Prostate Cancer

Monday, 10 September 2018 8:01 AM

• PSA - prostate specific antigen. Lytic agent for semen. Without PSA wouldn't have sper
transport
• Prostate - helps bulk up sperm

Prostate cancer
• Most commonly diagnosed cancer in men over 50
• 3500 diagnosed annually
• 600 die every year
• Inequities between maori and non-maori (due to access to healthcare. Diagnosed very
in maori/pacific)

• 10% are inherited

• 1st degree relative - 20% risk
• 2nd degree relative - 50% risk
• 3 first degree relatives - 100% risk
• Need to ask about family hx, very important, similar to breast (BRCA gene)

• Advanced prostate cancer is incurable

• No known prevention
• Some cancers are latent and don’t require immediate intervention
• Some cancers are incurable even with early detection
• Early detection will find cancers at an earlier and therefore more curable stage

Prostate cancer tests

• Digital rectal exam (DRE) - need to know limitations. If small cancer can't feel - missed
diagnosis
• PSA - high PSA in blood, it MIGHT indicate underlying prostate cancer. But big prostate
make lots of PSA so it's not a diagnostic test. if PSA is normal, can still have an aggressi
anaplastic cancer. Limitations.
• Prostate biopsy (only method of confirming diagnosis)
• Multi-parametric prostate MRI - ONLY imaging modality that can see malignancy insid
the prostate. Ultrasound will never show a cancer in the prostate.
• PSMA PET/CT scanning

DRE
• Must be done
• Normal DRE doesn't rule out
rm

y late

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ive

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 the prostate. Ultrasound will never show a cancer in the prostate.
• PSMA PET/CT scanning

DRE
• Must be done
• Normal DRE doesn't rule out
• Abnormal doesn't include it always
PSA
• Biomarker in 1970s
• Monitor disease progress
• First line screening for prostate cancer
• A crude biomarker - prostate size, infection, age, may not reflect grade or tumour burd
Prostate cancer mortality rates dropped by more than 40% from 1991 to 2009 - demonstrate
strength of early detection
Watch PSA increase over time
Set realistic PSA reference ranges for age
PSA testing increases change of detecting cancer at a curable stage
Treatment offers high cure rates for majority of tumours
Avoid morbidity of advanced disease

Prostate biopsy
• US guided
• Transrectal biopsies - infection risk (sepsis), may be done under LA
• Transperineal biopsies - low risk of infection, accurate, ability to take large number of
cores, needs specialized equipment. Needle through skin behind scrotum and in front
rectum so infection risk is very low

Transrectal biopsy
• Far from perfect as a diagnostic exam
• US not effective at detecting cancer
• 2/3 provide no useful data
• Clinically sig cancers usually found by chance
• Cancers that are found are often inappropriately sampled
• Risk of complications

Transperineal
• Needle goes up through perineum into prostate
• No risk of infec, very easy to do but need specialised equipment

MRI
• All about water
• Magnet detects diffusion through tissues
• T2 weighted imaging
• Diffusion weighted imaging
• Dynamic contrast-enhanced imaging - contrast used is called gadolinium

• Scoring system: PI-RADS

den
es

of
MRI
• All about water
• Magnet detects diffusion through tissues
• T2 weighted imaging
• Diffusion weighted imaging
• Dynamic contrast-enhanced imaging - contrast used is called gadolinium

• Scoring system: PI-RADS

1- Highly unlikely
2- unlikely
3- Uncertain
4- Likely
5- Highly likely

Higher the score, higher the risk of biopsy - score of 3, 4,5 indicated for biopsy

• Central zone
• Paler peripheral part of prostate
• Prostate cancer tissue is dense
• Water diffuses poorly through cancer
• For cancer - looking at dark areas

Grading - Gleason score (won't ask in exam)

• Prostate cancer histology is very different to other cancers
• Looking at cells through low power
• Degree of disruptiveness of cells
• More disruptive - higher the grade
• The score starts at 3 (1, 2 aren't cancers)
• No uniformity in prostate cancer
• With this system, first number is applied to what most of tumour is, second
number for if there is more/less aggressive cancer e.g. Gleason 3 + 3 = 6 (ISUP
grade group 1), 4+5 = 9 (ISUP grade group 5)

What if biopsy shows no cancer?

• False negative - limitation of biopsy of prostate
• Need to monitor

Staging
• Need to stage the tumour - MRI, PSMA (prostate specific membrane antigen),
PET/CT

• PSA also made by salivary glands, but mostly unique to prostate

• Radioactive tracer attached to ligand (will look for PSA)
- Inject IV, if there's any PSA, the ligand will bind to PSA.

Management
 • PSA also made by salivary glands, but mostly unique to prostate
• Radioactive tracer attached to ligand (will look for PSA)
- Inject IV, if there's any PSA, the ligand will bind to PSA.

Management
• Never do nothing
• Active surveillance - only way is to do repeat biopsies, PSA not good enough
on it's own to monitor
• Curative treatments:
- Radical prostatectomy (surgical removal) - erectile dysfunction, urinary
incontinence
- Branchytherapy
- External beam radiation therapy - doesn’t cause incontinence, erectile
dysfunction
• Second line treatments - androgen deprivation therapy
• Third line - chemo, immune therapy

Immunotherapy likely to provide long term benefit

Sipuleucal-T
• Dendritic cell --> activated dendritic cells (due to addition of antigen (prostate
acid phosphatase)) --> killer cells go after activated dendritic cells and destroy
it

Case 1
• 54 years
• Well, no symptoms
• Father and brother have prostate cancer
 it

Case 1
• 54 years
• Well, no symptoms
• Father and brother have prostate cancer
• Comes to you for advice

- Has 50% risk for prostate cancer

- DRE, PSA test- if both normal doesn’t exclude cancer
- Would repeat on annual basis

Case 2
• 54 years
• Well no symptoms
• Normal DRE
• PSA 7.8 (n=0.25)

- Risk of prostate cancer due to high PSA but it's not diagnostic
- Repeat the test after about 6 weeks
- Do MRI

Case 3
• 57 years
• Well no symptoms
• DRE hard nodule high on right lobe
• PSA on routine testing - 2.3 (n=0.25)

- Cant rule out cancer

- MRI to see other things in prostate, biopsy

Case 4
• 83 years
• Well no symptoms
• DRE hard nodule
• PSA = 12.9

- Chances are that you've got PC, common as men get older, more likely to die
of something else
- Can monitor, re-test in 3-4 months
- If mets, PSA will be in 20-30s, can get into 100s

Case 5
• 67 years
• 6 month sintermittent severe left hip pain
• DRE hard irregular prostate
• PSA 32.6
Case 5
• 67 years
• 6 month sintermittent severe left hip pain
• DRE hard irregular prostate
• PSA 32.6

- Probs cancer
- MRI, biopsy, PET scan

With advanced prostate cancer, it gets bigger, infiltrates locally. Ureters can be
blocked