CA of Prostate:Incidence In a 50 y/o man In a 50 y/o man In autopsy: 40% In autopsy: 40% Clinical: 10% Clinical: 10% Death: 3% Death: 3% Most common non-cutanous diagnosed cancer Most common non-cutanous diagnosed cancer Second cause of cancer death Second cause of cancer death

Risk factors Risk factors Age: peak 68 yrs, 63% in >65 yrs Age: peak 68 yrs, 63% in >65 yrs Race: African-American Race: African-American Family history (4-7 times) Family history (4-7 times) Fatty meal ( 2 times) Fatty meal ( 2 times) Androgen Androgen IGF-1 IGF-1 Inflamation and infection Inflamation and infection

CA of prostate (Pathology) Adenocarcinoma 95% Adenocarcinoma 95% Transitional cell carcinoma 5% Transitional cell carcinoma 5% Peripheral zone 60-70% Peripheral zone 60-70% Transitional zone 10-20% Transitional zone 10-20% Central zone 5-10% Central zone 5-10% Basal cell layer, Architecture Basal cell layer, Architecture PIN: HGPIN, LGPIN PIN: HGPIN, LGPIN

Grade and stage Grade and stage Gleason grade and score Gleason grade and score Well differentiated:2-4 Well differentiated:2-4 Moderate differentiated :4-6 Moderate differentiated :4-6 Poor differentiated : 8-10 Poor differentiated : ??? 7 ??? Staging by DRE and TRUS not biopsy Staging by DRE and TRUS not biopsy

CA of prostate (progression) Volume and grade are important factors Volume and grade are important factors Lymph node: obturator,common iliac, periaortic Lymph node: obturator,common iliac, periaortic Bone: lumbar vertebra,femur,pelvis Bone: lumbar vertebra,femur,pelvis Visceral: lung, liver, adrenal gland Visceral: lung, liver, adrenal gland

CA of prostate (clinical findings) Mostly asymptomatic Mostly asymptomatic Obstructive and irritative urinary symptom Obstructive and irritative urinary symptom Bone pain, cord compression Bone pain, cord compression Lymphedema Lymphedema DRE DRE

CA of prostate (paraclinical finding) Azotemia Azotemia Anemia Anemia Acid phosphatase Acid phosphatase Alkaline phosphatase (bone metastasis) Alkaline phosphatase (bone metastasis) PSA PSA

CA of prostate and PSA Not specific Not specific PSA velocity:0.75 ng/yr in 18 months PSA velocity:0.75 ng/yr in 18 months PSA density:0.12 gm in BPH,> PSA density:0.12 gm in BPH,> PSA and age: yrs 2.5,70-79 yrs 6.5 PSA and age: yrs 2.5,70-79 yrs 6.5 Molecular form: 90% bound, F/T>25% Molecular form: 90% bound, F/T>25%

CA of prostate (imaging) TRUS: BX, staging, volume, brachytherapy TRUS: BX, staging, volume, brachytherapy Endorectal MRI,MRS (sensitivity 50-90%) Endorectal MRI,MRS (sensitivity 50-90%) CT and MRI: R/O node metastasis, sensitivity 40-50% CT and MRI: R/O node metastasis, sensitivity 40-50% Bone scan: most common metastasis, negative if PSA<10 ng Bone scan: most common metastasis, negative if PSA<10 ng

CA of prostate (treatment) Watchful waiting Watchful waiting Radical prostatectomy Radical prostatectomy EBRT EBRT Brachytherapy Brachytherapy Cryosurgery + HIFU Cryosurgery + HIFU Hormone therapy Hormone therapy Systemic chemotherapy Systemic chemotherapy

Watchful waiting Watchful waiting No therapeutic benefit for radical Rx of early stage prostate cancer No therapeutic benefit for radical Rx of early stage prostate cancer Small, well diferentiated pc are associated with very slow growth rate Small, well diferentiated pc are associated with very slow growth rate Appropriate treatment for highly selected patients: old wit small well diferentiated cancers Appropriate treatment for highly selected patients: old wit small well diferentiated cancers

Radical prostatectomy Radical prostatectomy Prognosis correlates with the pathologic stage and grade Prognosis correlates with the pathologic stage and grade Retropubic, perineal, laparascopic Retropubic, perineal, laparascopic Immediate complications: blood loss, rectal injury, ureteral injury Immediate complications: blood loss, rectal injury, ureteral injury Late complications: urinary incontinence, impotence Late complications: urinary incontinence, impotence Total incontinence:3%, stress 20% Total incontinence:3%, stress 20%

Radical prostatectomy Radical prostatectomy Return of incontinence is gradual Return of incontinence is gradual Age is the single most important factor in restoration of incontinence Age is the single most important factor in restoration of incontinence Nerve sparing surgery Nerve sparing surgery Preservation of potency depend on age, preoperative sexual function and preservation of one or both neurovascular bundle Preservation of potency depend on age, preoperative sexual function and preservation of one or both neurovascular bundle

Raditherapy Raditherapy External beam radiotherapy (XRT) External beam radiotherapy (XRT) Conformal radiotherapy Conformal radiotherapy Less normal tissues is irradiated Less normal tissues is irradiated Better PSA response Better PSA response Brachytherapy Brachytherapy Precise dose of radiotherapy by TRUS can be applied Precise dose of radiotherapy by TRUS can be applied

Cryotherapy Cryotherapy For treatment of localized prostate cancer For treatment of localized prostate cancer 5 probe by TRUS 5 probe by TRUS Cell destruction needs -25 to -50c Cell destruction needs -25 to -50c Morbidity is significant Morbidity is significant Long term results are unknown Long term results are unknown In short term result in –ve post treatment biopsy and low or undetectable PSA In short term result in –ve post treatment biopsy and low or undetectable PSA

Hormonal therapy for PC. GnRH-agonists Hormonal therapy for PC. GnRH-agonists Leuproreline, Busereline, Gosereline Leuproreline, Busereline, Gosereline All product are equal in casteration in terms of effectiveness All product are equal in casteration in terms of effectiveness First injection will result in temporary increase of serum testostrone First injection will result in temporary increase of serum testostrone Side effects: impotence, loss of libido, hot flashes, anemia, osteoprosis, weight gain, mood changes Side effects: impotence, loss of libido, hot flashes, anemia, osteoprosis, weight gain, mood changes

Hormone therapy pc GnRH antagonists Hormone therapy pc GnRH antagonists Directly blocking the GnRH receptors Directly blocking the GnRH receptors Available in depot injections Available in depot injections Avoid the flare-up reaction Avoid the flare-up reaction Faster suppression of testosterone than GnRH agonists Faster suppression of testosterone than GnRH agonists Side effects: as GnRH agonists + histamine mediated reactions Side effects: as GnRH agonists + histamine mediated reactions