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    Marion Swall, MIV USC School of Medicine

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    mynoidanh19
    Prostate cancer is the most common cancer and second leading cause of cancer death among American men, with approximately 190,000 new cases and 27,000 deaths annually. It ranges from well-differentiated tumors to aggressive cancers with a high potential for invasion and metastasis. Prostate cancer is typically now detected via elevated PSA levels during asymptomatic screening, with biopsy recommended at various PSA level and velocity thresholds. Staging is critical for guiding treatment, which may include radical prostatectomy, radiation therapy, androgen deprivation, chemotherapy, active surveillance, or ablation depending on the cancer's stage. Advanced prostate cancer can metastasize widely, especially to bones, and is associated with symptoms such as anemia, pathologic fractures, and

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    Marion Swall, MIV USC School of Medicine

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    mynoidanh19
    36 views18 pages
    Prostate cancer is the most common cancer and second leading cause of cancer death among American men, with approximately 190,000 new cases and 27,000 deaths annually. It ranges from well-differentiated tumors to aggressive cancers with a high potential for invasion and metastasis. Prostate cancer is typically now detected via elevated PSA levels during asymptomatic screening, with biopsy recommended at various PSA level and velocity thresholds. Staging is critical for guiding treatment, which may include radical prostatectomy, radiation therapy, androgen deprivation, chemotherapy, active surveillance, or ablation depending on the cancer's stage. Advanced prostate cancer can metastasize widely, especially to bones, and is associated with symptoms such as anemia, pathologic fractures, and

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    Prostate Cancer

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    Prostate cancer is the most common cancer and second leading cause of cancer death among American men, with approximately 190,000 new cases and 27,000 deaths annually. It ranges from well-differentiated tumors to aggressive cancers with a high potential for invasion and metastasis. Prostate cancer is typically now detected via elevated PSA levels during asymptomatic screening, with biopsy recommended at various PSA level and velocity thresholds. Staging is critical for guiding treatment, which may include radical prostatectomy, radiation therapy, androgen deprivation, chemotherapy, active surveillance, or ablation depending on the cancer's stage. Advanced prostate cancer can metastasize widely, especially to bones, and is associated with symptoms such as anemia, pathologic fractures, and

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    36 views18 pages

    Marion Swall, MIV USC School of Medicine

    Uploaded by

    mynoidanh19
    Prostate cancer is the most common cancer and second leading cause of cancer death among American men, with approximately 190,000 new cases and 27,000 deaths annually. It ranges from well-differentiated tumors to aggressive cancers with a high potential for invasion and metastasis. Prostate cancer is typically now detected via elevated PSA levels during asymptomatic screening, with biopsy recommended at various PSA level and velocity thresholds. Staging is critical for guiding treatment, which may include radical prostatectomy, radiation therapy, androgen deprivation, chemotherapy, active surveillance, or ablation depending on the cancer's stage. Advanced prostate cancer can metastasize widely, especially to bones, and is associated with symptoms such as anemia, pathologic fractures, and

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    Marion Swall, MIV

    USC School of Medicine


    Epidemiology
    Prostate cancer is the most common cancer & #2
    cancer killer in American men
    Approx 190,000 cases will be diagnosed annually
    Approx 27,000 deaths will occur
    Clinically ranges from a well differentiated tumor to an
    aggressive cancer with substantial invasive and
    metastatic potential.
    Screening
    Prostate cancer used to be detected by digital rectal
    examination (DRE) findings of asymmetric areas of
    induration or frank nodules
    Now, prostate cancer is usually detected by an elevated
    serum PSA & is asymptomatic at presentation
    PSA >10 ng/mL Prostate biopsy is uniformly
    recommended. 50% probability of cancer
    PSA 4 to 10 ng/mL Prostate biopsy is advised. Specificity is
    lower, 20% probability of cancer
    PSA > 2.6 ng/mL & if PSA Velocity is 0.75 ng/mL per year
    Prostate biopsy is advised
    PSA velocity >2 ng/ml per year is high risk for life threatening
    cancer

    Diagnosis
    Prostate biopsy is the gold standard
    Transrectal ultrasonography (TRUS) biopsy is a relatively
    simple procedure done in the office


    Transrectal ultrasound in sagittal plane
    demonstrating hyperechoic biopsy tracts (arrows)
    evenly spaced throughout the gland.
    Staging
    Staging is critical to guide treatment options given
    high morbidity of therapy.
    Endorectal coil MRI & TRUS with staging biopsy can
    be used to assess the local extent of disease.







    US shows an extensive, hypoechoic T3
    tumor with capsular irregularity on the
    right and posteriorly (arrowheads)

    US also suggests infiltration into the rectal
    wall (arrow).
    Staging Continued
    Endorectal coil MRI
    provides a more accurate
    estimate of seminal vesicle
    involvement or
    extraprostatic extension

    Endorectal MRI in a patient with extensive
    prostate carcinoma showing a bulge in the
    capsular outline on the right side. This is a
    stage T3 tumor.
    Treatment Options
    Depending on stage, management includes:
    Radical Prostatectomy
    External Beam Radiation Therapy
    Brachytherapy,
    Androgen Deprivation Therapy (ADT)
    Chemotherapy
    Active Surveillance
    Ablation
    Or the new ablation therapy HIFU
    HIFU or Hooey?
    High-Intensity Focused Ultrasound (HIFU ) pulses energy into an area about
    the size of a grain of rice creating a sharply delineated point of increased
    temperature, melting cell membrane lipids and denaturing proteins.
    HIFU is currently approved in Europe and South America
    Targeting is planned to avoid the urinary sphincter, rectum, and the
    neurovascular bundles
    Complications include urinary incontinence (6%), UTI (7%), obstruction
    (14%), pelvic pain (6%) & significant erectile dysfunction in 57%.
    Failure-free survival rates at five & seven yrs were 66 & 59% in T1 & T2 cancers
    However, pathologic involvement is often more extensive than on imaging
    Studies suggests that there is a substantial risk of under treatment of
    biologically significant disease using the focal ablation, emphasizing the need
    for careful patient selection based on estimated life expectancy and a thorough
    pretreatment biopsy scheme.

    So what happened?
    HIFU didnt work
    External Beam Radiation didnt work
    Androgen Deprivation Therapy didnt work
    Chemical castration didnt work
    Now what?
    Distant metastasis
    Hematogenous spread of prostate cancer cells is common with tumor
    growth preferentially occurs in bones of the axial skeleton, where red
    marrow is most abundant
    Metastatic lesions in bone are frequently symptomatic, causing pain,
    debility, and functional impairment
    Radionuclide bone scan with technetium-99m advised in patients with
    PSA levels >10 ng/mL
    Radionuclide Bone Scan
    Bone Scan Findings
    Multiple focal areas of increased radiotracer
    uptake (hot spots) on RN bone scan are
    classic for metastatic disease.
    Metastases appear as hot spots on RN bone
    scan due to increased osteoblastic activity.
    RN bone scans are very sensitive for
    detecting osteoblastic activity, but are non-
    specific, osteolytic & osteosclerotic
    metastases present similarly.
    Fractures, arthritis, and tumors all present
    as hot spots.

    Note: the tracer is cleared through the urine, hence the
    "hot" bladder.

    The Superscan
    With diffuse bone metastases, a "superscan" may be
    seen.

    This superscan
    demonstrates high uptake
    throughout the skeleton,
    with poor or absent renal
    excretion of the tracer.
    What do you see?
    Ivory Vertebra
    Note sclerotic
    vertebral body of
    normal size at L2

    Osteosclerotic metastases
    are most common from
    prostate & breast cancer
    Other possibilities
    include lymphoma,
    vertebral hemangioma, or
    Paget's disease.
    Osteosclerotic vertebra
    decreased in height likely
    to be a compression or
    healing vertebral fracture.

    What do you see?
    Femoral Findings
    The distal femur demonstrates an
    eccentric, sclerotic lesion with
    periosteal reaction at the edge of the
    lesion in the form of a Codman
    triangle.
    A Codman triangle is an aggressive
    pattern of periosteal reaction, but
    aggressive is not synonymous with
    malignant.
    Codman triangle occurs with
    malignant bone tumors and
    metastases, but also with osteomyelitis
    and/or hemorrhage.
    The End
    Manifestations of advanced prostate cancer include:
    anemia, bone marrow suppression, weight loss,
    pathologic fractures, spinal cord compression, pain,
    hematuria, ureteral and/or bladder outlet obstruction,
    urinary retention, chronic renal failure, urinary
    incontinence, and symptoms related to bony or soft-
    tissue metastases.
    Life expectancy now 9 months to 2 years

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