Prostate Segmentation Challenge and MR-guided Prostate Biopsy
Ca prostate
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Transcript of Ca prostate
By Dr Ahmed Rehman
FCPS (URO)Assistant Professor UROLOGY
CA prostate Incidence and EpidemiologyMost common cancer diagnosed in males
>65
second commonest cause of death from cancer in the western world
1 in 6 men (FUNCTIONING TESTIS) will get prostate cancer
Role of ethnicity & geography
PSA testing has had a major impact
Mo among Men in the United States
Cancer Incidence Rates* for Men, US, 1975-2000
0
50
100
150
200
250
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1976
1977
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1979
1980
1981
1982
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CA prostate mortality
Risk Factors AgeRaceFamily history/age of onsetDiet / fatCadmium, cigaretteSuspected but Not confirmed
Vasectomy Infections sex
Etiology Oncogene
Familial CAP ----chromosome 1Suppresser gene
8p,10p,13p,16q,17p, 18p, p53Epithelial stromal interactions/growth factors
PathologyClassification
>95%------------------ adenocarcinoma 5%------------------
90%--------------TCC 10%--------------neuroendocrine (small cell) CA --------------sarcomas
PROSTATE CANCER Tumor distribution
% of glandular % of glandular tissue in tissue in prostateprostate
% of cancers% of cancersin zonein zone
10% 25% 65%
5-10% 70%20%
Oesterling J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1322-1386.
Transition zone Central zone Peripheral zone
Histopathological Grading Gleason grading system
Grade 1-5Score = primary + secondary grade
Well diffentiated (G1) 2-4 Mod diff (G2) 5-6 ??? 7(primary ?) Poorly dif (G3-4) 8-10
Prognosis
Early Disease : asymtomaticEarly Disease : asymtomatic• Peripheral zone: none• Transition zone: LUTS / UTIs / retention
Progressive DiseaseProgressive Disease• Hematuria, Hematospermia, Decreased ejaculate
volume• Impotence
Advanced DiseaseAdvanced Disease• Bone pain (back) & pathological #• Cord compression / nerve involvement
» Paraesthesias / weakness» Urinary / fecal incontinence
• Constitutional symptoms • Obstructive uropathy• Bleeding tendencies / DIC, anemia, pancytopenia• Limb edema, Intestinal obstruction,
Lymphadenopathy• Other manifestations of distant mets
SIGNS AND SYMPTOMS / PRESENTATIONS
Detection of cancer: the challengeDRE----- s/s-----------????????PSA------s/s-----------?/////////
Prostate specific but not cancer specificOther causes
BPH size of prosate Acute & CH prostatitis(TB), prostatic abscess Manipulation, instrumentation, biopsy
Poorly diff CA --- not raised
Detection of Prostate Cancer ; The Challenge
• DRE
• PSA
Currently, clinical practice guidelines recommend the use of both PSA and
DRE in asymptomatic men
Establishing the diagnosis----- TRUS & Biopsy
Staging Local
DRE, serum acid phosphatase, TRUS,CT / MRI / Endorectal MRI -pelvis
Skeletal & visceral mets (bone, lung, liver) Bone scan, Alkaline phosphatase (asymptomatic,PSA <10, >30) CXR, CT scan abdomen
Nodal (high risk----surgery /radiotherapy) Involvement <10% Sensitivity as low as 22-36% CT /MRI (FNA), sampling / frozen sections
Negative bone scan,PSA>20, T3, gleason ggade (p) 4/5
PROSTATE CANCER Stage I
T1 Clinically inapparent tumor not palpable nor visible by imaging
G1 Well differentiated (slight anaplasia) T1a No MO G1
T1a Tumor incidental histologic finding in 5% or less of tissue resected
N0 No regional lymph node metastasis
M0 No distant metastasis
T1a N0 M0 G2, 3-4 T1b N0 M0 Any G
T1a Tumor incidental histologic finding in 5% or less of tissue resected
T1b Tumor incidental histologic finding in more than 5% of tissue resected
N0 No regional lymph node metastasis
M0 No distant metastasis
T1c N0 M0 Any G
T1c Tumor identified by needle biopsy (e.g., because of elevated PSA)
T1 clinically inapparent tumor not palpable nor visible by imaging
PROSTATE CANCER Stage II
T2a N0 M0 Any GT2b N0 M0 Any G T2c N0 M0 Any G
T2a Tumor involves one lobe
T2b Tumor involves both lobes
N0 No regional lymph node metastasis
M0 No distant metastasis
T2 Tumor confined within prostate*
*Note: Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, classified as T1c.
PROSTATE CANCER Stage II ( Cont’d)
T3a N0 M0 Any GT3b N0 M0 Any G
T3c N0 M0 Any G
T3a Extracapsular extension(unilateral or bilateral)
T3b Tumor invades seminal vesicle(s)
N0 No regional lymph node metastasis
M0 No distant metastasis
T3 Tumor extends through the prostate capsule*
*Note: Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is not classified as T3, but as T2.
PROSTATE CANCER Stage III
T4 N0 M0 Any GAny T N1 M0 Any GAny T Any N M1 Any G
T4 Tumor is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
M1 Distant metastases
M1a Nonregional lymph node(s)
M1b Bone(s)
M1c Other site(s)
N1 Metastasis in regional lymph node or nodes
PROSTATE CANCER Stage IV
Lung
Bone
Liver
Epidural space
PROSTATE CANCER Distant metastatic spread
Natural History of Disease Latent / indolent CAVirulent
Clinically manifested disease Time of onset & doagnosis
Localized Locally advanced Metastatic Hormone refractory (HRCAP/ AICP)
Clinicallylocalized
Hormonerefractory
Local treatment Endocrine Chemotherapy
Relapsedand
newly diagnosed M+
Treatment: Localized DiseaseT1-2Options
Watchful waitingRadical prostatectomy ( Young/ Millon /
Walsh) Margin +ve adjuvent radiation radiation at relapse
Neoadjuvent hormone therapy + surgeryRadiation
External beam Brachytherapy
cryosurgery
Treatment: Locally Advance DiseaseT3-4Options
RadiatonNeoadjuvent hormone therapyradiation
2months before & during
Treatment: Recurrent DiseaseFollowing RP
Radiation
Following RXT Salvage RP cryosurgery
Treatment: Metastatic DiseaseAny T,M+N+
Options Hormone therapy (70-80%)
Testosterone Pituitary gonadal axis 95% testes 2% Free
cellDHTRECEPTORnucleus/transcription Surgical ablation
Bilateral Total orchidectomy Bilateral Subcapsular orchidectomy /
prosthesis Medical ablation
Treatment: Metastatic Disease/ Medical ablationPituitary -------Diethylstilbesterol (Hanovan)
LHRH Agonists Goserelin (zolladex) Leuoprolid Leuprorelin (Lucrin)
Adrenals------- Ketoconazole (DIC /cord compression) Aminoglutithemide
Prostate --------Antiandrogens Pure Antiandrogens Flutamide
(Eulexin/Flutamida) Nilutamide Bicalutamide (Casodex) Steridal / Progestational
Antiandrogens Ceproterone
Acetate (Androcur) Mesesterol acetate
Treatment: Metastatic DiseaseComplete androgen blockade
Testicular +adrenalLHRH/ orchedectomy + antiandrogensBetter initial & prolong response but not
confirmed by others. Intermittent androgen blockade
?delays refractory stateEarly versus late blockade
Veteran’s ----- no survival benefitMRC -----better survival + less
complication rate
Treatment: HRPC ChemotherapyWhy refractory incomplete blockade / resistant cells
Responsiveness time 18 months-3years
Logivity 6-9 / 12 months
No standard chemotherapy regimen has been defined
Early Management of Endocrine Failure:discontinution / addition of antiandrogrns
No single agent or combination had improved survival in randomised trials
Complete remissions were rare
Physicians were reluctant to use chemotherapy in prostate cancer
Androgen-independent prostate cancer may respond toWithdrawal of anti-androgensKetoconazoleCorticosteroids prednisoloneAminoglutethimideAnti-androgensOestrogensProgestational agentsChemotherapy estramustine,mitoxantrone,
vinblastine etoposide, cyclophosphamideNovel agents paclitoxel, Docetaxel
Clinicallylocalized
Hormonerefractory
Local treatment Endocrine Mitoxantrone+Pfor symptoms
Relapsedand
newly diagnosed M+
PROSTATE CANCER Treatment Paradigms
No survivalbenefit
Clinicallylocalized
Hormonerefractory
Local treatment EndocrineTaxotere + P
q3 wks
Relapsedand
newly diagnosed M+
PROSTATE CANCER Treatment Paradigms
Improves SurvivalImproves SurvivalImproves SurvivalImproves Survival
A multimodal approach to evaluating and treating a patient with androgen – insensitive prostate cancer
VOL. 5 SUPPL. 3 2003 REVIEWS IN UROLOGY
PROSTATE CANCER (HRPC / AIPC) Multi-modality Team
VOL. 5 SUPPL. 3 2003 REVIEWS IN UROLOGY
Prostate cancer: algorithm
(DRE, TRUS, CT + bone scan)
• Surgery• Radiotherapy • Adjuvant
hormones
Presentation
Diagnosis
MetastaticLocalised Locally advanced
• Hormone therapy
• Surgery + neoadjuvant hormone therapy
• Radiotherapy ± hormone therapy
• Hormone therapy
Local control PalliativeCurative Observation
(symptoms/PSA)
(biopsy)
Staging
CT = computed tomography; DRE = digital rectal examination; PSA = prostate-specific antigen; TRUS = transrectal ultrasound