PROSTATE CANCER.

DR. MUGALO E.L.

MBchB,M.MED
SURG/UROLOGY.
 INTRODUCTION.
• Most Common Malignancy in Men

• Usually Slowly Progressive and

Without Symptoms Until Late in the
Disease

• Prior to PSA Marker, 50 % Were

Metastatic at Diagnosis; Now < 15 %
 RISK FACTORS.
• Family history of Ca.prostate-risk
higher (2 fold)in first degree
relatives(brother or father) than in
second degree relative (grandfather
or uncle).
• African american race.
• Higher age (especially age >65).
 Data from our region
• Statistics:
---------------------Population--------New
cases 2004

– USA: 295,000,000 220,000

– Kenya: 33,000,000 23,000
– Tanzania: 36,000,000 25,000
– Uganda: 26,400,000 18,400
 PRESENTATION.
• Age-usually present at age ≥65 (30-
40% of men>50 years of age have
prostete cancer)
• Most patients are asymptomatic
• Advanced cancer symptoms include-
hematuria,urinary obstruction,bone
pain from bone metastasis,lower limb
edema,deep perineal pain,erectile
dysfunction.
DIAGNOSIS-DRE
DIAGNOSIS-TRANSRECTAL
NEEDLE BIOPSY.
 Indications for biopsy.
• Abnormal DRE
• Abnormal PSA
• Rising PSA or elevated PSA velocity
• TECHNIQUE
• At least 10 systematic core biopsies.
• Use TRUS guided biopsy.
• Patient without anus(after AP
resection)-CT or MRI guided biopsy.
 CA. PROSTATE.
• HISTOLOGICAL TYPES-
• adenocarcinoma>95% arise from the
gland epithelial cells.
• Non-adenocarcinoma<5%-TCC,small
cell carcinoma,sarcoma.
• LOCATION OF CA.PROSTATE.
• Peripheral zone -70%
• Transition zone -20%
• Central zone 5-10%
• Anterior prostate -Rare
McNeal Model of the
Prostate
 AJC/UICC TNM STAGING
SYSTEM
• T = Tumor Stage
– Tx : Tumor not evaluable
– T1 : Localized [ T1a small < 5%; T1b >
5%]
• T1c : impalpable – found because of
elevated PSA
– T2 : Intracapsular: [T2a in 1 lobe; T2b >
1 lobe]
– T3 : Local Invasion: [T3a extracapsular;
T3b involves seminal vesical]
 AJC/UICC TNM STAGING
SYSTEM
• N = Nodes
– Nx : Not evaluable
– No : No Regional Node Metastases
– N1 : Metastasis to Regional Node(s)

• M = Metastases
– Mx : Not evaluable
– M1 or + : Metastases are Present
 Gleason TUMOR GRADING
SYSTEM
• Donald Gleason (1961, ff)
– Gleason Grade: Grade assigned to each
of 2 most common tumor patterns (from
1 to 5)

– Gleason Score: Sum of the Two Gleason

Grades
• Usually Expressed as “3 + 3,” “3+4,” “4+4”
etc

• The Higher the Score, The less

AJC/UICC TNM STAGING
SYSTEM
AJC/UICC TNM STAGING
SYSTEM

T1c – Normal DRE;

Elevated PSA
PATTERNS OF METASTASIS
 PATTERNS OF METASTASIS
• Common sites include-pelvic LN,bone
,lungs,liver.
 Local cancer spread.
• Capsular penetration near the
neurovascular bundle.common in the
peripheral zone.
• More common in patients with a
higher clinical stage,higher gleason
score,higher preoperative PSA.
 TREATMENT- options for
treatment
• Localized Disease:
– Surgery
• Radical Perineal Prostatectomy
• Radical Retropubic Prostatectomy
– Radiation Therapy
• External Beam Radation (Teletherapy)
• Radioactive Seed Implants (Palladium103 or
Iodine125 )
(Brachytherapy)
• Combined
– No Therapy
RADICAL PERINEAL
PROSTATECTOMY
RADICAL RETROPUBIC
PROSTATECTOMY
RADIATION THERAPY
 OPTIONS FOR TREATMENT
• Advanced (Metastatic) Disease
– Bilateral Orchiectomy
– Estrogen Therapy
• Diethylstilbestrol
• TACE
– Androgen Agonist Therapy
• Goserilin (Zoladex)
• Leuprolide (Leupron)
OPTIONS FOR TREATMENT
 OPTIONS FOR TREATMENT
• Prognosis – Survival 10-yr Survival
– Surgical Removal – Limited to Capsule >80%
– ExtracapsularExtension 55 %
– Distant Metastases 20-35 %

• Many Patients will Have Elevated PSA After

Treatment but show No Evidence of Disease for
Many Years
• Many Patients Are Elderly at Diagnosis and May
Die of Intercurrent Illness Not Related to Prostate
Cancer
 PREVENTION.
• 1.PCPT(prostate cancer Trial) use of fenesteride in
>18,000 men aged ≥55,normal DRE,and PSA≤3.0
were randomosed to fenesteride 5mg po q day or to
placebo and followed for 7 years.[N Engl J
Med,349:213.2003].
a).finesteride decreased the risk of deveolping prostate
cancer by 25%, but men taking finesteride were more
likely to have high grade cancers and sexual side
effects (e.g. erectile dysfunction and loss of libido)
• 2. REDUCE trial –evaluation of dutesteride for
prevention of prostate cancer.Result pending.
• 3.SELECT trial-examinig the use of Vit E and seleniun
for the prevention of prostate cancer.Men with age
≥55,normal DRE,PSA ≤4.0 are randomised to one of
four treatment arms:placebo,selenium and VitE.
• 4.Dietary changes may help prevent prostate cancer