organ-confined prostate cancer by Dr. Ali Mujtaba (Resident Urology) Sindh Institute of Urology and Transplantation (SIUT)

1. PROSTATE CANCER-
ORGAN CONFINED
Dr. Ali Mujtaba
Department of Urology
SIUT , Karachi22-04-2020

2. OUTLINE
§Definition
§Epidemiology
§Anatomy
§Aetiology
§Pathophysiology
§Clinical Findings
§Diagnosis
§Management
§Follow Up
§References

3. DEFINITION
According to The National Comprehensive Cancer
Network (NCCN)-Clinical Guideline for the
Treatment of Prostate Cancer
§Organ-confined prostate cancer is the cancer that's
inside the prostate and hasn't spread to other parts
of the body.
§It is also called localised prostate cancer, or stage
T1 or T2 prostate cancer (Pca).

4. EPIDEMIOLOGY
An estimated 174,650 new cases of prostate cancer
diagnosed in 2019, accounting for 20% of new cancer
cases in men (NCCN Clinical Practice Guidelines in
Oncology)
In Pakistan, the prevalence rates is 98.6% for prostate
cancer account for 2nd most prevailing cancer in men
Idrees, R. et al., World J .Surg. Onc. 16,
2018

5. EPIDEMIOLOGY
Age-Standardized (World) Incidence and motility rates, top 10 cancers

6. ANATOMY
NCCN, Guidelines for
patients, Prostate Cancer,
2019

7. PROSTATE ANATOMY
§Partly glandular tissue, while more
fibromuscular, anterior to the prostatic urethra.
§Lies beneath the bladder and above the
urogenital diaphragm.
§Approximately 4 × 3 × 2cm in size.
§Penetrated by the proximal part of the urethra

8. CAPSULES OF PROSTATE
§TRUE CAPSULE
A thin strong layer of connective tissue at the periphery
of the gland forms the ‘true capsule’ of the prostate.
§FALSE CAPSULE
Outside of thin or true capsule there is a condensation of
pelvic fascia forming the ‘false capsule’.
Between these two capsules lies the prostatic plexus of
veins
Gray’s Anatomy for Students-
4th Edition –Elsevier

9. CAPSULES OF PROSTATE

10. ZONES OF THE PROSTATE
§Peripheral zone
§Central zone
§Transitional zone
The peripheral zone is almost
exclusively the site of origin for
carcinoma of the prostate.

11. AETIOLOGY
§ Family history/genetics
At least two or more relatives who have developed early-onset PCa
(< 55 years)
§ Metabolic syndrome (MetS)
§ Diabetes
Metformin users (but not other oral hypoglycaemic agents) were
found to be at a decreased risk of PCa diagnosis compared with
never-users
§ Cholesterol/statins
Obesity increased risk of high-grade Pca
§ Testosterone
Promotes prostate cancer development.
Men with very low concentrations of free testosterone (lowest
10%) have a below average risk of Pca.

12. AETIOLOGY
§Chromosomal abnormalities
§At 8p, 10q, 11q, 13q, 16q, 17p, and 18q have been described
in prostate cancers.
§specific loss at 8p23.2 and/or gain at 11q13.1 are predictive
of prostate cancer progression.
§Family specific BRCA1/2 mutations may increase the risk of
breast and prostate cancers.

13. AETIOLOGY
§ Risk factors
Exogenous/environmental factors have been discussed as being
associated with the risk of developing Pca.
Prostatitis.

14. PATHOPHYSIOLOGY
J. Cheng, et al. Neoplasia, 2006

15. PATHOPHYSIOLOGY
§ According to the International Continence Society (ICS)
Urinary incontinence as “the complaint of any involuntary loss
of urine”
§ Adenocarcinoma 95% of Pca
Developing in the acini of prostate duct
§ Rare histopathology types of prostate carcinoma (5% of Pca)
Small cell carcinoma
Mucinous carcinoma
Transitional cell carcinoma
Basal cell carcinoma
Neuroendocrine cancer
Squamous cell carcinoma
Mikael Haggstrom, 2019

16. CLINICAL FINDINGS
§Symptoms
• Early-stages (Asymptomatic)
• Obstructive or irritative voiding
• Nocturia
• Heamturia
• Dysuria
• Hesitancy

17. CLINICAL FINDINGS
§ Physical Examination,
DRE
Further evaluation (PSA, TRUS, and biopsy).

18. CLINICAL FINDINGS

19. CLINICAL FINDINGS
Tumor Makers
PSA
A serine protease in the human kallikrein (hK) family
produced by benign and malignant prostate tissues.
PSA is used both as a diagnostic (screening) tool and as
a means of risk-stratifying for known prostate cancers.
Normal PSA is ≤4 ng/ mL,
Serum PSA between 4 and 10 ng/mL (20–30%)
Levels >10 ng/mL, the positive predictive value
increases from 42% to 71.4%.
Oesterling et al, 1993

20. CLINICAL FINDINGS
§Prostate cancer antigen 3 (PCA3)
Overexpressed in the majority of prostate
cancers, with a median 66-fold up-regulation
compared with adjacent non-cancer tissue
PCA3 predicts the presence of cancer in a biopsy
setting with an accuracy of 74.6%
Hessels et al, 2007; Groskopf et al, 2006

21. DIAGNOSIS AND EVALUATION
§A. Prostate Biopsy
Prostate biopsy considered in men with an elevated
serum PSA, abnormal DRE, or a combination.
Prostate biopsy is performed under TRUS guidance
Biopsies are taken throughout the peripheral zone.
Laterally directed biopsies of the peripheral zone
increases the detection rates 14–20%.

22. B. GRADING AND STAGING
TNM staging system for prostate cancer

23. GRADING AND STAGING
TNM staging system for prostate cancer
American joint committee on cancer: Cancer staging manual, 7th ed. Lippincott-Raven ,2010

24. STAGES OF PROSTATE CANCER

25. GLEASON SCORE OR GLEASON
SUM
Traditionally, Gleason grades ranged from 1
to 5, and Gleason scores thus ranged from 2
to 10.
Gleason scores of 2–4, 5–7, and 8–10
corresponded to well-, moderately, and
poorly differentiated tumours, respectively.

27. GLEASON SCORE AND
INTERNATIONAL SOCIETY OF
UROLOGICAL PATHOLOGY(ISUP)
2014 GRADE

28. EAU RISK GROUPS FOR
BIOCHEMICAL RECURRENCE OF
LOCALISED AND LOCALLY
ADVANCED PROSTATE CANCER

29. C. IMAGING
§ TRUS
Guide prostatic biopsies and other prostate-directed
interventions.
§Endorectal magnetic resonance imaging (MRI)
Accuracy of endorectal MRI varies from 51% to 92%.

30. C. IMAGING
§Axial imaging
CT
MRI
§Bone scan
To role out prostate cancer metastasis
§Antibody imaging
FDA approved for initial staging and recurrent disease.

31. CAPRA SCORE
§ CAPRA (Cancer of the Prostate Risk
Assessment) Score predicts outcomes of patients post-
treatment for prostate cancer.
§CAPRA scores in the 0–2 range indicate relatively low-
risk disease, CAPRA 3–5 tumors are intermediate risk,
and CAPRA 6–10 tumors are high risk.

32. MANAGEMENT
§General Considerations
§Watchful waiting and active surveillance

33. MANAGEMENT
§Radical Prostatectomy
Open Prostatectomy
Laparoscopic prostatectomy

34. § External beam radiotherapy (XRT)
Techniques allow the safe delivery of 6500–7000 cGy to
the prostate..
§ Radiation therapy—brachytherapy
To place radioactive seeds under TRUS guidance.
MANAGEMENT

35. §Cryosurgery
Extensively used for the treatment for localized CaP.
MANAGEMENT

36. MANAGEMENT
In Cryosurgery freezing of the prostate is carried out by
using a multiprobe cryosurgical device.
The temperature at the edge of the iceball is 0°C to
−2°C, while actual cell destruction requires −25°C to
−50°C.
Actual tissue destruction occurs a few millimeters
inside the iceball edge and cannot be monitored
precisely by ultrasound imaging

37. § Focal therapy
Treating only the tumor while sparing the normal prostate
and surrounding structures
MANAGEMENT
Methods for focal therapy

38. MANAGEMENT
FDA-approved drugs for prostate cancer
Docetaxel
Cabazitaxel
Mitoxanthrone Hydrochloride

40. REFERENCES
§ Gray's Anatomy. 41st Edition. The Anatomical Basis of Clinical
Practice.
§ Smith and Tanagho's General Urology (Smith's General Urology).
§ NCCN Guidelines for Patients™ for Prostate Cancer
§ Johansson JE, Andrén O, Andersson SO, Dickman PW, Holmberg
L, Magnuson A, Adami HO. Natural history of early, localized
prostate cancer. Jama. 2004 Jun 9;291(22):2713-9.
§ Idrees, R., Fatima, S., Abdul-Ghafar, J. et al. Cancer prevalence in
Pakistan: meta-analysis of various published studies to determine
variation in cancer figures resulting from marked population
heterogeneity in different parts of the country. World J Surg Onc
16, 129 (2018).

41. THANK YOU