intermediate risk for PSA recurrence, while serum
PSA level >20 ng/ml represent a high-risk for
developing PSA recurrence after RP.
Gleason grade ≥4, or a Gleason score >7 on RP
specimens is predictive of a high-risk for PSA
recurrence.
28. Histopathological determinants and molecular
markers have been evaluated to predict PSA
recurrence and survival.
p53 tumor suppressor gene expression, bcl-2
protooncogene expression, expression of Ki-67 &
p27, apoptotic index, DNA ploidy and tumor
angiogenesis (microvessel density):- all are possible
predictive factors of PSA recurrence after RP.
29. TESTS TO DETERMINE SITE OF
RECURRENCE
Current methods of detecting recurrence whether in
prostatectomy bed, an irradiated gland, or metastatic
sites such as bone or lymph nodes, are of very limited
value.
Bone Scintigraphy:
Bone scintigraphy will only detect metastatic disease
that interferes with normal osteoblast/osteoclast
interactions to produce abnormal bone deposition.
Areas of marrow involvement that do not impact bone
metabolism will remain undetected.
30. No single PSA value predicts scan positivity,
although PSAs will be well above 20 to 30 ng/mL
before bone scintigraphy reflects metastatic disease.
Tracer uptake in areas of trauma, infection, or
inflammation can easily be mistaken for metastatic
disease.
31. CT SCAN:
CT scans are not sufficiently sensitive for detecting
local recurrence until increasing rate of PSA becomes
>20 ng/ml per year.
CT is suboptimal for detection of metastasis as it has
a lower limit of detection of 0.5 cm & the scans are
nonspecific, making it difficult to distinguish scar
tissue or fibrosis from tumor.
32. Sensitivity & specificity of MRI and MR
spectroscopy are improving; most useful for
detecting nodal and bony metastases. But not
sufficiently useful early in the course of PSA
recurrence.
Positron emission tomography (PET-CT
using FDG, 18F choline, 11C choline, 11C acetate), a
biochemical imaging modality, still investigational,
cannot accurately distinguish post-operative scars
from local recurrence.
33. PROSTASCINT (Antibody based imaging/
Immunoscintigraphy):
Approved by the U.S. FDA to detect occult metastatic
disease in early prostate cancer, also indicated for a
rising PSA and a negative or equivocal standard
metastatic evaluation when there is a high clinical
suspicion of metastatic disease.
Based on a murine antibody, 7E11, combined with
indium-111 to target the internal domain of PSMA, a
transmembrane type II glycoprotein found on normal
prostate tissue and prostate cancers.
34. PREDICTING LOCAL Vs SYSTEMIC
RECURRENCE
Combination of Gleason score, pathological stage
and serum PSA velocity 1 year after surgery best
distinguished local recurrence from distant
metastases.
PSADT and Gleason score are highly prognostic for
clinical outcome.
35.
36. TREATMENT OF PSA RECURRENCE
Depends on the site of recurrence: namely local,
systemic or a combination of both.
Treatment options for presumed local recurrence
include external beam radiotherapy and, for
presumed distant metastasis, hormonal therapy.
Observation only is also one of the treatment options
regardless of recurrence site.
37. Routine tests cannot identify site of recurrence
untilnPSA reaches 20–50 ng/ml, at which level
effectiveness of radiotherapy can no longer be
expected.
Therefore, treatment is mainly selected according
to the pathological findings of RP specimen and
post-operative serum PSA parameters.
38. OBSERVATION:
Natural course from PSA recurrence to development
of metastatic disease or prostate cancer-specific
death is quite long.
Hence observation with delayed hormonal therapy
for symptomatic or metastatic disease can be a valid
treatment option.
39. RADIATION THERAPY:
Salvage radiotherapy is the recommended
terminology for curative-intended radiation for
post-operative PSA recurrence as opposed to
adjuvant radiotherapy administered shortly after
RP based on adverse pathological findings.
Candidates must have a life expectancy of >10
years, since salvage radiation therapy is sometimes
associated with high morbidity.
40. Preoperative PSA level, pre-radiotherapy PSA level
and seminal vesicle involvement are significant
risk factors for actuarial biochemical disease-free
survival following post-operative radiotherapy.
ASTRO Consensus Panel demonstrated a serum
PSA level of 1.5 ng/ml as the threshold level for
optimal success rates.
European Consensus Group recommended a PSA
level of 1.0–1.5 ng/ml as appropriate cut-off point
to initiate salvage radiotherapy for presumed local
recurrence.
41. Dose of radiation:
ASTRO Consensus Panel- 64.8Gy radiation to the
prostatic bed.
European Consensus group- 64 Gy, with 1.8-2.0 Gy
per fraction.
Predictors of disease progression following salvage
radiotherapy: negative/close margins, an absence
of extracapsular extension, presence of seminal
vesicle invasion, a Gleason score of 8–10, a pre-
radiotherapy PSA level >2.0 ng/ml, a PSA doubling
time of ≤10 months.
42. Hormonal therapy may increase sensitivity to
irradiation, may be effective for possible distant
metastases in such patients.
But the European Consensus Group mentioned
that hormonal therapy is not standard in patients
receiving salvage radiotherapy.
43. HORMONAL THERAPY:
Androgen deprivation therapy by surgical(B/L
scotal orchiectomy) or medical castration using a
LH-RH agonist or antiandrogens may improve
survival.
PSA level at which hormonal therapy should be
initiated remains unclear, though time to
metastatic disease was delayed on starting at PSA
level ≤5 ng/ml than at PSA level ≤10mg/dl.
44. INTERMITTENT HORMONAL THERAPY- this
concept introduced to avoid the side effects of
hormonal therapy.
Long-term efficacy remains unclear.
Finasteride may have an ability to delay disease
progression patients in PSA recurrence after RP;
long-term studies are required.
45. CONCLUSION
Clinical state of “Rising PSA/Biochemical
recurrence” after RP- second in size only to localized
disease.
Unique in that patients are characterized by an
absence of symptoms, radiographic findings or
pathologic findings—standard measures of treatment
effects.
46. PSADT is one of the most common elements for
stratifying patients & allocating Rx.
Patients can be divided into three groups based on
prognosis:
low-risk patients are unlikely to develop metastases
or symptoms or die of their disease and should be
managed expectantly;
intermediate-risk patients receive androgen
deprivation or can be considered for investigational
approaches designed to slow the disease to the point
where the patient dies of other causes; and
high-risk patients (those with PSADTs of ≤9 months)
can be considered for androgen deprivation or ideally,
enrolled in a clinical trial(TAX3503- Docetaxel 10
cycles; Mitoxantrone & Prednisone).