carcinoma of the prostate pptx - د.عدي

prostatic cancer

CARCINOMA OF THE PROSTATE

Prostate cancer is the most common cancer detected in American men.
prostate cancer is the second leading cause of cancer death for men.
mortality rates have been declining since the mid-1990s.

prostatic cancer

unlike most cancers, which have a peak age of incidence, the incidence of CaP continues to increase with advancing age.
The probability of CaP developing in a man under the age of 40 is 1 in 10,000; for men 40–59 it is 1 in 100, and for men 60–79 it is 1 in 8.
many prostate cancers are indolent , while others are virulent, and if detected too late or left untreated, they result in a patient’s death.

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Risk Factors For Prostate Cancer

Age.
Black race.
Chemicals.
Diet.
Family history .

prostatic cancer

Pathology

Over 95% of the cancers of the prostate are adenocarcinomas.
Of the other 5%, 90% are transitional cell carcinomas, and the remaining cancers are neuroendocrine (“small cell”) carcinomas or sarcomas.
Approximately, 60–70% of cases of CaP originate in the peripheral zone, while 10–20% originate in the transition zone, and 5–10% in the central zone.

prostatic cancer

Grading

The Gleason grading system is the most commonly employed grading system.
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 and the score range from 2 - 10.

prostatic cancer

Staging

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prostatic cancer

Clinical Findings A. SYMPTOMS

Most 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 vertebral column with impingement on the spinal cord may be associated with symptoms of cord compression.
Bone pain due to metastasis to bone( osteoblastic lesions).

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SIGNS

• General Examination .

• Abdominal Examination ( palpable kidney or mass due to metastasis to liver or adrenals).
• DRE.
• Specific signs of cord compression relate to the level of the compression.
• Lymphedema of the lower extremities.
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C. LABORATORY FINDINGS

Azotemia can result from bilateral ureteral obstruction Either from direct extension into the trigone or from retroperitoneal Adenopathy.
Anemia may be present in metastatic Disease.
Alkaline phosphatase may be elevated in the Presence of bone metastases.
Serum acid phosphatase may Be elevated with disease outside the confines of the prostate.

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TUMOR MARKERSPROSTATE-SPECIFIC ANTIGEN PSA

PSA is a serine protease produced by benign and malignant prostate tissues.
It circulates in the serum as uncomplexed (free) or complexed (bound) forms.
Normal PSA values are those ≤4 ng/mL.
Unfortunately, PSA is not specific for CaP, as other factors such as BPH, urethral instrumentation, and infection can cause elevations of serum PSA.

prostatic cancer

PSA
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Attempts at refining PSA have included:

• PSA velocity (change of PSA overtime).
• PSA density (standardizing levels in relation to the size of the prostate).
• age-adjusted PSA reference ranges
• PSA forms (free versus total of PSA).

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Differential Diagnosis

Not all patients with an elevated PSA concentration have CaP.(BPH, urethral instrumentation, infection, prostatic infarction, or vigorous prostate massage)
Not all patients with an Induration of the prostate have CaP.(chronic granulomatous prostatitis, previous TURP or needle biopsy, or prostatic calculi).
Not all patients with sclerotic bony lesion and elevated alk. phosphatase have CaP.(Paget disease)

prostatic cancer

IMAGING

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1. TRUS (transrectal ultrasound):
is useful in performing prostatic biopsies and in providing local staging information if cancer is detected.
Almost all prostate needle biopsies are performed under TRUS guidance. This makes lesion-directed biopsies possible.
If visible, CaP tends to appear as a hypoechoic lesion in the peripheral zone.

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2. Endorectal (MRI).

3. Axial imaging (CT, MRI).

4. Bone scan.

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Screening for CaP
Any male ≥ 50 years of age should underwent annual DRE and PSA test .
Screening to date has resulted in considerable stage migration (more lower stage cancers being detected) and morality rates are falling.

prostatic cancer

Treatment

A. LOCALIZED DISEASE (T1 and T2)
Currently, treatment decisions are based on the grade and stage of the tumor, the life expectancy of the patient, the ability of each therapy to ensure disease-free survival, its associated morbidity, and patient and physician preferences.

1- Active Monitoring or Watchful Waiting

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2. Radical prostatectomy

prostatic cancer

3. Radiation therapy

external beam therapy
brachytherapy

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4- Cryosurgery

5-high-intensity focused ultrasound
(HIFU)

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b. Locally invasive ca.( T3 )

Neoadjuvant hormonal therapy followed by radiotherapy.
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c. METASTATIC DISEASE

Hormonal therapy
Androgen blockade therapy
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There are four general forms of ADT:

• ablation of androgen sources.
• inhibition of androgen synthesis.
• antiandrogens.
• inhibition of LHRH.

prostatic cancer

Hormone-Refractory Prostate Cancer

Although androgen deprivation therapy (ADT), is extremely effective initially, virtually most of the patients eventually develop clinical evidence of resistance to treatment(poor prognosis).
Management:
• Add or Stop antiandrogens.
• 2nd . Line hormonal therapy.
• Chemotherapy ( as docetaxel or paclitaxel + estramustine+ prednisolone).
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