Dr Mukosai Simon

Department of Surgery
University Teaching Hospital
5th year lecture
24th April 2015

Layout of Presentation
Introduction
Risk factors
Diagnosis
Grading
TNM classification
Imaging
Treatment
Questions

Introduction
Prostate cancer
Disease
Hormonal management
Most common malignancy in
elderly men
Second most common cause of
death in elderly men

Prostate Cancer: Etiology

Risk Factors Currently Under
Investigation
Racial origin
Environmental factors
Dietary factors
Genetic factors

Risk factors for Prostate

Cancer
Increased risk
Family history
First degree relation
Family history of
BRCA gene mutation
Race
Scandinavian
African American

Decreased risk
Race
Asian
Diet high in:
Plant Vitamin A
Isoflavonoids
Lycopenes
Selenium
Vitamin E

Prostate Cancer:
Diagnosis
Method of Detection
DRE
Localized 50% -

diagnosis1,2

60% at time of

PSA

Localized 90% at time of diagnosis1

Pathologically confined two thirds

of time

Diagnostic triad

Transrectal ultrasound biopsy

Gleason Grading System

TNM Classification
System (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor
T1 Clinically unapparent tumornot palpable or visible by imaging
T1a
Tumor found incidentally in tissue removed at transurethral resection of the
prostate (TURP);
5% or less of tissue is cancerous
T1b
Tumor found incidentally in tissue removed at TURP; more than 5% of tissue
is cancerous
T1c
Tumor identified by prostate needle biopsy because of elevated PSA
T2 Palpable tumor confined within the prostate
T2a
Tumor involves half of a lobe or less
T2b
Tumor involves more than half of a lobe, but not both lobes
T2c
Tumor involves both lobes
T3 Palpable tumor extending through prostate capsule and/or seminal vesicle(s)
T3a
Unilateral extracapsular extension
T3b
Bilateral extracapsular extension
T3c
Tumor invades seminal vesicle(s)
T4 Tumor is fixed or invades adjacent structures other than the seminal vesicles
T4a
Tumor invades bladder neck and/or external sphincter and/or rectum
T4b
Tumor invades levator muscles and/or is fixed to pelvic wall

TNM Classification
System
(N)
N+ Involvement
of regional lymph nodes
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastases
N1 Metastasis in a single regional lymph
node, <2
cm in greatest dimension
N2 Metastasis in a single regional lymph
node, >2
cm but not >5 in greatest
dimension, or multiple
regional lymph
nodes, none >5 cm in greatest
dimension
N3 Metastasis in regional lymph node >5 cm
in greatest dimension

TNM Classification
System
(M)
M+ Distant metastatic spread
MX Presence of distant metastases cannot
be assessed
M0 No distant metastasis
M1 Distant metastasis
M1a Involvement of nonregional lymph
nodes
M1b Involvement of bone(s)
M1c Involvement of other distant sites

Imaging Tests
Bone Scan
Low detection rate.
Provides additional information in patients
with skeletal symptoms.
Computed Tomography (CT)
Useful for staging in T4 disease.
Recommended in patients with Gleason score
of 8 to 10, clinical stage T3 or T4.

Typical regions of metastatic disease

Bone scan of metastases

Radiography

Bone scan

Treatment Options
Watchful waiting
Therapies of curative intent
Radical prostatectomy
Retropubic
Perineal
Laparoscopic
Radiotherapy

External beam radiation

Brachytherapy

Cryotherapy

Hormonal therapytestosterone deprivation

LHRH-A
Bilateral orchidectomy
Antiandrogen

Therapies of Curative
Intent
Radical prostatectomy
Retropubic
Perineal
Laparoscopic
Radiotherapy
External beam radiation
Brachytherapy
Cryotherapy

Radical Prostatectomy
Advantages
Primary treatment

Stage-

dependent

Disadvantages
Major operation
Erectile dysfunction
Incontinence
Bowel complications

External Beam Radiation

Advantages
Efficacy equal to
prostatectomy
Outpatient
procedure

Disadvantages
Erectile dysfunction
Chronic bowel
complications
Incontinence

Brachytherapy
Advantages
As effective as EBRT
or surgery

Disadvantages
Urinary voiding
symptoms
Erectile dysfunction
Rectal discomfort
Edema

Cryotherapy
Advantages
Short hospital stay
Relatively
noninvasive

Disadvantages
Erectile dysfunction
Urinary problems
(short-term)
Unknown long-term
effectiveness

Hormonal Therapy:
Current Treatment Options
Bilateral orchidectomy
LHRH-A
LHRH-A + antiandrogen (CAB)
Bilateral orchidectomy +

antiandrogen (CAB)

Blockade of androgen action

LHRH-A
Advantages
As effective as
bilateral
orchidectomy in
decreasing
testosterone levels
Administered every
1, 3, 4, or 12 months
Potentially reversible

Disadvantages
Hot flashes
Decreased libido
Erectile dysfunction

Management of Advanced
Prostate Cancer
Inhibit testosterone production
Surgical castration
Medical castration with an

LHRH-A
Block androgen receptor binding
Antiandrogen

What percentage of men with clinically

significant prostate cancer will have a
normal PSA level?
5%
20%
40%

If the result of is 8 ng/ml. You therefore

advise him to consider a trans-rectal
ultrasound guided biopsy. What
percentage of tumours are missed at
biopsy?
1%
20%
40%

THANK

YOU

What percentage of men with clinically

significant prostate cancer will have a
normal PSA level?
20%
Catalona W, Smith D, Ratliff T,
Basler J

If the result of is 8 ng/ml. You therefore advise

him to consider a trans-rectal ultrasound guided
biopsy. What percentage of tumours are missed
at biopsy?
20%
Rabbani F, Stroumbakis N, Kava BR, Cookson MS, Fair WR

Prostate cancer is an important health problem that affects

mainly older men

Each year over 20 000 men are diagnosed with prostate
cancer and 9500 die from the disease
There is no good evidence to indicate whether a population
screening programme would reduce mortality
Because of the uncertainties surrounding PSA testing it is
important that you give men who request a test balanced
information to help them make an informed decision
Up to 20% of men with clinically significant prostate cancer
will have a normal PSA level
About two thirds of men with an elevated PSA level will not
have prostate cancer detectable at biopsy
Up to 20% of tumours are missed at trans-rectal ultrasound
guided biopsy