1. EARLY DETECTION OF
CARCINOMA PROSTATE
Dr. U.K.Shrivastava
MBBS,MS,FAIS,DHA
Professor and Head of surgery
AIMST University, Malaysia

2. Anatomy and Function of Prostate
Situated in men in lower pelvis, at neck of
bladder and in front of rectum, plum size
It secretes alkaline fluid 1/3 of fluid in semen
Fluid from prostate, seminal vesicles and
Cowper's gland together make real bulk
semen ejaculations, nourishes sperms,
PSA comes from prostate epithelium, keeps
semen in fluid form, avoid coagulation

3. Anatomy

4. Anatomy

5. Prostate Cancer
Became commonly diagnosed cancer 1989
Generally affects after the age of 50 years
Starts in the peripheral zone of prostate
Second leading cancer death in male after lung
cancer
It is slow growing cancer, do metastasize
Most common type is adeno carcinoma
Early detection started from 1990 with PSA

6. MODALITIES
• SERUM P.S.A.
• DIGITAL RECTAL EXAMINATION
• TRANS RECTAL ULTRA SONOGRAM
• MAGNETIC RESONANCE IMAGING

7. SERUM P.S.A.
• serine protease, single chain glycoprotein
• It contains 90% amionoacids 10% glycopr
• organ specific marker not c.a. specific
• Mostly secreted from prostatic epithelium
• secreted mainly transitional zone BPH
• secreted mainly peripheral zone Ca.P
• Involved in liquefaction of seminal
coagulum

9. PSA
Useful in diagnosing and staging Ca P
Useful in monitoring response of treatmt.
Discovery of PSA is major advancement
It has been a most valuable tumor marker
Very useful in detecting early Ca prostate
Normal value ranges from o to 4.0ng/ml

10. P.S.A
Annual PSA testing is recommended from
50 years of age
If it is less than 1.0ng/ml every 5 years
If it is lower than 2.0ng/ml alternate year
If more than 2.0ng/ml get it every year
It is advisable to have from same LAB

11. PSA DENSITY
Introduced by Benson 1992
It is a quotient of serum PSA divided, by
volume of prostate gland
PSA level dependent on number of prostatic cells
Very high in BPH and also in CA prostate
This confirms cancerous cells leak more PSA
This facts help in detecting the malignancy
The volume measurement of gland is
achieved by TRUS
Density variable with age

12. Recent concept
Measurement of TZ volume by TRUS is
more reliable than measuring entire
prostate volume
upper limit of 0.15 higher incidence of CA
Most of the PSA entering the circulation
arise from TZ
But in cancer they come from PZ
CA cells produce more PSA per unit
volume

13. Prostate hyperplasia

14. Ca Prostate

15. PSA VELOSITY
It is a measurement of rate of change
in PSA volume over the time
Concept introduced by Carter et al
BPH patients will have linear rise in PSA
CA patients linear rise in beginning, later
exponential rise is PSA volume
Carter says 0.75ng/ml rise per year has
greater chance of developing CAP

16. AGE SPECIFIC PSA
REFERENCES
AGE
40 - 49 == 0– 2.5ng/ml
50- 59 == 0– 3.5 ng/ ml
60- 69 == 0—4.5ng/ ml
70- 79 == 0---6.5ng/ml
The importance of this is that –
It increases the sensitivity in men younger
than 60yrs of age and specificity in men older
than 60 years of age
Over all specificity 95%

17. PSA VELOCITY
Normal value 0- 4ng/ml
Half life 2 to 3 days
Rate of change non BPH 0--.04ng/ml/yr
BPH------.07 -0.27ng/ml/yr
0.75 ng/ml/yr risky CA
Any disruption in prostatic architecture-PSA
leaks in circulations

18. FREE PSA
Percentage of PSA circulates in blood without a
carrier protein ( unbound)
PSA gets bound to alpha 1 anti chymotrypsein
and alpha2 macroglobulin (ACT/AMG)
It also remains free in serum
PSA ACT found to be high in CAP
than in BPH
Free PSA low with inverse rise in PSA/ACT seen
in Carcinoma of prostate
Higher the free PSA in BPH

19. FREE PSA
As the percentage of f/PSA declines, the
probability of a cancer prostate increases
The f/PSA is more discriminatory in
distinguishing between cancer and BPH
Size <40cc percent f/PSA 0.137and low
detect 90% OF CAP
Size >40cc cut of point 0.205 detect90%CA

20. FACTORS INFLUENCING
SERUM PSA LEVELS
• Prostatitis
• BPH and Carcinoma
• Biopsy
• DRE
• TRUS
• Cystoscopy
• Ejaculation
• Variable with age/race/ volume
• U T I , vigorous exercise ,any sexual
drive

21. PSA
PSA screening recommended annually
all men >50 years
Family history, black men –PSA testing
at 40years
It is very helpful in detecting organ
confined cancer prostate
Total prostatectomy can achieve the cure

22. DIGITAL RECTAL EXAMINATION
Cancer detected by DRE are generally
locally advanced in50% of cases
Should never be abandoned, may detect
at times with normal serum PSA<4ng/ml
Positive predictive value of DRE
Serum PSA-- 0– 2.9ng/ml------4-11%
3.00-- 9.9ng/ml-----33—83%
DRE--- any nodule, hardness, fixity to R. mucosa

23. DRE
It should always be combined with
serum PSA testing for early detection
Always advisable to have DRE either
annually or twice in a year above 50
yrs
Any suspicious finding --- Advise TRUS
followed with sextant biopsy

24. DIGITAL RECTAL EXAMINATION

25. PSA/ DRE
PSA and DRE– complementary to each
other
25% men of Ca P have PSA < 4ng/ml
Cancer detected with DRE- 75%will have
metastasis
PSA – gets decreased after– orchiectomy,
LHRH agonist, Flutamide , 5 alpha
reductase inhibitor – helpful in medical treatment.
of BPH

26. TRUS
It helps in seeing deep into the prostatic
tissues and finds the hypo echoic zone
It detects the size of prostate
seminal vesicles
spread of ca beyond prostate
Not to be used1st line screening study
lacks specificity, expensive , not helpful
in diagnosis, if already detected by DRE/PSA

27. TRUS

28. TRUS
Limitation that ,most hypo echoic lesions
are not cancer
It could be cancer, infarct or even abscess
Always insure during bx for wide area sampling of
prostatic tissues
Indications--------- raised PSA
abnormal DRE
PZ 30-50% cancer may be of isoechoic
TZ up to 80% may be isoechoic

29. TRUS guided BX
It can be---
Directed biopsy
Sextant biopsy ,now 12 core bx done
Anterior biopsy from TZ
Lateral lobe biopsy
Extended field biopsy

30. Gleason Scores
1 The pathologist examine the bx cores and
assign the no 1-5to most common pattern seen
2 Grade of 1 means cancer cells more like a
normal cell
3 Pathologist further identifies the second
most common pattern and grade 1-5 so
it ranges from 2-10
4 5-7 common type of slow growing tumor
8-10 aggressive tumors

31. TRUS BX
Can be done as OPD procedure
it takes about 15 minutes
Precautions---- enema
local anesthesia
prior antibiotics
stop aspirin
Complications ---- haematuria
haemospermia

32. MRI (endo rectal coil)
This test is complimentary to TRUS
In the event of malignancy this tells about
the growth really confined to organ only
or gone beyond that
Involvement of seminal vesicles pelvic
lymph nodes and bladder can be
detected
It is expensive------ NOT a screening tool

33. ALGORITHM FOR EARLY
DETECTION
DRE PSA DIOGNOSTIC ACTION
Negative < age spec range annual PSA
and DRE
Negative > age spec. range TRUS bx
and sextant bx
Positive Any value TRUS bx and
sextant bx

34. ADVANTAGE
Help to pick up significant disease before
it becomes symptomatic
Help to monitor men who have higher risk of
developing cancer
Help to pick up aggressive cancer early
when treatment is feasible
Help in investigating the prostatic disease
when the value of PSA high

35. DISADVANTAGE
2/3 of men with raised PSA --- no cancer
Some with normal PSA can have cancer
It does not tell whether cancer is fast/ slow
nature
Slow growing cancer does not affect the
life of the patient to that extent
Raised value demands bx its own hazard

36. CONCLUSION
To screen or not to screen ?
Screening supported by—
Disease is burdensome
PSA detects curable tumor
No cure for metastatic diseases
PSA levels are strong predictor of future CA
Studies are still on for guidelines for early
detections of carcinoma of prostate

37. PREVENTION
AND SUPPLEMENTS
• If its Heart Healthy---its Prostate healthy
• Whatever is good for heart, good for Pros
• Univ. of Arizona work on Selenium.
• Role of natural Vitamin E d gamma
tocopherol ,d alpha tocopherol,best
dietary
• found, in soya products,tofu,soya nuts
• Omega-3fatty acids good role
• Heart healthy oil-Soya, canola and ,Olive

38. Supplements
• Plant estrogen supplements- by reducing
• androgen, but can lead to Erectile dysf.
• Breast tenderness, loss of libido hair loss
• and DVT
• Use of Aspirin good but bleed tendency
, salicylic acid found in fruits and vegi.
Use of Soya very good in , in all forms

39. Supplements
• Drugs
a Androgen
b Dutastride
Exercise always good
Keep cholesterol low and HDL high