1. PROSTATE CANCER LETS DEBATE !!!! Dr Fred C Tyler MBChB FRCS FCS UROL

2. Case Presentation Mr D N 44yr referred PSA 6,49 Low libido, poor erections PMH : Hypertension PSH: Nil Alllergies: Nil Smoking : 20/d OH : social

3. Case Presentation Abdo: soft NAD Genitalia: NAD PR: BPH Testosterone 20.48

4. Case Presentation Cystoscopy: Narrow bladder neck,nil else TRNB Prostate: One tiny focus of Gleason 6/10 ( 3 +3) 0.5 mm of one core Prostatitis

5. Prognostic Grouping Group 1 T1a-c NO, M0,PSA <10, GLS < 6 T2a Group 2a T1a-c N0 M0 PSA < 20 GLS 7 PSA 10-20 GLS <6 T2a,b PSA <20 GLS,7 Group 2b T2c N0,M0,Any PSA, Any GLS T1 -2 PSA > 20 or GLS >8 Group 3 T3a-b Group 4 T4

6. MR D N Low risk Group 1

7. WHAT NOW !!!!!!

8. EUA Guidelines Clinical Stage 1c 40%-50% of new cases SPGC 4 study showeds advatage of RP over WW but on;ly 5% of thise patients were PSA screened Prevalence of under scoring GLS grades

9. Watchful Waiting T1a well or moderately differentiated if > 10 yrs life expectancy restaging with TURP and TRNB advised T1b to T2b standard rx for well or moderately diff tumours in asymptomatic patients with life expectancy < 10 yrs. NB Criteria – PSA <10. GLS <6, < 2 positve biopsies, < 50% of the biopsy involved.

10. Radical Prostatectomy Reduced cancer mortality and risk of metastases in men <65yr with little or no benefit 10 or more years after surgery Standard rx if <65yrs age and who except rx related complications. Role of Laparoscopic and Robot assisted Radical prostatectomy…..

11. Extended pelvic node dissection No benefit in low risk CAP

12. Recommendations for Radical Prostatectomy Neoadjuvant GNRH for 3 months is not recommended for T1 – T2 disease. Nerve sparing surgery may be attempted for Low risk Disease: T1c, GLS 7, PSA,10

13. Definitive Radiation Therapy Transperineal Interstitial Brachytherapy – T1c-T2a – GLS,7 (3+4) – PSA<10 – Prostate vol <50ml – No previous TURP, Good IPSS Localised CAP: T1c T2c, N0, M0, – 3D CRT +- IMRT even for young patients who refuse surgery ??? – Low, Intermediate,high risk patients benefit from dose escalation.

14. Cryosurgery of the Prostate Low risk CAP : PSA<10, <T2a,GLS<6 Intermediate Risk: PSA > 10, GLS 7, Stage.T2b 5 yr BDFR inferior to RP in low risl patients. All other minimally invasive options are experimental……….

15. Our patient…… 3 months after diagnosis PSA 4.27 (9%) 3 months later PSA 3.39 3months later PSA 4.51.