Prostate Cancer Expected Management & curative treatment

1. Prostate CancerExpected Management & curative treatment Dr. Abdullah A. Ghazi (R5) KSMC

2. Incidence of PC

3. Mortality of PC • Life time risk 17% • Dying 3.6% • Doubling time 2-4y. • 42% of men <50y die from other cause.

5. Watchful waiting: • Active surveillance:

6. Life expectancy in US, 2008

7. 157 pt. • T1c. • 0.2ml • GS ≤6 • No grade 4 or 5 by biopsy. • PSAD 0.1ng/ml/gm, <3 cores with tumor, not > 50%. • PSAD 0.15ng/ml/gm, <3mm cancer • Predict value for a significant disease 95% • 73% of their patients were insignificant tumor.

8. Active Surveillance • The aim is to avoid unnecessary treatment on low-grade tumor that not affect the life or health for the next 5-10y. • Life expectancy > 10y have risk of metastasis. • Compliance.

9. Active Surveillance • 31% will progress (GS, %specimen involvement, NO + biopsy

10. Active Surveillance • About ½ of the patient on AS remain free of progression within 10y. • Definitive treatment is appropriate in those with progression.

11. 299 pt. • 55M F/U, 60% remaining on AS. • At 8y: OS 85% DSS 99%

12. AS for whom? • Eligibility criteria: • Clinically confined PCa (T1-T2). • Gleason score < 7. • PSA < 15-20 ng/mL . • Prostatic biopsy (at 5y 83% have N sample)

13. AS progression • Criteria to define cancer progression: • PSAD: between < 2 and < 4 years; • Gleason score progression to > 7 at re-biopsy, at intervals ranging from 1-4 years.

14. SUMMARY • Pt with life expectancy <10y, GS ≤ 6 are suitable for AS. • AS may be safe alternative to immediate treatment in compliant men with low risk of progression.

16. Prostate Cancer • Immediate treatment → risk of overtreatment. • AS → risk of progression

17. Prostate Cancer • The pt with AS may become anxious with an untreated cancer. • AS is more appropriate for old pt’s with limited life expectancy.

18. Radical Prostatectomy • It is still the gold standard. • Wide use or RP due to: • Early detection (PSA & TRUS). • Anatomical development of preserve cavernosal nerve & external sphincter. (90%).

19. Radical Prostatectomy • Advantage: • Cure with minimal damage. • Accurate staging. • Smooth post-op course. • Rare need blood transfusion. • Hospital stay 1-3 days. • ↓local recurrence & distal metastasis vs WW. • Salvage of recurrence with RT.

20. Radical Prostatectomy • Disadvantage: • hospitalization. • Recovery period. • Risk of ED & incontinence.

21. Radical Prostatectomy • Surgical approach • Perineal: • Retropubic: • Laparoscopic: • Robotic:

22. Radical Prostatectomy • Salvage RP: • Has higher complication rate. • Incontinence 44% • Bladder neck contraction 22% Ward et al 2005

23. Radical Prostatectomy • Selection of pt for RP: • Life expectancy at least 10y (upper limit 75y). • Pre-op clinical & pathologic parameter.

24. Radical Prostatectomy • Contraindication of nerve sparing: • Extensive cancer in biopsy (>50%). • PSA > 10ng/ml • GS > 7 • Site of the tumor • T2 disease. • Adhesion of the NV bundle to the prostate. • Poor erection pre-op. • Lack of sexual relationship. • Medical illness adverse erection.

25. Radical Prostatectomy • Post-op ED should be D/W pt. • Complication of adjuvant therapy (HT, RT).

26. Radical Prostatectomy • Adverse prognostic feature: • Perineural invasion. • Extracapsular extension. • + surgical margin. • SV invasion. • L.N. metastasis. • High PSA is the early sign of recurrence.

27. Radical Prostatectomy • Complications: • Continent 90%. • Eerection: 95% 40y 50% 70y. • It return partially at 3-6M up to 3y. • Complications < 10%. • Mortality rare.

28. Radical Prostatectomy • Complication: • Early: • Hemorrhage • Injury to adjacent organs. • Urinary leak & fistula. • Thromboembolic & CVA events. • UTI. • Lymphocele. • Wound complication. • Late: • ED • Incontinence. • Urethral stricture.

31. RP is a reasonable option in a selected pt. • The pt must be inform about multimodal approach. • T3N0M0 PC (431pt) • Adjuvant RT • Better met-free survival with RT. Thompson • Adjuvant ADT vs observation in +LN • 11.9 f/u • Better OS with ADT. Messing et al

32. Pelvic LN dissection • Limited “Obturator. Ext.iliac”, 8-10. • Extend, 20. • Therapeutic role • Morbidity of eLND (x3) • Lymphoedema. • Lymphocele. • DVT. • PE

33. Pelvic LN dissection

34. Neoadjuvant HT with RP • Effect on pathology results ? • Pathology down-staging. • More organ confined. • Less + margin. • Less LN involvement. • Effect on OS & DFS.

35. Adjuvant HT with RP • No survival advantage.

38. RADIATION THERAPY • 3D-CRT • IMRT • It is comparable result with RP (?? Not the same end point). • Standard dose 76-80Gy. • IMRT limit outside radiation by 1-1.5cm.

39. RADIATION THERAPY • Side effect: • Microvascular injury. • IBS, rectal bleeding, bladder irritability, hematuria. • Relative C/I: • Prior TURP (urethral stricture, seeds of brachiotherapy not hold). • Severe LUTS. • IBD.

40. RADIATION THERAPY WITH HORMONAL • They include the locally advanced prostate cancer (T2c-4) • STAD-RT vs LTAD-RT. • Improvement of all end point with LTAD-RT except OS.

41. RADIATION THERAPY WITH HORMONAL • Increase OS in high risk group (more with LAD-RT).

42. RADIATION THERAPY • Endpoints for failure: • PSA ↓ within 2-3y. • PSA measurement Q6M. • PSA bounce. • Definition of PSA failure.

43. RADIATION THERAPY • Result: • 50% cure rate for clinically localized PC. • HT for 2-3y can be given after RT. • EB-RT can combined with brachytherapy.

44. BRACHYTHERAPY • Indication: • stage cT1b- T2a N0, M0; • Gleason score < 6 assessed on a sufficient number of random biopsies. • Initial PSA level of < 10 ng/mL. • < 50% of biopsy cores involved with cancer. • Prostate volume of < 50 cm3. • IPSS < 12.

45. BRACHYTHERAPY • To be given under GA or regional anesthesia. • Ioden-125 (145Gy), palladium-103(125Gy). • CT scan after implant. • Results: • Cancer control: 5y 85% 8y 80% progression-free survival rate.

46. BRACHYTHERAPY • S/E: • Urinary symptoms. • AUR 22%. • Need TURP 10% (risk of incontinence 20-40%). • 62-86% preserve erection. • Proctitis, rectal injury. • Migration. • Rectourethral fistula.

47. ADJUVANT RT AFTER RP • Given 67-64Gy. • Wait 3-4M. • Recent study → benefit. • Option: RT vs wait for PSA failure. • Most likely benefit is the + margin & extracapsular invasion.

49. ?? • Definition of PSA failure: • Post RP • Post RT

50. http://www.youtube.com/watch?v=A-5RiAxfbRY