Download Prostate cancer diagnosis

Urologická klinika 3. LF UK a FNKV
Prostate cancer
As. MUDr. Jan Pokorný, FEBU
Head: Doc. MUDr. Robert Grill, Ph.D.
Vice-head: As. MUDr. Lukáš Bittner, FEBU
Prostate cancer
Epidemiology:
 Incidence:
ČR 80/100 000
USA 120/100 000
 Mortality:
ČR 15/100 000
Prostate cancer
Epidemiology:
ČR
Prostate cancer
Epidemiology:
Prostate cancer:
EU – 2nd in men mortality for cancer (1st lung cancer)
USA – 1st in men mortality for cancer
Prostate cancer
Epidemiology:
 Risk factors:
Increasing age, race (afroamericans), heredity
 Exogenous factors:
Diete, UV radiation, alcohol consumption, risk sexual
behavior, infection (HPV?)
Prostate cancer
Epidemiology:
 Increasing age:
The prostate cancer incidence in per cent
generaly correlates to the patient´s age
Prostate cancer
Epidemiology:
Basic check-up:
Discussion about the mass screening
 Expenses
 Unapparent (asymptomatic) tumors treatment
Prostate cancer
Epidemiology:
Basic check-up:
Recommended:
 Screening in risk population – positive family
history
 Positive clinical symptoms
 In patients who actively visit doctor and ask for
check-up
Prostate cancer
Epidemiology:
Basic check-up:
Recommended:
 Digital rectal examination in all men in all time
 PSA only in recommended case (previous slide)
Prostate cancer
Epidemiology:
Basic check-up:
Recommended:
 Start PSA test between 45-50 years
 Start PSA test in the positive family history case
between 40-45 years
Prostate cancer
Epidemiology:
Basic check-up:
Recommended:
In patient unfit for treatment (age, co-morbidity, weak
life prognosis) there is NO INDICATION FOR PSA
TESTING !!!
Prostate cancer
Diagnosis:
Basic exams:
 Digital rectal exam (DRE)
 Prostate specific antigen (PSA)
Prostate cancer
Diagnosis:
DRE:
Prostate cancer
Diagnosis:
DRE:
 Prostate shape, volume, consistence, demarcation
 Semen vesicules examination
 Bimanual palpation (in anesthesia)
Prostate cancer
Diagnosis:
DRE:
 95 % of cancer originates from the peripheral
zone of prostate
 Suitable for palpation
Prostate cancer
Diagnosis:
Prostate specific antigen (PSA):
 33 kD molecular weigh glycoprotein
(Proteases enzyme)
 Gene in 19th chromosome
 Half-life period 3-5 days
Prostate cancer
Diagnosis:
Prostate specific antigen (PSA):
 Produced almost exclusively by the epithelial cells
of the prostate
 Prostate-specific marker, no cancer-specific
 High sperm concentration
Prostate cancer
Diagnosis:
Prostate specific antigen (PSA):
 Venous blood sample
 The exact cut-off level of what is considered to be
a normal PSA value has yet to be determined
 Generally used cut-off level: 4-4.2 ng/ml
 Values of approximately < 2-3 ng/ml are often
used for younger men
Prostate cancer
Diagnosis:
Prostate cancer diagnosis:
 PSA elevation or DRE suspicion
 Prostate biopsy – Transrectal USG
(TRUS biopsy)
 PCA3 (Prostate Cancer Antigen 3)
Prostate cancer
Diagnosis:
TRUS prostate biopsy:
 Prostate morphology
 Peripheral zone biopsy
 Min. of 12 samples, according to prostate volume
correction
 In case of negative first biopsy repet one is
needed
Prostate cancer
Diagnosis:
TRUS prostate biopsy:
Biopsy gun
Prostate cancer
Diagnosis:
Prostate Cancer Antigen 3 (PCA3):
 Genetic marker
 Cancer - specific
 Urine sampled after DRE
 Additional test, no standard
Prostate cancer
Diagnosis:
Prostate Cancer Antigen 3 (PCA3):
Indications:
 PSA elevation and negative prostate biopsy
 Decision on re-biopsy
 No treatment in PCA3 elevation only
Prostate cancer
Diagnosis:
Prostate Cancer Antigen 3 (PCA3):
 Some studies present the PCA3 level and
Gleason Score correlation (tumor aggressiveness)
Prostate cancer
Diagnosis:
Morphology:
Histological types:
 Acinar adenocarcinoma
 Papilar (ductal) carcinoma
 Small cell carcinoma
 Ring cell carcinoma
 Sarcomatoid carcinoma (No PSA production)
Prostate cancer
Diagnosis:
Grading:
Gleason grade
Prostate cancer
Diagnosis:
Grading:
Gleason score:
 The Gleason score is the sum of the most
dominant and second most dominant (in terms of
volume) Gleason grade. If only one grade is
present, the primary grade is doubled.
 Examples include: GS 2+2, GS 3+4, GS 4+3 etc.
Prostate cancer
Diagnosis:
Grading:
 Gleason scoce correlates to the tumor
dedifferentiation (aggressiveness)
Prostate cancer
Diagnosis:
Staging:
 DRE
 TRUS
 CT scan and bone scan in PSA value > 20 ng/ml
(in case of GS ≥ 7 even in PSA value > 10 ng/ml)
 MRI
Prostate cancer
Diagnosis:
Staging:
TNM classification:
 T1 – Clinically unapparent tumour not palpable or
visible by imaging
 T2 – Tumour confined within the prostate
 T3 – Tumour extends through the prostatic
capsule
 T4 – Tumour is fixed or invades adjacent
structures other than seminal vesicles
Prostate cancer
Diagnosis:
Staging:
TNM classification:
 N1 – Lymph nodes involvement
 M1 – Distant metastases (non-regional lymph
nodes, bones, liver, lungs)
Prostate cancer
Diagnosis:
Staging:
Prostate cancer
Diagnosis:
Staging:
Prostate cancer
Diagnosis:
Prognotic factors:
 Gleason score (Tumor aggressiveness)
 PSA level
 Age and biological condition
Prostate cancer
Treatment:
Localised prostate cancer (T1-T2):
 Watchful Waiting / Active Monitoring
 Surgery – Radical Prostatectomy
 Radiation therapy (Tele, Brachy)
 Experimental – Kryosurgery, HIFU ( High Intensity
Focused Ultrasound)
Prostate cancer
Treatment:
Watchful waiting (WW):
 Deferred treatment
 Treatment starts in case of clinical symptoms
developement
 No cure intention
 Suitable for patients with shorter life expectancy
Prostate cancer
Treatment:
Active surveillance or monitoring (AS):
 Deferred treatment with cure intention
 Active monitoring of tumor activity (PSA, repet
TRUS biopsy – progression of number of positive
samples, Gleason Score progression etc.)
 Treatment starts at the moment of progression
 Well-informed patient only
Prostate cancer
Treatment:
Radical prostatectomy:
 Complete prostate, prostate capsule, vesicles and
prostate part of urethra removal
 Lymphadenectomy only in indicated cases
Prostate cancer
Treatment:
Radical prostatectomy:
 Retropubic access
 Open surgery
 Laparoscopy
 Robot - assisted
Prostate cancer
Treatment:
Radical prostatectomy:
 T1-2 stages
 „Younger“ patients – life expectancy > 10 years
Prostate cancer
Treatment:
Radical radiation therapy:
Teleradiotherapy:
 External beam of radiation of prostate, vesicles
and surrounding tissues, in special cases of
regional lymph nodes
Prostate cancer
Treatment:
Teleradiotherapy:
 Linear accelerators
 Three-dimensional conformal radiotherapy (3D-
CRT) and intensity modulated external beam
radiotherapy (IMRT)
 Dose escalation
 Adverse events minimalization
Prostate cancer
Treatment:
Teleradiotherapy:
Innovative techniques:
 Proton beam accelerators
 Carbon ion beam accelerators
Prostate cancer
Treatment:
Teleradiotherapy:
 T1-2 stages and no plan of radical prostatectomy
 T3-T4, N1 stages
Prostate cancer
Treatment:
Transperineal Brachytherapy:
 Effective technique in T1-2 stages, PSA ≤ 10
ng/ml, GS ≤ 6 and prostate volume ≤ 50-60 ml
Prostate cancer
Treatment:
Transperineal Brachytherapy:
 Transperineal access, USG guided technique
 Permanent radioactive implats application
(Palladium-103)
Prostate cancer
Treatment:
Transperineal Brachytherapy:
 Local anesthesia only
 One-shot application
Prostate cancer
Treatment:
Local advanced prostate cancer (T3-T4, N1):
 Watchful waiting
 Radiation therapy (Teleradiotherapy)
Prostate cancer
Treatment:
Metastatis prostate cancer:
 Watchful waiting
 Hormonal therapy
 Chemotherapy
 Palliative therapy
Prostate cancer
Treatment:
Hormonal therapy:
 Stage M1
Endogeneous androgen production:
 Testicles 90 – 95 %
 Adrenal glands 5 – 10 %
Prostate cancer
Treatment:
Hormonal therapy:
Testosterone is essential
for the prostate tissue
growth and prostate
cancer growth as well
http://www.oncoprof.net
Prostate cancer
Treatment:
Hormonal therapy:
 LHRH analogs – central blocade
 Antinadrogens – peripheral blocade
 Ketokonazole – adrenal production blocade
 Surgical– bilateral orchiectomy
 Combinations
Prostate cancer
Treatment:
Chemotherapy:
 Taxans – Docetaxel, Cabazitaxel
 Estramustin
Treatment of relapse after hormonal therapy in
stage M1
Prostate cancer
Treatment:
Palliative therapeutic options:
Bone metastases:
(Bone resorption inactivation)
 Bisphosphonates
 Denosumab
Painful bone metastases – i.v. aplication of
radionuclides (Stroncium)
Prostate cancer
Treatment:
Palliative therapeutic options:
Urinaty retention:
 TURP (Transurethral Prostate Resection)
 Urethral catheter, epicystostomia
 Ureteral stents
 Nephrostomy tube
Prostate cancer
Treatment:
Palliative therapeutic options:
 Opoids
 Blood supplementation
 Corticosteroids
 Surgical treatment of pathological bone fractures
and vertebral compression
Prostate cancer
Follow-up :
Basic periodic exam.:
 PSA
 DRE
Prostate cancer
Follow-up :
PSA elevation - restaging
 CT
 Bone scan
Prostate cancer
Follow-up :
In special cases:
 PET – CT
 MRI
Prostate cancer
Prognosis:
 Generally excellent (in T1-N1 stage generally
complete cure)
 Majority of patients in M1 stage survive years!
 Prognosis estimation: Entering Gleason score,
PSA, biological condition
Prostate cancer
Contact:
[email protected]