Prostate Cancer

David Wilkinson MD

Gulfshore Urology

Male Sexual Gland

Adds nutrients andfluids for sperm

This fluid is addedto sperm duringejaculation

Urethra (urinechannel) runs throughthe middle of theprostate

What is the Prostate?

Abnormal cells growing out of control

Spreads and invades local tissues

Prostate Cancer◦ Begins with a small tumor in the gland

◦ First spreads to the local lymph nodes

◦ Then spreads to the bony skeleton and other areasof the body

What is Prostate Cancer?

Prostate Cancer◦ Leading type of cancer in men (1 in 6)◦ Second leading cause of death in American males◦ Over 40,000 deaths each year in the United States

Recent alarming increase in diagnosis of advanced cancer secondary to less screening in men over 70.

Early Detection◦ Best prognosis is early detection◦ lower mortality rates of prostate cancer with early

detection◦ Affords patients with many options for treatment

Prostate Cancer Facts

Birth to 39 0.01% (1 in 12,833)

40 to 59 2.28% (1 in 44)

60 to 79 14.20% (1 in 7)

Birth to Death 17.15% (1 in 6)

Probability of Developing InvasiveProstate Cancer at Various Ages

Two tests used in combination for early detection previously◦ Prostate Specific Antigen (PSA) test◦ Digital Rectal Exam (DRE)Combined with PSA because it is generally less effectiveNow DRE, Prostate Health index , 4K scoreand

multiparametric MRI of prostate, PCA 3, Select MDX, Iso

Only tissue biopsy confirms a diagnosis of cancer◦ Tissue sample is obtained by needle, guided by

transrectal ultrasound

Prostate Cancer Detection

PSA (Prostate specific antigen)

Gamma seminoprotein or Kallikrein KLK3

Secreted by normal epithelial cells in prostate and also by prostate cancer cells

In healthy prostate tissue, liquefies ejaculate to allow sperm motility and thins cervical mucous

Originally approved by FDA in 1986 to monitor PROGRESSION of known prostate cancer

FDA approved in 1994 to screen asymptomatic men IN COMBINATION WITH DRE

THE PROBLEMS WITH PSA

Can be elevated for MANY reasons that are NOT prostate cancer

Benign prostatic hyperplasia, urinary tract infection, prostatitis, urinary retention, recent catheterization of the bladder, recent prostate surgery, mechanical agitation of the prostate (ejaculation, long distance cycling)

Can lead to false positives (elevated PSA and NO cancer) causing anxiety and unecessarybiopsies

Can lead to false negatives (PSA level normal with cancer present) causing delayed diagnosis and possible morbidity/mortality from prostate cancer

3x more specific than total or free PSA in detecting prostate cancer

PSA, Free PSA, proPSA (or PSA2)

Differentiate prostate cancer from benign prostate conditions that elevate PSA

decrease unecessary prostate biopies by 26%

Increase probability of finding prostate cancer and identifying aggressive cancers (Gleason 7 or greater)

Prostate Health Index (PHI)

4 K score

Blood test Research on > 10,000 patients at Memorial Sloan Kettering 4 kallikreins : Total PSA, Free PSA, Intact PSA and

kalliekrein hk2 The 4 kallikreins combined in algorithm with age, DRE

findings, Family Hx, prior biopsy results (if available) Reported as percentage risk of aggressive prostate cancer

(Gleason 7 or greater)

Created for men with elevated PSA, abnormal DRE or continued PSA elevation after prior negative prostate biopsy

PCA 3 (prostate cancer antigen 3)

Urine test

First urine specimen after DRE

mRNA only expressed in human prostate tissue

Highly overexpressed in prostate cancer

Most useful when evaluating continued elevated PSA after negative prostate biopsy

Select MDx

Urine test

First urine after DRE

mRNA of DLX1 and HOXC6 combined with algorithm including PSA , age, family history or prostate cancer

Elevation of DXL1 and HOXC6 are associated with increasing probability or Gleason grade 7 or greater prostate cancer

Combined with PSA (KLK3) to determine need for initial biopsy or repeat biopsy

ExoDx (Prostate (intelliscore)

Urine test

NO DRE required

PCA3, ERG, SPDEF all increased in expression with prostate cancer

In men > 50 with PSA between 2 to 10, 94% negative predictive value for Gleason grade 7 or greater prior to first biopsy

Accurately predicted stage and aggressive Gleason score prostate cancers prior to prostatectomy (pathology correlated)

Has a score reported 0 to 100

Score of greater than 15.6 (binary cut point) at increased risk of Gleason grade 7 prostate cancer or greater

Conclusion

Currently no test REPLACES PSA

Many new minimally invasive tests can be used to AUGMENT PSA

PSA combined with testing discussed allows best determination of who is at risk for high grade prostate cancer and who truly needs prostate biopsy or to progress to treatment from active surveillance

Diagnosis of Prostate CancerStaging

Most often used for prostate biopsy

Not recommended as a routine test for the early detection of prostate cancer

Transrectal Ultrasound

Done with endorectal coil

Multi phase study which identifies areas within prostate that are concerning for prostate cancer

Can differentiate between benign growth, infection/inflammation and cancer

Allows for targeted biopsy of prostate

Potential for focal treatment in the future

MRI of prostate

Uses images obtained from prostate MRI with endorectal coil

MRI images fused to ultrasound used during biopsy

3 dimensional real time graphic imaging of biopsy and mapping of biopsies

Increases sensitivity of cancer detection

Allows for focal biopsy of only abnormal areas

UroNav Prostate biopsy

The pathologist assigns the Gleason score to grade the cancer

◦ Low grade (6 points): slow growth

◦ Middle grade (7 points): intermediate growth

◦ High grade (8-10 points): most aggressive form of cancer

Biopsy and Gleason Score:Good and Bad Grades

Cannot be felt

T1a – cancer found in <5% TURP specimen

T1b – cancer found in >5% TURP specimen

T1c – cancer found as a result of PSA elevation only

Prostate Cancer T1 disease

Can be felt during DRE (digital rectal exam)

T2a – felt on less than ½ of one side of the prostate

T2b – felt on over half of one side of the prostate

T2c – felt on both sides of the prostate

Prostate Cancer T2

Has spread beyond the prostate

T3a – extra capsular extension

T3b – tumor invades seminal vesicle(s)

Prostate Cancer T3

Cancer has invaded local organs

Bladder invasion

Invasion into surrounding pelvic side wall

May cause pain in joints and back

Prostate Cancer T4

Dependent upon…

◦ Stage of the disease

◦ Patient’s age and health

◦ Patient’s personal preference

Treatment Options

No treatment given initially

Reserved for people with

◦ Non-aggressive cancer

◦ Overall poor health

Close follow-up, included repeat biopsies, PHI,

and genetic testing of initial prostate biopsies

Delayed hormone therapy

Watchful Waiting/Active Surveilence

Without testosterone production at puberty, the prostate gland would not develop

In adults, prostate growth stops in the absence of the male hormone, testosterone

Prostate cancer usually stops when the testes are removed because prostate tissue and prostate cancer are uniquely sensitive to testosterone

Hormone Therapy: Background

Treatment for localized prostate cancer

Recurrent prostate cancer

Cancer cells are destroyed by freezing

A heated catheter minimizes damage to surrounding tissue

Outpatient procedure

Risk of ED and incontinence

Cryosurgery

Uses radiation to kill cancer cells

Various types

◦ External beam radiation therapy Intensity-modulated radiation therapy (IMRT) Image guided radiation therapy (IGRT)Rapid arc, radiation delivered in 360 degree fashion

◦ BrachytherapySeed implantationHigh dose rate (HDR)

CyberknifeGamma RadiationCreated by neurosurgeon for inoperable brain tumorsUsed with prostate, colon, breastMixed results for prostate

Radiation Therapy

Radical Prostatectomy

◦ Retropubic

◦ Perineal

◦ Laparoscopic

◦ Robotic

Surgery for Prostate Cancer

Removes the prostate and cancer

High cure rates for localized disease

Preserve urinary function

Preserve erectile function

Analyze the prostate after surgery to assess risk of recurrence of cancer

Goals of Radical Prostatectomy

Preserves nervesresponsible for erections

Nerves run alongsideprostate

Nerve-sparing Prostatectomy

Minimally invasivesurgery

Ability to operatethrough smallkeyhole incisions

Camera andinstruments fitthrough the keyholeincisions

Better visualizationthan open surgery

Laparoscopic Surgery

Provide a high resolution 3-D color image

Interpose a computer between the surgeon’s hand an the instrument tip

Increase the surgeon’s dexterity for the difficult aspects of the procedure◦ Sparing the nerves to preserve erectile function

◦ Preserving continence

◦ Preserving quality of life

Advantages of Robotic Lap Surgery

Powered by state-of-the-art robotic technology

Surgeon is in control and operates at the console

Assistant surgeon is next to the patient

What is the da Vinci® SurgicalSystem?

Surgeon is immersed in 3-Dimensional image of the surgical field

Vision System

The surgeon’s handsare placed in specialdevices called mastersthat direct the preciseinstrument movements

The Surgeon Directs theInstruments

Stereoscopic Camera

Traditional laparoscopic instruments are straight and do not bend

EndoWrist® instruments move like a human wrist

◦ Allows increased dexterity, maneuverability, and precision

Wrist and Finger Movement

da Vinci® Surgical System EndoWrist® Instruments are small and are able to fit through keyhole incisions

A wide range of instruments are available

Small Instruments throughKeyhole Incisions

Robotic-Assisted SurgeryAccess

Decreased blood loss

Shortened length of hospital stay

Decreased postoperative pain

Less scarring

Shorter urinary catheter time

Faster return to regular activities

Anticipation of improved potency and continence

Benefits of da Vinci®Prostatectomy

Now FDA approved in United States for ablation of prostate

Single treatment

High frequency sound to ablate tissue

Currently limited by size of gland (< 30 grams)

Requires bladder outlet procedure at the same time

Sonoblade (Hand held) Ablatherm EDAP (robotically controlled)

HIFU

www.Gulfshoreurology.com

Questions & Answers