1. PROSTATE CANCER Dr.GOVINDRAJAN SRMC & RI
Department of Urology & Renal Transplantation
SRMC & RI

2. PROSTATE GLAND Present only in the male (base of the urinary bladder)
Prostatic secretions - add volume to semen
Most common male organ for occurrence of benign or malignant tumors.

3. ZONAL ANATOMY McNeal (1968) - Zonal anatomy of prostate Three zones:
Peripheral zone (60-70% of CaP origin)
Central zone (5 –10% of CaP origin)
Transition zone (10-20% of CaP origin)

4. PROSTATE CANCER (Ca P) Incidence: Men >65 Yrs
Incidence Increases With Age
Longevity More
So In Future More Cases

5. RISK FACTORS FOR Ca P Hereditary Prostate Cancer
First Degree Relative with CaP – 5 to 11 fold risk
5-α Reductase Polymorphism (SRD5A2 gene)
Cytochrome P459C17 & Cytochrome P4503A4
Androgen receptor- CAG repeat

6. OTHER FACTORS VITAMIN STATUS DIET
Low levels of Vitamin D – Increased risk
Vitamin E Supplementation – Decreased risk
DIET
Saturated Fatty Acids Increased risk
Lycopene (Tomato sauce) Decreased risk
Selenium Decreased risk

7. MISCELLANEOUS FACTORS
Vasectomy? times more risk
Cigarette smoking - both + and – results
Heavy alcohol lower risk
Sexual activity (infection) - increased risk
IGF 1 (taller men) - more risk

8. PATHOLOGY OF Ca P 95% of Ca P - Adenocarcinoma Other 5% :
90% Transitional cell carcinoma
Remaining - Neuroendocrine sarcomas
- Squamous cell carcinoma

9. PATHOLOGY PERIPHERAL ZONE TRANSITIONAL ZONE CENTRAL ZONE
60- 70% of Ca P origin
TRANSITIONAL ZONE
10-20% of Ca P origin
CENTRAL ZONE
5-10% of Ca P origin
TURP / open prostatectomy does not eliminate risk of Ca P

10. GLEASON GRADING SYSTEM
Most commonly used
Glandular architecture on low power microscope
Prognosis and progression correlates well

11. STAGING- WHITMORE & JEWETT
A1 - Tumor found incidentally at TURP, < 5% tissue
A2 - Tumor found incidentally at TURP, > 5% tissue
B1 - Tumor less than one half of lobe
B2 - Tumor involves both lobes
C1 - Extracapsular extention
C2 - Infiltration to seminal vesicles
D Disseminated disease

12. TNM STAGING T1a - Less than 5% of resected tissue has Ca P, normal DRE
T2a - More than 5% of resected tissue has Ca P, normal DRE
T2 - Palpable tumor confined to prostate
T3 - Tumor extends beyond prostate & seminal vesicle
T4 - Tumor fixed or invades other structures like
bladder neck,rectum

13. TNM STAGING… Nx - Regional nodes not assessed N 0 - No nodes
N 1 - Single node 2cm or smaller
N 2 - Node 2-5cm or multiple nodes
N 3 - Node more than 5cms
Mx - Not assessed
M 0 - No distant metastasis
M 2 - Non regional nodes , bones& viscera

14. STAGING EARLY STAGE LOCALLY ADVANCED ADVANCED METASTATIC DISEASE
T1 AND T2 (TNM)
A AND B (W & JEWETT)
LOCALLY ADVANCED
T3,T4,N1 (TNM)
C (W & JEWETT)
ADVANCED METASTATIC DISEASE
STAGE M (TNM)
STAGE D (W & JEWETT)

15. CLINICAL SYMPTOMS EARLY STAGE LOCALLY ADVANCED DISEASE
Asymtomatic
Cancer is in the peripheral zone
LOCALLY ADVANCED DISEASE
Obstructive / irritative voiding
Retention of urine
Hematuria
Renal failure
Pelvic pain
METASTATIC DISEASE
Bone pain
Spinal cord compression symptoms
Paraperesis
Paraplegia

16. CLINICAL SIGNS DIGITAL RECTAL EXAM Distended bladder
Nodes-iliac, inguinal, supraclavicular
Lower limb edema
Paraperisis
Paraplegia
DIGITAL RECTAL EXAM
Nodular
Indurated
Asymmetrical
Firm to hard in consistency

17. DIGITAL RECTAL EXAM … Differential diagnosis (Hard prostate)
Chronic granulomatous prostatitis
Prostatic calculi
Prostatic infarction

18. LOCAL SPREAD OF Ca P LYMPH NODES Prostatic capsule Seminal vesicle
Bladder neck
Trigone – ureters -renal failure
Rectum - rare – due to strong Denonviller’s fascia
LYMPH NODES
Obturator node - commonest and earliest
Iliac
Presacral
Paraaortic

19. DISTANT METASTASIS Bones commonest, osteoblastic type
Lumbar vertebrae, pelvic bone (Cord compression)
Proximal femur
Thoracic spine
Ribs, sternum
Skull

20. LABORATORY INVESTIGATIONS
Blood urea, S .Creatinine
Anemia
Thrombocytopenia
Acid phosphatase
Alkaline phosphatase (Bone metastasis,liver metastasis)

21. LABORATORY INVESTIGATIONS
PROSTATE SPECIFIC ANTIGEN
Glycoprotein secreted by prostatic epithelium,aids in semen liquefaction
Normal up to 4 ng/ml
Mild elevation 4-10 ng/ml
Significant elevation more than 10 ng/ml
Suggestive of bone metastasis
DRE does not raise PSA levels significantly
Prostate biopsy raises PSA
TURP significantly raises PSA

22. IMPORTANCE OF PSA TESTING
Diagnosis
Pre-operative staging
Monitoring response to therapy
Detecting recurrence after therapy

23. TRANS RECTAL ULTRASOUND
More sensitive than DRE
Hypoechoic lesions
Local staging
Sextant biopsy
Brachytherapy,cryosurgery

24. BONE SCAN Radionuclide bone scan for secondaries PSA > 20 ng / ml
Bone pain
More sensitive than X-ray
False +ve results
Fractures,arthritis etc

25. ROLE OF X- RAY Axial skeleton Osteoblastic secondaries Chest X- ray
Pulmonary metastasis
Miliary pattern

26. CT SCAN & MRI Not routinely done
When radical prostatectomy is being planned
CT - Nodes
MRI -Perivesical extension

27. TREATMENT EARLY PROSTATIC CARCINOMA T1&T2(TNM)A&B(W&JEWETT)
WATCHFUL WAITING
>70YRS
SMALL WELL DIFFERENTIATED TUMORS

28. TREATMENT… RADICAL PROSTATECTOMY Less than 60 yrs Good general health
Life expectancy >10yrs
No life threatening ancillary disease
Removal of entire prostate and seminal vesicle
Pelvic lymphadenectomy for staging
Preservation of distal sphincter
Preservation of cavernosal nerves-to prevent impotence

29. RADICAL PROSTATECTOMY…
Retropubic route
Laproscopic
Survival >10yrs
Complications
Bleeding
Incontinence
Erectile dysfunction (nerve sparing technique)

30. RADICAL RADIOTHERAPY External beam therapy
Gy to prostate and nodes
BRACHYTHERAPY
Placement of radioactive seeds inside tumor under TRUS guidance
ADVANTAGES
As good as surgery
No incontinence
DISADVANTAGES
Radiation cystitis
Radiation prostatitis

31. TREATMENT… LOCALLY ADVANCED DISEASE
> 70 YRS ASYMTOMATIC WATCHFUL WAITING
EXTERNAL BEAM RT
HORMONAL ABALATION
RT&HORMONAL ABALATION

32. TREATMENT METASTATIC DISEASE
BILATERAL ORCHIDECTOMY
Gold standard
Done under local anesthesia
Rapid lowering of serum testosterone level
Side effects less
Testicular prosthesis –cosmetic result

33. TREATMENT METASTATIC DISEASE
OESTROGENS
STILBESTEROL (1MG) - 3 TIMES DAILY
COMPLICATIONS
Cardiovascular-ischemia, infarction
CVA
Thromboembolic complications
Gynecomastia

34. TREATMENT METASTATIC DISEASE
LHRH AGONISTS
CAUSES PITUTARY DESENSITISATION BY ALTERING PULSATILE RELEASE OF LHRH
DIMINISHED LH
FALL IN TESTOSTERONE-<50NG/ML
ADVANTAGES
LESS CVS COMPLICATIONS
LESS GYNECOMASTIA

35. TREATMENT METASTATIC DISEASE
DISADVANTAGES
Flare phenomenon due to initial rise of testosterone.
Might worsen symptoms
GIVE ANTI ANDROGEN BEFORE STARTING THERAPY
COST-RS 6000 FOR 3 MONTHLY DEPOT INJECTION

36. TREATMENT METASTATIC DISEASE
ANTI-ANDROGENS
COMPETITIVELY INHIBITS DHT RECEPTORS
FLUTAMIDE (250MG) 3TIMES
BICALUTAMIDE 50MG OD
WITH HORMONAL ABALATION COMPLETE ANDROGEN BLOCKAGE

37. TREATMENT METASTATIC DISEASE
CHEMOTHERAPY
Very limited role
RADIOTHERAPY
Local RT for isolated bone secondaries
Hemibody RT –multiple secondaries
Strontium 89-painful bone metastasis