PROSTATE CANCER EXPECTED MANAGEMENT & CURATIVE TREATMENT Dr. Abdullah A. Ghazi (R5) KSMC

Incidence of PC

Mortality of PC  Life time risk 17%  Dying 3.6%  Doubling time 2-4y.  42% of men <50y die from other cause.

 Watchful waiting:  Active surveillance:

 Life expectancy in US, 2008

 157 pt.  T1c.  0.2ml  GS ≤6  No grade 4 or 5 by biopsy.  PSAD 0.1ng/ml/gm, 50%.  PSAD 0.15ng/ml/gm, <3mm cancer  Predict value for a significant disease 95%  73% of their patients were insignificant tumor.

Active Surveillance  The aim is to avoid unnecessary treatment on low- grade tumor that not affect the life or health for the next 5-10y.  Life expectancy > 10y have risk of metastasis.  Compliance.

Active Surveillance  31% will progress (GS, %specimen involvement, NO + biopsy

Active Surveillance  About ½ of the patient on AS remain free of progression within 10y.  Definitive treatment is appropriate in those with progression.

 299 pt.  55M F/U, 60% remaining on AS.  At 8y: OS 85% DSS 99%

AS for whom?  Eligibility criteria:  Clinically confined PCa (T1-T2).  Gleason score < 7.  PSA < ng/mL. Prostatic biopsy (at 5y 83% have N sample)

AS progression  Criteria to define cancer progression:  PSAD: between < 2 and < 4 years;  Gleason score progression to > 7 at re-biopsy, at intervals ranging from 1-4 years.

SUMMARY  Pt with life expectancy <10y, GS ≤ 6 are suitable for AS.  AS may be safe alternative to immediate treatment in compliant men with low risk of progression.

Prostate Cancer  Immediate treatment → risk of overtreatment.  AS → risk of progression

Prostate Cancer  The pt with AS may become anxious with an untreated cancer.  AS is more appropriate for old pt’s with limited life expectancy.

Radical Prostatectomy  It is still the gold standard.  Wide use or RP due to:  Early detection (PSA & TRUS).  Anatomical development of preserve cavernosal nerve & external sphincter. (90%).

Radical Prostatectomy  Advantage:  Cure with minimal damage.  Accurate staging.  Smooth post-op course.  Rare need blood transfusion.  Hospital stay 1-3 days.  ↓ local recurrence & distal metastasis vs WW.  Salvage of recurrence with RT.

Radical Prostatectomy  Disadvantage:  hospitalization.  Recovery period.  Risk of ED & incontinence.

Radical Prostatectomy  Surgical approach  Perineal:  Retropubic:  Laparoscopic:  Robotic:

Radical Prostatectomy  Salvage RP:  Has higher complication rate.  Incontinence 44%  Bladder neck contraction 22% Ward et al 2005

Radical Prostatectomy  Selection of pt for RP:  Life expectancy at least 10y (upper limit 75y).  Pre-op clinical & pathologic parameter.

Radical Prostatectomy  Contraindication of nerve sparing:  Extensive cancer in biopsy (>50%).  PSA > 10ng/ml  GS > 7  Site of the tumor  T2 disease.  Adhesion of the NV bundle to the prostate.  Poor erection pre-op.  Lack of sexual relationship.  Medical illness adverse erection.

Radical Prostatectomy  Post-op ED should be D/W pt.  Complication of adjuvant therapy (HT, RT).

Radical Prostatectomy  Adverse prognostic feature:  Perineural invasion.  Extracapsular extension.  + surgical margin.  SV invasion.  L.N. metastasis.  High PSA is the early sign of recurrence.

Radical Prostatectomy  Complications:  Continent 90%.  Eerection: 95% 40y 50% 70y.  It return partially at 3-6M up to 3y.  Complications < 10%.  Mortality rare.

Radical Prostatectomy  Complication:  Early: Hemorrhage Injury to adjacent organs. Urinary leak & fistula. Thromboembolic & CVA events. UTI. Lymphocele. Wound complication.  Late: ED Incontinence. Urethral stricture.

 RP is a reasonable option in a selected pt.  The pt must be inform about multimodal approach.  T3N0M0 PC (431pt)  Adjuvant RT  Better met-free survival with RT. Thompson  Adjuvant ADT vs observation in +LN  11.9 f/u  Better OS with ADT. Messing et al

Pelvic LN dissection  Limited “Obturator. Ext.iliac”,  Extend, 20.  Therapeutic role  Morbidity of eLND (x3)  Lymphoedema.  Lymphocele.  DVT.  PE

Pelvic LN dissection

Neoadjuvant HT with RP  Effect on pathology results ?  Pathology down-staging.  More organ confined.  Less + margin.  Less LN involvement.  Effect on OS & DFS.

Adjuvant HT with RP  No survival advantage.

RADIATION THERAPY  3D-CRT  IMRT  It is comparable result with RP (?? Not the same end point).  Standard dose 76-80Gy.  IMRT limit outside radiation by 1-1.5cm.

RADIATION THERAPY  Side effect:  Microvascular injury. IBS, rectal bleeding, bladder irritability, hematuria.  Relative C/I:  Prior TURP (urethral stricture, seeds of brachiotherapy not hold).  Severe LUTS.  IBD.

RADIATION THERAPY WITH HORMONAL  They include the locally advanced prostate cancer (T2c-4)  STAD-RT vs LTAD-RT.  Improvement of all end point with LTAD-RT except OS.

RADIATION THERAPY WITH HORMONAL  Increase OS in high risk group (more with LAD-RT).

RADIATION THERAPY  Endpoints for failure:  PSA ↓ within 2-3y.  PSA measurement Q6M.  PSA bounce.  Definition of PSA failure.

RADIATION THERAPY  Result:  50% cure rate for clinically localized PC.  HT for 2-3y can be given after RT.  EB-RT can combined with brachytherapy.

BRACHYTHERAPY  Indication:  stage cT1b- T2a N0, M0;  Gleason score < 6 assessed on a sufficient number of random biopsies.  Initial PSA level of < 10 ng/mL.  < 50% of biopsy cores involved with cancer.  Prostate volume of < 50 cm3.  IPSS < 12.

BRACHYTHERAPY  To be given under GA or regional anesthesia.  Ioden-125 (145Gy), palladium-103(125Gy).  CT scan after implant.  Results:  Cancer control: 5y 85% 8y 80% progression-free survival rate.

BRACHYTHERAPY  S/E:  Urinary symptoms.  AUR 22%.  Need TURP 10% (risk of incontinence 20-40%).  62-86% preserve erection.  Proctitis, rectal injury.  Migration.  Rectourethral fistula.

ADJUVANT RT AFTER RP  Given 67-64Gy.  Wait 3-4M.  Recent study → benefit.  Option: RT vs wait for PSA failure.  Most likely benefit is the + margin & extracapsular invasion.

??  Definition of PSA failure:  Post RP  Post RT

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