Prostate Cancer - Urology

1. PROSTATE CANCER
Yuzbasheva Nihal
221B
Azerbaijan Medical
University

2. The prostate gland is the
male organ most
commonly afflicted with
either benign or malignant
neoplasms
70%
25
%
5
%

3. BENIGN PROSTATIC HYPERPLASIA

4. BPH is the most common benign tumor in men, and its incidence is age
related
Risk factors unknown, supposedly hereditary
Age 41-50 20%
Age 51-60 50%
Age 80+ 90%

5. ETIOLOGY
 The etiology of BPH is not completely understood, but it seems to be
multifactorial and endocrine controlled.
 Observations and clinical studies in men have clearly demonstrated that
BPH is under endocrine control.
 Castration results in the regression of established BPH and improvement
in urinary symptoms.
 Additional investigations have demonstrated a positive correlation
between levels of free testosterone and estrogen and the volume of BPH.

6. PATHOLOGY
• It is truly a hyperplastic
process resulting from an
increase in cell number.
• Microscopic evaluation
reveals a nodular
growth pattern that is
composed of varying
amounts of stroma
and epithelium.
• Stroma is composed of
varying amounts of
collagen and smooth
muscle.

7. PATHOLOGY
 As BPH nodules in the transition zone enlarge, they
compress the outer zones of the prostate, resulting in
the formation of a so-called surgical capsule.
 This boundary separates the transition zone from the
peripheral zone and serves as a cleavage plane for
open enucleation of the prostate during open simple
prostatectomies performed for BPH.

8. PATHOPHYSIOLOGY
1. Obstructive
component of the
prostate: a.
mechanical b.
dynamical
2. Response of
the bladder to the
outlet resistance

10. CLINICAL FINDINGS

11. SYMPTOMS
-
Obstructive hesitancy
decreased force
and caliber of
stream
sensation of
incomplete
bladder emptying
straining
to urinate
postvoid dribbling
Irritative urgency Frequency nocturia

13. SYMPTOMS
Score ranges from 0-35
0-7 mild
8-19 moderate
20-35 severe

14. SIGNS
A physical examination, DRE, and
focused neurologic examination are
performed on all patients.
The size and consistency of the prostate
is noted.
BPH usually results in a smooth, firm,
elastic enlargement of the prostate.
Induration, if detected, must alert the
physician to the possibility of cancer
and the need for further evaluation (ie,
prostate-specific antigen [PSA],
transrectal ultrasound [TRUS], and
biopsy).

15. LABORATORY FINDINGS
 Urinalysis to exclude infection or hematuria
 Serum creatinine measurement- to asses renal function
 Serum PSA – optional, increased ability to detect CaP
 DRE – the general idea of the size and condition of the gland

16. IMAGING
 Upper-tract imaging (renal ultrasound or computed
tomography [CT] urogram) is recommended only in the
presence of concomitant urinary tract disease or complications
from BPH
 TRUS is useful to determine prostate size for men planning to
undergo prostate surgery who are suspected to have severe
prostate enlargement based on DRE

17. IMAGING

18. IMAGING

19. CYSTOSCOPY
• Cystoscopy is not
routinely recommended
to determine the need for
treatment but may assist
in choosing the
surgical approach in
patients opting for
invasive therapy.
• If BPH is associated with
hematuria, then
cystoscopy is mandatory
to rule out other bladder
pathology.

20. ADDITIONAL TESTS
 Measurement of flow rate
 Determination of postvoid residual urine
 Pressure-flow studies
 Cystometrograms and urodynamic profiles -
for patients with suspected neurologic disease or
those who have failed prostate surgery

21. DIFFERENTIAL DIAGNOSIS
 Other obstructive conditions of the lower urinary
tract, such as urethral stricture, bladder neck
contracture, bladder stone, or CaP
 Urethral stricture or bladder neck contracture
 Bladder Stones
 Urinary tract infection
 Carcinoma
 Neurogenic bladder disorders

22. TREATMENT

23. A. WATCHFUL WAITING
 The risk of progression or complications is
uncertain.
 As mentioned earlier, watchful waiting is the
appropriate management of men with mild
symptom scores (0–7).
 Neither the optimal interval for follow-up nor
specific end points for intervention have
been defined.

24. B. MEDICAL THERAPY
1. -Blockers - phenoxybenzamine, prazosin, terazosin, doxazosin
2. 5-Reductase inhibitors – finasteride
3. Combination therapy
4. Phytotherapy - saw palmetto berry (Serenoa repens), the bark of
Pygeum africanum, the roots of Echinacea purpurea and Hypoxis
rooperi, pollen extract, and the leaves of the trembling poplar

25. SURGICAL THERAPY
1. Transurethral resection of the prostate:
- Risks of TURP include retrograde ejaculation (75%), impotence (5–10%),
and incontinence (<1%).
- Complications include bleeding; urethral stricture or bladder neck contracture; perforation of the
prostate capsule with extravasation; and, if severe, transurethral resection (TUR) syndrome resulting
from a hypervolemic, hyponatremic state due to absorption of the hypotonic irrigating solution.
- Clinical manifestations of the TUR syndrome: nausea, vomiting, confusion, hypertension, bradycardia,
and visual disturbances.
- The risk of the TUR syndrome increases with resection times >90 minutes and is usually seen in
older men.
-Treatment includes diuresis and, in severe cases, hypertonic saline administration.

26. SURGICAL THERAPY
2. Transurethral incision of the prostate
- Men with moderate to severe symptoms and a small prostate often hav posterior commissure
hyperplasia (elevated bladder neck).
- This procedure is more rapid and less morbid than TURP.
-Outcomes in well-selected patients are comparable, although a lower rate of retrograde ejaculation
with transurethral incision has been reported (25%).
3. Transurethral vaporization of the prostate (TUVP)
- Increasingly popular in recent years, ablative techniques use photo- or electroevaporation to ablate
obstructing prostate tissue.
-(Nd:YAG) KTP “GreenLight” laser; plasma vaporization “Button” electrode

27. SURGICAL THERAPY
4. Holmium laser enucleation of the prostate (HoLEP)
5. Simple (subtotal) prostatectomy
- When the prostate is too large to be removed endoscopically, an open enucleation is necessary.
- Glands >100 g are usually considered for open enucleation.
- Open prostatectomy may also be initiated when concomitant bladder diverticulum or a large bladder
stone is present or if dorsal lithotomy positioning is not possible.
- Open prostatectomies can be done with either a suprapubic or retropubic approach.
6. Transurethral microwave thermotherapy

28. CARCINOMA OF THE PROSTATE

29. INCIDENCE AND EPIDEMIOLOGY

30. INCIDENCE AND EPIDEMIOLOGY

31. RISK FACTORS

32. PATHOLOGY
 More than 95% of the prostate cancers are adenocarcinomas.
 Nonadenocarcinoma variants can be categorized into two
groups based on the cellular origin: epithelial and nonepithelial.
 Epithelial variants consist of endometrioid, mucinous, signet-
ring, adenoid cystic, adenosquamous, squamous cell, transitional cell,
neuroendocrine, and comedocarcinoma.
 Nonepithelial variants include rhabdomyosarcoma, leiomyosarcoma,
osteosarcoma, angiosarcoma, carcinosarcoma, malignant
lymphoma, and metastatic neoplasms among others.

33. PATHOLOGY
• The cytologic characteristics of CaP include
hyperchromatic, enlarged nuclei with prominent nucleoli
• Cytoplasm is often abundant; thus, nuclear-to-
cytoplasmicratios are not often helpful in making a diagnosis
of CaP, unlike their usefulness in diagnosing many other
neoplasms.
• Cytoplasm is often slightly blue tinged or basophilic,
which may assist in the diagnosis.

34. PATHOLOGY
 A: Glands are well developed
with variation in contour
and morphology. The glands
grow in an infiltrative pattern.
Nuclear features of
malignancy include mild nuclear
enlargement,.
 B: Malignant cells have
trabecular, glandular, Malignant
nuclear features include marked
nuclear enlargement and
macronucleoli.
 C: Highly infiltrative growth
pattern with single cells..
Cytologic features include
marked nuclear pleomorphism
and anisonucleosis with irregular
contours, coarse irregular

35. CLINICAL FINDINGS

36. SYMPTOMS
 The large majority of patients with
early-stage CaP are asymptomatic.
 The presence of symptoms often
suggests locally advanced or metastatic
disease.
 Obstructive or irritative voiding
complaints.
 Metastatic disease to the bones may
cause bone pain.
 Metastatic disease to the vertebral
column may be associated
with symptoms of cord compression,
including paresthesias and weakness of
the lower extremities and urinary or
fecal incontinence.

37. SIGNS
 A physical examination, including a DRE, is needed.
 Induration or nodularity, if detected, must alert the
physician to the possibility of cancer and the need for
further evaluation (ie, PSA, TRUS, and biopsy).
 Locally advanced disease with bulky regional
lymphadenopathy may lead to lymphedema of the lower
extremities.
 Specific signs of cord compression

38. GENERAL LABORATORY FINDINGS
 Azotemia
 Anemia
 Elavated alkaline phosphatase
 Elevated serum acid phosphatase

39. PROSTATE -SPECIFIC
ANTIGEN AND
OTHER TUMOR MARKERS
 A “normal” PSA has
traditionally been defined
as ≤4 ng/ mL, and the
positive predictive value
of a serum PSA
between 4 and 10 ng/mL
(20–30%).
 For levels in excess of 10
ng/mL, the positive
predictive value increases
from 42% to 71.4%.

40. DIAGNOSIS AND EVALUATION

41. PROSTATE BIOPSY
 Prostate biopsy should be considered in
men with an elevated serum PSA,
abnormal DRE, or a combination of the
two, depending additionally on patient's
other factors.
 Biopsies are taken throughout the
peripheral zone of the prostate, with
optional additional sampling of any
abnormal areas on DRE and/or TRUS.
 Traditionally, six (sextant) biopsies were
taken along a parasagittal line between
the lateral edge and the midline of the
prostate at the apex, midgland, and
base bilaterally.

42. GRADING AND
STAGING
 The Gleason system is the
most commonly
employed grading system
 In assigning a grade to a
given tumor, pathologists
assign a primary grade to
the pattern of cancer that
is most commonly
observed and a
secondary grade to the
second most commonly
observed pattern in the
specimen.
 Grades range from 1 to 5

44. IMAGING
1. TRUS
- As described earlier, TRUS is useful in helping guide prostatic biopsies and
other prostate-directed interventions.
2. Endorectal magnetic resonance imaging (MRI)
- Use of an endorectal coil improves cancer detection and staging compared
with the use of a standard body coil.
3. Axial imaging (CT, MRI)
- Cross-sectional imaging of the pelvis in patients with CaP is selectively
performed to exclude lymph node metastases in high-risk patients who are
thought to be candidates for definitive local therapy, whether it be surgery
or irradiation.
4. Bone scan
5. Antibody imaging

45. IMAGING

46. TREATMENT

47. LOCALIZED DISEASE
1. General considerations
- The optimal form of therapy for all stages of CaP remains a
subject of great debate.
2. Watchful waiting and active surveillance
- Although local cancer progression may occur, with watchful
waiting for early stage prostate cancer, disease-specific mortality
at 10 years is low varying generally between 4% and 15%.

48. LOCALIZED DISEASE
3. Radical prostatectomy
4. Radiation therapy—external beam therapy
5. Radiation therapy—brachytherapy
6. Cryosurgery
7. Focal therapy

49. RECURRENT DISEASE
1. Overview
- A substantial number of men who are treated with
either surgery or radiation for presumed
clinically localized prostate cancer will relapse based on
evidence of a detectable or rising serum PSA after
treatment, respectively.
2. Following radical prostatectomy
3. Following radiation therapy

50. THANK YOU FOR
ATTENTION!