Prostate cancer

The prostate secretes fluid that nourishes and protects ________

Sperm

What is the most common malignancy in males in the United States?

Prostate cancer

Incidence of prostate cancer in men

1 in 8

Family predisposition is responsible for ___ of cases

5-10%

___ leading cause of cancer death in men

2nd

The chance of getting prostate cancer increases rapidly after age ___

50

Incidence ________ with age.

Increases

Approx. ___ of cases occur in men 65 years and older

60%

70% higher in ________ than in other races

Black men

Having a ________ with prostate cancer more than doubles a man’s risk of developing this disease

Father or brother (risk higher if brother)

What genetic syndromes and mutations associated with prostate cancer?

BRCA1 and 2 mutations and Lynch syndrome

________ increase the risk of developing fatal prostate cancer

Obesity and smoking

Prognostic indicators for prostate cancer

Tumor stage and histologic differentiation

Prostate-specific antigen level (PSA)

Lymph node status

What age should relatively healthy men at average risk begin to have a conversation with their health care provider about the benefits and limitations of PSA testing?

50

What age should black men or those with a close relative diagnosed with prostate cancer before the age of 65 start discussing screening?

45

What age should those with several close relatives diagnosed at an early age and BRCA mutation carriers start discussing screening?

40

Clinical presentation

Asymptomatic in early stages

Weak urine flow

Interrupted urine flow

Difficulty starting urine flow

Frequent urination, especially at night (nocturia)

Hematuria

Pain or burning with urination

Advanced prostate cancer commonly spreads to ________

Bone

Prostate cancer screening

Clinical exams: H&P, Digital Rectal Exam (DRE)

Laboratory exams: CBC and blood chemistry, Serum PSA

Radiographic imaging: CT of pelvis and abdomen, MRI of pelvis and abdomen, Chest x-ray, Bone Scan, Transrectal US

Biopsy: Needle bx of prostate (transrectal, US guided and/or with MRI fusion

What is DRE?

Used to palpate the prostate and feel for abnormalities or enlargement of the prostate and of the seminal vesicles

PSA normal range

1-4

Most prostate tumors are multifocal and develop in the ________ of the prostate

Peripheral glands

Can prostate cancer have distant mets?

Yes

Prostate cancer can invade which routes?

Perineural spaces, lymphatics, and blood vessels

What is the order of lymphatic drainage?

a. Common iliac

b. External iliac

c. Hypogastric

d. Periaortic

e. Periprostatic and obturator nodes

e, b, c, a, d

Gleason scoring system

Based on how it looks under a microscope (morphology). Scores range from 2 to 10 and indicate how likely it is that a tumor will spread

Low Gleason score indicates what?

The tissue is close to normal and the tumor is less likely to spread

High Gleason score means what?

The tissue is very different from normal and the tumor is more likely to spread

Most common pathology

Adenocarcinoma

How is staging determined?

Gleason score is considered in grading

DRE findings and imaging studies determine the stage of the disease

Since prostate cancer is slow-growing, ________ is acceptable in early-stage diagnosis

Watchful waiting

Which patients receive radiacal prostatectomy?

Cancer confined to the gland (T1, T2)

Life expectancy of at least 10 years

Post-op radiation is used when

1. PSA does not decrease to the undetectablerange immediately after prostatectomy, signaling that all tumor has not been removed

2. PSA is undetectable after surgery, but tumor margins contain tumor or seminal vesicles are involved

3. PSA is undetectable immediately after surgery but after a period begins to rise.

Doses (non-SBRT)

64-66 Gy - when undetectable PSA

70 Gy - when rising PSA levels

Hormonal therapy

Considered ineffective alone, but plays a large part in shrinking or limiting growth of the tumor by halting the proliferation of prostate cells by cutting supply of testosterone

What is mainstay treatment?

MAB (maximum androgen blockage)

• mimics result of orchiectomy which minimizes testosterone

Chemotherapy

Limited for cancer that has spread outside of prostate

• Single-agent doxorubicin (Adriamycin), cyclophosphamide

Most often used as primary treatment if patient has intact prostate gland but can be used in lieu of the the brachytherapy boost

SBRT

SBRT doses

Treated to the GTV to 45Gy and PTV to 40Gy

Conventional doses consist of 76 Gy in 38 fractions with 2.0 Gy per fraction

low or intermediate-grade prostate cancer

Proton

Low entrance and no exit dose

Right and left lateral fields, 76-82 Gy

Laterals don’t work well with seminal vesicle coverage (too much rectal coverage because vessels wrap around rectum) patients with more extensive tumors benefit greater from proton therapy

Seeds are distributed ___ cm apart, approx. 25 needles and 100 seeds

1

Permanent isotopes

I-125, Pd-103, Cs-131

Uses a grid or template against the perineum with the patient in the ________ position

Dorsal lithotomy

Dose for implant alone

I-125 160 Gy to prostate plus margin

HDR dose

Iridium-192 (Ir-192), 7 fractions of 6.5 Gy over 3.5 days for a total dose of 45.5 Gy

Patients with significant risk of tumor extension outside the prostate capsule receive ________

Brachy boosts

5-year survival rate

98%

Common side effects of radiation

Acute GI side effects: diarrhea, abdominal cramping, rectal discomfort, rectal bleeding

Severe late sequelae: persistent proctitis (inflammation of the rectum lining), rectal bleeding, and ulceration

Sexual impotence (erectile dysfunction)