1. Carcinoma of prostate

2. Carcinoma of prostate
CaP is the most common cancer diagnosed and is the second leading cause of cancer death in American men, and the prevalence of CaP increases with age.
60-70% of CaP originates in the peripheral zone, 10-20% in the transitional zone, 5-10 % in the central zone.

4. Risk factors
Increasing age: probability of CaP developing in men under the age of 40 is 1 in and for men it is 1 in 8.
Race: African American are at higher risk for CaP than whites. And tumor tends to be more aggressive than in white race also.
Positive family history increase the risk: and age of disease onset in the family member with the diagnosis affects a patient’s relative risks e.g. if age of onset is 70 the relative risk is 4 fold, if the age of onset is 50 the relative risk is increased 7 fold.
High dietary fat intake increases the relative risk by 2 fold.
Exposure to cadmium increases the risk, which found in cigarette smoke, alkaline batteries, and in the welding industries

5. Pathology Over 95% of the cancers are adenocarcinoma, others e.g.
transitional cell carcinoma
small cell carcinoma
sarcoma.
Histological classification commonly used is (Gleason)
(Relies upon the lower power appearance of the glandular architecture under the microscope). In which we have 5 grades.

7. Spread
Local spread:
seminal vesicles, bladder neck, trigon, and distal urethral sphincter, involving the trigon may obstruct of one or both ureter may result in anuria if bilateral.
Rectal involvement is rare as denonvillier’fascia represent a strong barrier. But may become stenosed by tumor infiltrating around it.
Spread by the bloodstream:
Particularly to bones (most common site of origin for skeletal metastasis is CaP ),most frequently the pelvic bones and the lower lumbar vertebrae , femoral head ,rib cage and the skull.
Lymphatic spread:
spreads to obturator lymph nodes and internal iliac and external iliac and common iliac lymph nodes and to the presacral lymph nodes. And periaortal lymphnodes.

9. Types of prostate cancer
Microscopic latent cancer found on autopsy or at cystoprostatectomy.
Tumors found incidentally during TURP or following screening by PSA (T1a and T1b)
Early, localized prostate cancer (T2).
Advanced local prostate cancer (T3-T4)
Metastatic disease either originate from apparent tumor or from occult prostate cancer (apparently benign gland)(T0-T1)

10. Clinical features Symptoms of advanced disease include:
Most patients with early stage CaP are asymptomatic. The presence of symptoms often suggests locally advanced or metastatic disease.
Symptoms of advanced disease include:
BOO (IVS and OVS), pelvic pain and hematuria, bone pain malaise, anemia, renal failure (uremia), urinary and fecal incontinence.
Early disease usually found incidentally following
TURP for BPH, or by DRE

12. suspicion of prostate cancer :
because of either local findings (DRE)
nodule
indurations
diffuse hardness of the prostate).
raised PSA (>10ng/ml highly suspicious ),
4-10 ng/ml suspicious
below 4 ng/ml regard as normal ),
then transrectal ultrasound guide sextant biopsy taken

17. Lab findings
Uremia can result from bilateral ureteral obstruction either from direct extension into the trigon or from retroperitoneal adenopathy.
Anemia may be present in metastatic diseas.
Alkaline phosphatase may be elevated in the presence of bone metastasis, or extensive liver metastasis.
Serum acid phosphatase may be elevated with disease outside the confines of the prostate.

18. staging the tumor PSA is a useful as tumor marker for
screening,
Staging e.g. >20ng/ml go with advanced disease <10ng/ml most of the case localized tumor
evaluate respond to the treatment (follow up).
CXR for lung, or ribs metastasis, abdominal X-ray for lumbar and pelvic bone metastasis which is commonly osteoblastic.
Ultrasound and IVP for evaluation of the upper urinary tract.
Bone scan if PSA >20ng/ml in which performed by injection of technetium-99m which is then monitored using gamma camera.

19. staging
TRUS is useful in performing prostatic biopsy and in providing some useful local staging information if cancer is detected. If visible CaP tends to appear as a hypoechoic lesion in the peripheral zone.
Endorectal MRI used for local staging also has high accuracy.
CT, MRI of the pelvis in patients with CaP is selectively performed to exclude lymph node metastasis in high risk.
CT-guided fine-needle aspiration.
Antibody imaging—ProstaScint is a murine monoclonal antibody to an intracellular component of the prostate-specific membrane antigen (PSMA), which is conjugated to 111 indium.
However, this antibody recognizes the intracellular domain of PSMA; only soft tissues are imaged

26. DDX Factors leads to elevation of PSA include (BPH
urethral instrumentation
prostatitis, prostatic infarction
vigorous prostatic massage).
indurations of prostate others as
(chronic granulomatous prostatitis
previous TURP
previous needle biopsy
prostatic calculi

27. Treatment decision are based on
Grade
Stage
Life expectancy
Ability of each therapy to ensure
disease free survival
Associated morbidity
Patient and physician preferences

28. Treatment A. localized disese(T1-T2):
1.watchful waiting (surveillance):
For highly selected patients with CaP, old age with limited life expectancy, concomitant illnesses, small, well differentiated tumor.(cancer death rate 10%)
2. Radical prostatectomy (RP):
Includes removal of prostate+seminal vesicles +pelvic lymphadenectomy and anastomosis of bladder to the membranous urethra can be performed
Retropubically
Perinealy
Laparoscopically.

42. Complications of RP Immediate includes blood loss rectal injury
ureteral injury
and perioperative complications include
DVT
pulmonary embolism
lymphocele formation
wound infection.
Late complications include
urinary incontinence
impotence

43. Localized disease 4. Radiation therapy- brachytherapy :
3. Radiation therapy –external beam therapy
By 3 dimensional conformal radiotherapy (CT guided), in which use 3 dimensional treatment planning software. In which treatment field accurately placed allow higher dose of radiation to be given without exceeding the tolerance of surrounding normal tissue
4. Radiation therapy- brachytherapy :
Deliver a very high dose of radiation to a localized area . and this by placing radioactive seeds under TRUS guidance.

46. Localized disease
5. Cryosurgery:
By freezing of the prostate by using a multiprobe cryosurgical device, percutaneously under TRUS guide,

50. B. locally advanced disease
Most patients with T3 cap are treated with neoadjuvant hormonal therapy followed by XRT.

51. D.metastatic disease Endocrine therapy:
Most of the prostatic carcinoma are hormone dependant and 70-80% of men with metastatic cap respond to various forms of androgen deprivation.
Androgen deprivation may be induced at several levels along the pituitary-gonadal axis using variety of methods or agents:

54. Level
Agent
route
Dose(mg)
Frequency
Pituitary
Diethylstilbesterol
Goserlin
Leuprolide
Oral SC IM
1-3
10.8
3.6
22.5
7.5
Daily
Every 3 month
Every month
Every 3month
Adrenal
Ketoconazole
400
Testicle
Orchiectomy
Prostate cell
Bicalutamide
Flutamide
Nilutamide 50
250
150
3 times a day
daily

55. Current administration of LHRH agonists and orchiectomy are the most common form of primary androgen blockade used.
Suppression of both testicular and adrenal androgens (complete androgen blockade. And this can be achieved by LHRH agonist+ antiandrogen.
Antiandrogen appear to act by competitively binding the receptor for DHT the intratesticular androgen responsible for prostate cell growth and development.

56. Prognosis

57. Prognosis Organ confined cancer ,10 years free survival range 70-85%
Focal extracapsular extension ,free survival 70% at 5 years 40% at 10years
High grade, free survival 15% at 10 years

58. Thank you