prostate cancer as. mudr. jan pokorný, febu head: doc. mudr. robert grill, ph.d. vice-head: as....

Prostate cancer

As. MUDr. Jan Pokorný, FEBU

Head: Doc. MUDr. Robert Grill, Ph.D.

Vice-head: As. MUDr. Lukáš Bittner, FEBU

Urologická klinika 3. LF UK a FNKV

Prostate cancer

Epidemiology:

Incidence:

ČR 80/100 000

USA 120/100 000

Mortality:

ČR 15/100 000

Prostate cancer

Epidemiology:

ČR

Prostate cancer

Epidemiology:

Prostate cancer:

EU – 2nd in men mortality for cancer (1st lung cancer)

USA – 1st in men mortality for cancer

Prostate cancer

Epidemiology:

Risk factors:

Increasing age, race (afroamericans), heredity

Exogenous factors:

Diete, UV radiation, alcohol consumption, risk sexual behavior, infection (HPV?)

Prostate cancer

Epidemiology:

Increasing age:

The prostate cancer incidence in per cent generaly correlates to the patient´s age

Prostate cancer

Epidemiology:

Basic check-up:

Discussion about the mass screening

Expenses

Unapparent (asymptomatic) tumors treatment

Prostate cancer

Epidemiology:

Basic check-up:

Recommended:

Screening in risk population – positive family history

Positive clinical symptoms In patients who actively visit doctor and ask for

check-up

Prostate cancer

Epidemiology:

Basic check-up:

Recommended:

Digital rectal examination in all men in all time

PSA only in recommended case (previous slide)

Prostate cancer

Epidemiology:

Basic check-up:

Recommended:

Start PSA test between 45-50 years

Start PSA test in the positive family history case between 40-45 years

Prostate cancer

Epidemiology:

Basic check-up:

Recommended:

In patient unfit for treatment (age, co-morbidity, weak life prognosis) there is NO INDICATION FOR PSA TESTING !!!

Prostate cancer

Diagnosis:

Basic exams:

Digital rectal exam (DRE)

Prostate specific antigen (PSA)

Prostate cancer

Diagnosis:

DRE:

Prostate cancer

Diagnosis:

DRE:

Prostate shape, volume, consistence, demarcation

Semen vesicules examination

Bimanual palpation (in anesthesia)

Prostate cancer

Diagnosis: DRE:

95 % of cancer originates from the peripheral zone of prostate

Suitable for palpation

Prostate cancer

Diagnosis:

Prostate specific antigen (PSA):

33 kD molecular weigh glycoprotein

(Proteases enzyme)

Gene in 19th chromosome

Half-life period 3-5 days

Prostate cancer

Diagnosis:

Prostate specific antigen (PSA):

Produced almost exclusively by the epithelial cells of the prostate

Prostate-specific marker, no cancer-specific

High sperm concentration

Prostate cancer

Diagnosis:

Prostate specific antigen (PSA):

Venous blood sample The exact cut-off level of what is considered to be

a normal PSA value has yet to be determined Generally used cut-off level: 4-4.2 ng/ml Values of approximately < 2-3 ng/ml are often

used for younger men

Prostate cancer

Diagnosis:

Prostate cancer diagnosis:

PSA elevation or DRE suspicion

Prostate biopsy – Transrectal USG

(TRUS biopsy)

PCA3 (Prostate Cancer Antigen 3)

Prostate cancer

Diagnosis:

TRUS prostate biopsy:

Prostate morphology Peripheral zone biopsy Min. of 12 samples, according to prostate volume

correction In case of negative first biopsy repet one is

needed

Prostate cancer

Diagnosis:

TRUS prostate biopsy:

Biopsy gun

Prostate cancer

Diagnosis: Prostate Cancer Antigen 3 (PCA3):

Genetic marker Cancer - specific

Urine sampled after DRE

Additional test, no standard

Prostate cancer

Diagnosis: Prostate Cancer Antigen 3 (PCA3):

Indications: PSA elevation and negative prostate biopsy

Decision on re-biopsy

No treatment in PCA3 elevation only

Prostate cancer

Diagnosis:

Prostate Cancer Antigen 3 (PCA3):

Some studies present the PCA3 level and Gleason Score correlation (tumor aggressiveness)

Prostate cancer

Diagnosis:

Morphology:

Histological types:

Acinar adenocarcinoma Papilar (ductal) carcinoma Small cell carcinoma Ring cell carcinoma Sarcomatoid carcinoma (No PSA production)

Prostate cancer

Diagnosis:

Grading:

Gleason grade

Prostate cancer

Diagnosis:

Grading:

Gleason score: The Gleason score is the sum of the most

dominant and second most dominant (in terms of volume) Gleason grade. If only one grade is present, the primary grade is doubled.

Examples include: GS 2+2, GS 3+4, GS 4+3 etc.

Prostate cancer

Diagnosis:

Grading:

Gleason scoce correlates to the tumor dedifferentiation (aggressiveness)

Prostate cancer

Diagnosis:

Staging: DRE TRUS

CT scan and bone scan in PSA value > 20 ng/ml (in case of GS ≥ 7 even in PSA value > 10 ng/ml)

MRI

Prostate cancer

Diagnosis:

Staging:

TNM classification: T1 – Clinically unapparent tumour not palpable or

visible by imaging T2 – Tumour confined within the prostate T3 – Tumour extends through the prostatic

capsule T4 – Tumour is fixed or invades adjacent

structures other than seminal vesicles

Prostate cancer

Diagnosis:

Staging:

TNM classification:

N1 – Lymph nodes involvement

M1 – Distant metastases (non-regional lymph nodes, bones, liver, lungs)

Prostate cancer

Diagnosis:

Staging:

Prostate cancer

Diagnosis:

Staging:

Prostate cancer

Diagnosis:

Prognotic factors:

Gleason score (Tumor aggressiveness) PSA level Age and biological condition

Prostate cancer

Treatment: Localised prostate cancer (T1-T2):

Watchful Waiting / Active Monitoring Surgery – Radical Prostatectomy Radiation therapy (Tele, Brachy) Experimental – Kryosurgery, HIFU ( High

Intensity Focused Ultrasound)

Prostate cancer

Treatment:

Watchful waiting (WW): Deferred treatment Treatment starts in case of clinical symptoms

developement No cure intention Suitable for patients with shorter life expectancy

Prostate cancer

Treatment:

Active surveillance or monitoring (AS): Deferred treatment with cure intention Active monitoring of tumor activity (PSA, repet

TRUS biopsy – progression of number of positive samples, Gleason Score progression etc.)

Treatment starts at the moment of progression Well-informed patient only

Prostate cancer

Treatment:

Radical prostatectomy:

Complete prostate, prostate capsule, vesicles and prostate part of urethra removal

Lymphadenectomy only in indicated cases

Prostate cancer

Treatment:

Radical prostatectomy:

Retropubic access

Open surgery Laparoscopy Robot - assisted

Prostate cancer

Treatment:

Radical prostatectomy:

T1-2 stages

„Younger“ patients – life expectancy > 10 years

Prostate cancer

Treatment:

Radical radiation therapy:

Teleradiotherapy:

External beam of radiation of prostate, vesicles and surrounding tissues, in special cases of regional lymph nodes

Prostate cancer

Treatment:

Teleradiotherapy:

Linear accelerators Three-dimensional conformal radiotherapy (3D-

CRT) and intensity modulated external beam radiotherapy (IMRT)

Dose escalation Adverse events minimalization

Prostate cancer

Treatment:

Teleradiotherapy:

Innovative techniques:

Proton beam accelerators Carbon ion beam accelerators

Prostate cancer

Treatment:

Teleradiotherapy:

T1-2 stages and no plan of radical prostatectomy

T3-T4, N1 stages

Prostate cancer

Treatment:

Transperineal Brachytherapy:

Effective technique in T1-2 stages, PSA ≤ 10 ng/ml, GS ≤ 6 and prostate volume ≤ 50-60 ml

Prostate cancer

Treatment:

Transperineal Brachytherapy:

Transperineal access, USG guided technique

Permanent radioactive implats application (Palladium-103)

Prostate cancer

Treatment:

Transperineal Brachytherapy:

Local anesthesia only

One-shot application

Prostate cancer

Treatment: Local advanced prostate cancer (T3-T4, N1):

Watchful waiting

Radiation therapy (Teleradiotherapy)

Prostate cancer

Treatment:Metastatis prostate cancer:

Watchful waiting Hormonal therapy Chemotherapy Palliative therapy

Prostate cancer

Treatment:

Hormonal therapy: Stage M1

Endogeneous androgen production: Testicles 90 – 95 % Adrenal glands 5 – 10 %

Prostate cancer

Treatment:

Hormonal therapy:

Testosterone is essential

for the prostate tissue

growth and prostate

cancer growth as well

http://www.oncoprof.net

Prostate cancer

Treatment:

Hormonal therapy:

LHRH analogs – central blocade Antinadrogens – peripheral blocade Ketokonazole – adrenal production blocade Surgical– bilateral orchiectomy Combinations

Prostate cancer

Treatment:

Chemotherapy: Taxans – Docetaxel, Cabazitaxel Estramustin

Treatment of relapse after hormonal therapy in stage M1

Prostate cancer

Treatment:

Palliative therapeutic options:

Bone metastases:

(Bone resorption inactivation) Bisphosphonates Denosumab

Painful bone metastases – i.v. aplication of radionuclides (Stroncium)

Prostate cancer

Treatment:

Palliative therapeutic options:

Urinaty retention:

TURP (Transurethral Prostate Resection) Urethral catheter, epicystostomia Ureteral stents Nephrostomy tube

Prostate cancer

Treatment:

Palliative therapeutic options:

Opoids Blood supplementation Corticosteroids Surgical treatment of pathological bone fractures

and vertebral compression

Prostate cancer

Follow-up :

Basic periodic exam.:

PSA

DRE

Prostate cancer

Follow-up :

PSA elevation - restaging

CT

Bone scan

Prostate cancer

Follow-up :

In special cases:

PET – CT

MRI

Prostate cancer

Prognosis:

Generally excellent (in T1-N1 stage generally complete cure)

Majority of patients in M1 stage survive years!

Prognosis estimation: Entering Gleason score, PSA, biological condition

Prostate cancer

Contact:

jan.pokorny@fnkv.cz