Prostate cancer is the most common non-cutaneous cancer in men in North America. Risk factors include advancing age, family history, and African ancestry. Early stages are often asymptomatic, while advanced stages can cause urinary issues, bone pain, and weight loss. Diagnosis involves a PSA test, digital rectal exam, and prostate biopsy. Pathology determines Gleason score and grade. Treatment depends on risk level and includes active surveillance, surgery, radiation, hormone therapy, and chemotherapy. Advanced disease focuses on disease control and palliation of symptoms.
2. Most common non-cutaneous
malignancy in men in North America
2nd most common cause of cancer-
related deaths in men
1 in 7 men will be diagnosed WITH PR_ CA
Lifetime risk of being diagnosed with
prostate cancer is 18/100 but risk of
dying of prostate cancer is only 3/100
5. Early stages usually asymptomatic
Most cases detected by serum PSA
screening
Palpable nodule or firmness on DRE
Advanced stages
Urinary retention/renal failure
Bone pain
Anemia
Weight loss, fatigue
Spinal cord compression
6.
7. Fusión TMPRSS2-ERG
• En hasta 80% de los cánceres de próstata
• ERG es un factor de transcripción
– Proliferación
– Fenotipo resistente a la castración
• TMPRSS2 es un gen que responde al AR
– Es una serina proteasa
• Es una diana molecular potencial
– El silenciamiento ERG con RNAi disminuye
proliferación
8. Prostate cáncer diagnosis
Indications for transrectal ultrasound (TRUS)
guided biopsy
Palpable nodule on DRE
Elevated serum PSA
Biopsy involves 10-18 needle cores taken mostly
from the peripheral zone of the prostate
Transrectal ultrasound alone/CT scan/MRI not
sensitive enough to make the Diagnosis
9. Enfoque diagnóstico – Cáncer de Próstata
Enfoque
diagnóstico –
cáncer de
próstata
Síntomas
urinarios o
PSA anormal
Evaluación
rectal digital
(DRE) / PSA
(si falta)
DRE: Normal
PSA: Normal
PSA de 2, o
menos
PSA de 2+
Velocidad PSA
0.75+/año
TRUB
Repetir 1-3
años
DRE: Anormal
o
PSA: Anormal
TRUB
PSA 10, o menos
+ PSA libre 15%
o menos
Repetir en 6
meses
TRUB: Biopsia transrectal eco-dirigida
PSA: Antígeno específico de próstata
No
Si
No
PSA 10+
16. PATHOLOGY GROUPINGS IN PROSTATE
CANCER
• GROUP 1
– Gleason score 3+3, or less.
• GROUP 2
– Gleason score 3+4
• GROUP 3
– Gleason score 4+3
• GROUP 4
– Gleason total score 8
• GROUP 5
– Gleason total score 9 or 10
17. Prostate cáncer staging
Can spread to adjacent organs (seminal
vesicles, bladder), lymph nodes, bone
Most bone mets are osteoblastic
Prior to initiating treatment consider
Bone scan (PSA>10, Gleason Score >7)
CT scan pelvis/abdomen (PSA >10, Gleason
Score >7))
These tests are typically not required in
asymptomatic men with low risk prostate
cancer
18. Maniobras de estadificación
• Consideraciones
– Tumores MUY tempranos pueden no necesitar estudios
adicionales para metástasis a distancia
• T1c/T2a; PSA de 10, o menos; Gleason 6, o menos.
• RM de próstata con antena rectal – para planeación terapia
– Tumores MUY avanzados pueden ser investigados con:
• Gammagrafía ósea / TAC de tórax, abdomen y pelvis
– Tumores POTENCIALMENTE avanzados pueden beneficiarse de:
• RM corporal total
• El PET-CT es ineficaz en cáncer de próstata
– Tumores candidatos a terapia local (Prostatectomía /
Braquiterapia) o candidatos a Radioterapia
• RM Multiparamétrica de próstata con antena rectal
20. Carcinoma de Próstata
TNM
• T1 - Tumor primario no aparente clínicamente ni visible por imágenes.
T1a - Hallazgo incidental que compromete <= 5% del tejido resecado.
T1b - Hallazgo incidental que compromete > 5% del tejido resecado.
T1c - Diagnóstico obtenido por biopsia ciega inducida por un PSA
elevado.
• T2 - Tumor confinado a la próstata.
T2a - Compromete la mitad o menos de un lóbulo.
T2b - Compremete más de la mitad de un lóbulo.
T2c – Compromiso de ambos lóbulos prostáticos
• T3 - Tumor que se extiende más allá de la cápsula prostática.
T3a - Extensión extracapsular.
T3b - Invade la vesícula seminal.
• T4 - Fijado a otras estructuras distinto a las vesículas seminales.
• N1 - Ganglios linfáticos comprometidos.
• M1 - Metástasis a distancia.
M1a - Ganglios linfáticos no regionales.
M1b – Huesos.
M1c - Otros sitios.
21. Grado T1a T1b T1c T2a T2b T2c T3a T3b T4 N1 M1 PSA
1 I I I I IIa IIa IIIb IIIb IIIb IVa IVb <10
1 IIa IIa IIa IIa IIa IIa IIIb IIIb IIIb IVa IVb 10-20
2 IIb IIb IIb IIb IIb IIb IIIb IIIb IIIb IVa IVb <20
3 IIc IIc IIc IIc IIc IIc IIIb IIIb IIIb IVa IVb <20
4 IIc IIc IIc IIc IIc IIc IIIb IIIb IIIb IVa IVb <20
1-4 IIIa IIIa IIIa IIIa IIIa IIIa IIIb IIIb IIIb IVa IVb ≥20
1-4 IIIb IIIb IIIb IVa IVb Any
5 IIIc IIIc IIIc IIIc IIIc IIIc IIIc IIIc IIIc IVa IVb Any
Any Any Any Any Any Any Any Any Any Any IVa IVb Any
Prostate cancer staging system
22. Very low risk (must fulfill all)
T1c
Grade Group 1
PSA less than 10
Less than 4 core+, with less
than 50 per-cent cancer in
each
Psa density less than 0.15
23. low risk (must fulfill all)
T1-T2a
Grade Group 1
PSA less than 10
30. Early stage Prostate cáncer
treatment
Early stage Cancer
1. Radical Prostatectomy
2. External Beam Radiotherapy
3. Radioactive Seeds (Brachytherapy)
4. Active Surveillance
5. Observation – Watchful Waiting
31. Early stage Prostate cáncer
treatment: radical prostatectomy
Radical Prostatectomy
Complete surgical removal of entire prostate,
seminal vesicles
Considered a good treatment for men <70
years of age with clinically organ confined
cancer who are healthy
Open or laparoscopic/robotic approaches
33. radical prostatectomy:
complications
<10% risk of blood transfusion
Wound infection
Rectal injury (<1%)
Urinary incontinence (~10%)
Erectile dysfunction (variable but common)
Anesthetic related
34. Prosate cancer treatment:
radiotherapy
Radiotherapy Options
External Beam
Brachytherapy (seed implant)
Concept of maximizing dose to the tumor and
minimizing collateral damage
Curative options for patients at high risk for
morbidity from radical prostatectomy
Age, medical co-morbidities
Patient preference
40. Active surveillance
Observing low grade tumors in men <70 yrs and >10 yr
life expectancy
Delay definitive treatment until it is necessary and
cancer is still curable
Goal is to delay potential treatment-related morbidity
Monitor DRE, PSA, and periodic repeat biopsy
Ideal candidate:
PSA < 10
Normal DRE
Gleason <7 (low grade)
Only 1-3 / 12 biopsy cores positive
41. Watchful waiting
Observing low grade tumors in men
>70 yrs or <10 yrs life expectancy
Institute hormonal therapy when
patient becomes symptomatic
No curative intent
42. Todos:
T1c (detectado por PSA)
Grupo 1 (Gleason 3 + 3)
PSA<10
<3 cores positivos
≤50% de tumor por core
Densidad de PSA <0.15
Vigilancia activa
Todos:
T1-T2a (Compromiso <50% de un lóbulo)
Grupo 1 (Gleason 3 + 3)
PSA<10
Vigilancia activa
Cualquiera:
T2b-T2c (>50% de un lado o bilateral)
Grupo 2 (Gleason 3 + 4), 3 (Glason 4 + 3)
PSA 10-20
Tratamiento
Ultrabajo
Bajo
Intermedio
CaPróstata
43. Cualquiera
T2b-T2c (>50% de un lado o bilateral)
Grupo 2 (Gleason 3 + 4), 3 (Glason 4 + 3)
PSA 10-20
Favorable
Intermedio
CaPróstata
1 solo core afectado
y grupo 1 o 2, y <50%
de tejido afectado
Desfavorable
>1 core afectado, o
grupo 3, o >50% de
tejido afectado
Radioterapia Radioterapia + bloqueo
androgénico corto
44. Alguno
T3a
Grupo 4 o 5 (Gleason 8-10)
PSA>20
RT + ADT
Alguno:
T3b-T4
Gleason primario 5
>4 cores con Grupo 4 o 5
RT + ADT
Alto
Ultra-alto
CaPróstata
48. Advanced or metastatic prostate
cancer
Not curable disease
Goals shift to disease control
Development of cancer cells unresponsive
to androgen deprivation
Typically occurs slowly over time, although
it can occur rapidly
49. Treatment strategies for
metastatic prostate cancer
Androgen Deprivation (Hormonal Rx)
Orchidectomy
LHRH analogues
Antiandrogens
Supportive therapies
Analgesics
Steroids
Bisphosphonates/Vitamin
D/Calcium for bone health
Chemotherapy
Taxotere, Docetaxel
Last line of treatment