This document provides an overview of localized prostate cancer, including:
1. It describes the anatomy of the prostate and surrounding structures.
2. It discusses diagnosis and imaging for prostate cancer including DRE, PSA testing, multiparametric MRI, and prostate biopsy.
3. It covers risk stratification for prostate cancer based on factors like Gleason score, PSA, and tumor stage to determine appropriate management strategies.
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diagnosis and outline of management of localized prostate cancer for non-urologist
1. LOCALIZED PROSTATE
CANCER
âDr Mayank Mohan Agarwal
MBBS, MS, MRCS(Ed), âDNB, MCh (PGIMER, Chandigarh)
VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction
(MSKCC, NY; UCLA, LA; WFUBMC, NC)â
Formerly, Associate Professor of Urology (PGIMER, Chandigarh)
Formerly, Consultant & Head of Urology (NMCSH, Abu Dhabi)
Consultant and Head of Urology
(Aster) Dr. Ramesh Cardiac and Multispecialty Hospitals Pvt. Ltd.
Guntur (AP), India
9. DIAGNOSIS AND IMAGING
⢠DRE
⢠PSA
⢠MULTIPARAMETRIC MRI
⢠TRUS guided prostate biopsy
UROLOGIST
10. Population based PSA screening
⢠Population based RCT n = 182000
0
0.2
0.4
0.6
0.8
1
1.2
50-54 55-59 60-64 65-69 70-74
CAP specific deaths per 1000 person-year
screening control
Schroder FH et al. N Engl J Med 2009;360:1320-8.
11. PSA (human Kallikrein peptidase 3)
⢠Serine protease, member of a family of 15 hkpâs
⢠preproPSA ď proPSA ď PSA ď _mg/ml into semen
A millionth (_ng/ml)
unprocessed
Processed
in prostate
(70-80%)
(90-95%)
(5-10%)
(1-2%)
(20-30%)
12. PSA (human Kallikrein peptidase 3)
⢠Serine protease, member of a family of 15 hkpâs
⢠preproPSA ď proPSA ď PSA ď _mg/ml into semen
A millionth (_ng/ml)
unprocessed
Processed
in prostate
(70-80%)
(90-95%)
(5-10%)
(1-2%)IN
CANCER
(<20-30%)
13. PSA (human Kallikrein peptidase 3)
⢠Organ specific (almost)
â breast tissue, breast milk, breast/kidney/adrenal cancer, parotid
⢠Disease non-specific
â prostatic hyperplasia, prostatitis, prostate manipulation, prostate cancer
14. Risk of CAP based on PSA
⢠PSA is a continuous variable
⢠There is actually no ânormalâ value
⢠âprobabilityâ of having CAP proportional to PSA
0
20
40
60
80
100
0.0-0.5 0.6-1.0 1.1-2.0 2.1-3.0 3.1-4.0 4.1-10.0 10.1-20.0 >20.1
% risk of CAP
Thompson, I.M., et al. N Engl J Med 2004; 350: 2239.
17. HOW TO IMPROVE SPECIFICITY OF PSA 4-10
⢠PSA > 3ng/ml â indication for biopsy ~25% PPV
⢠Can we avoid biopsies in some of these patients?
18. Percent free PSA
⢠âmore the merrierâ
0
20
40
60
80
100
8 10 11 12 13 14 15 17
perc free PSA
sensitivity specificity
unprocessed
Processed
in prostate
(70-80%)
(90-95%)
(5-10%)
(1-2%)IN
CANCER
(<20-30%)
19. PSA density
⢠PSA per unit volume (PSAD) 0.10 â 0.15
⢠PSA per unit TZ volume (PSAD-TZ) ?? 0.20 â 0.30
0
20
40
60
80
100
0.1 0.15 0.2 0.3
sensitivity specificity
PSAD-TZ
0
20
40
60
80
100
0.075 0.1 0.15 0.2 0.25
sensitivity specificity
PSAD
20. PSA velocity
⢠Various cutoffs sensitivity â specificity balance poor
⢠Valid only in long term follow up (at least 3 values, at least 18m duration)
⢠For PSA 4-10 cutoffs 0.35-0.75 ng/ml/yr have been used with relatively
high specificity but low sensitivity
Mettlin C. Cancer 1994; 74:1615-20; Lee SC. Korean J Urol 2004;45:747-752
21. TRUS GUIDED PROSTATE BIOPSY
⢠Proper preparation
- Control of sugar
- Urine culture (+/_ stool culture to detect MDR / ESBL)
- Reduce anticoagulation (max aspirin 75mg/d)
- Bowel preparation
- Antibiotic prophylaxis
⢠Counseling for complications
- Sepsis
- Retention
- Hematuria
⢠At least 12 cores
+ lesion guided (if applicable)
+ more cores for larger prostates
24. Risk stratification
Factors to consider â
1. TNM staging
2. Gleason scoring
3. PSA
4. PSAD
5. No. of biopsy cores (+)
6. % of a core (+)
T1
T2
T3
T4
25. Risk stratification
Factors to consider â
1. TNM staging
2. Gleason scoring
3. PSA
4. PSAD
5. No. of biopsy cores (+)
6. % of a core (+)
1-3
4
5
26. Risk stratification
Factors to consider â
1. TNM staging
2. Gleason scoring
3. PSA < 10 â 20 <
4. PSAD
5. No. of biopsy cores (+)
6. % of a core (+)
27. Risk stratification
Factors to consider â
1. TNM staging
2. Gleason scoring
3. PSA < 10 â 20 <
4. PSAD
5. No. of biopsy cores (+)
6. % of a core (+)
Minor factors for
âfine tuningâ
28. Management strategies for localized cancer
Determinants â
⢠Risk-group
⢠Patientâs physiological status
ď§ Charlsonâs comorbidity index
ď§ Life expectancy
⢠Availability and affordability
⢠Patientâs preferences
RADICAL
PROSTATECTOMY
RADICAL
RADIOTHERAPY
ACTIVE
SURVEILLANCE
29. ACTIVE SURVEILLANCE
Diagnosis progression metastasis Death by disease
Natural Death
Very low
low
Int. favorable
Int. unfavorable
Intermediate high
low Very high
high
⢠Gleason score 6
⢠PSA <10
⢠T1 â 2a
30. ACTIVE SURVEILLANCE
⢠Is not watchful waiting
⢠Actively monitoring disease status throughout
⢠Suitable for very low risk and low risk patients
⢠Monitoring by
⢠PSA velocity
⢠MRI
⢠Re-biopsy
Diagnosis progression metastasis Death by disease
Natural Death
34. Radical prostatectomy
⢠Open
⢠Laparoscopic
- Without
- With robotic assistance
Retropubic transperitoneal
radical prostatectomy
retropubic retroperitoneal
radical prostatectomy
laparoscopic
transperitoneal radical
prostatectomy
extraperitoneoscopic radical
prostatectomy robotic
assisted transperitoneal
radical prostatectomy
robotic assisted
extraperitoneoscopic radical
prostatectomy intrafascial
prostatectomy, transfascial
prostatectomy extrafascial
prostatectomy partial
prostatectomy sexuality
preserving prostatectomy
open perineal radical
prostatectomy robotic
perineal radical
prostatectomy veil of
Aphrodite procedure
complete posterior
reconstruction complete
anterior reconstruction
Roccoâs stitch
⢠Most effective local
clearance of localized
disease
⢠Most accurate biopsy to
design further treatment
⢠Incontinence
⢠Erectile dysfunction
⢠LUT dysfunction
35. Radical Radiotherapy
⢠3d-CRT
⢠IMRT
⢠With or without IGRT ** - preferred
⢠Non-invasive
⢠Incontinence
⢠Erectile dysfunction
⢠LUT dysfunction
⢠LGI dysfunction
36. Admissions MIS urology Rectal proceduresOpen surgery
Radical prostatectomy vs Radical Radiotherapy
⢠32465 men with CAP almost 1:1 open RP and RT
⢠32465 men without CAP comparator
Nam et al. Lancet Oncol 2014
37. Radical prostatectomy vs Radical Radiotherapy
⢠68665 men with CAP almost 1:2 RP and RT
Abdollah et al. Int J Urol 2012