Marion Swall, MIVUSC School of Medicine

EpidemiologyProstate cancer is the most common cancer

& #2 cancer killer in American menApprox 190,000 cases will be diagnosed

annuallyApprox 27,000 deaths will occurClinically ranges from a well differentiated

tumor to an aggressive cancer with substantial invasive and metastatic potential.

ScreeningProstate cancer used to be detected by digital

rectal examination (DRE) findings of asymmetric areas of induration or frank nodules

Now, prostate cancer is usually detected by an elevated serum PSA & is asymptomatic at presentationPSA >10 ng/mL — Prostate biopsy is uniformly

recommended. 50% probability of cancer PSA 4 to 10 ng/mL — Prostate biopsy is advised.

Specificity is lower, 20% probability of cancerPSA > 2.6 ng/mL & if PSA Velocity is ≥ 0.75 ng/mL

per year – Prostate biopsy is advisedPSA velocity >2 ng/ml per year is high risk for life

threatening cancer

DiagnosisProstate biopsy is the gold standard Transrectal ultrasonography (TRUS) biopsy is a

relatively simple procedure done in the office

Transrectal ultrasound in sagittal plane demonstrating hyperechoic biopsy tracts (arrows) evenly spaced throughout the gland.

StagingStaging is critical to guide treatment options

given high morbidity of therapy.Endorectal coil MRI & TRUS with staging biopsy

can be used to assess the local extent of disease.

 

 

US shows an extensive, hypoechoic T3 tumor with capsular irregularity on the right and posteriorly (arrowheads)

US also suggests infiltration into the rectal wall (arrow).

Staging ContinuedEndorectal coil MRI

provides a more accurate estimate of seminal vesicle involvement or extraprostatic extension

Endorectal MRI in a patient with extensive prostate carcinoma showing a bulge in the capsular outline on the right side. This is a stage T3 tumor.

Treatment OptionsDepending on stage, management includes:

Radical ProstatectomyExternal Beam Radiation TherapyBrachytherapy,Androgen Deprivation Therapy (ADT)Chemotherapy Active Surveillance Ablation

Or the new ablation therapy… HIFU

HIFU or Hooey? High-Intensity Focused Ultrasound (HIFU ) pulses energy into an area about

the size of a grain of rice creating a sharply delineated point of increased temperature, melting cell membrane lipids and denaturing proteins.

HIFU is currently approved in Europe and South America Targeting is planned to avoid the urinary sphincter, rectum, and the

neurovascular bundles Complications include urinary incontinence (6%), UTI (7%), obstruction

(14%), pelvic pain (6%) & significant erectile dysfunction in 57%. Failure-free survival rates at five & seven yrs were 66 & 59% in T1 & T2

cancers However, pathologic involvement is often more extensive than on imaging Studies suggests that there is a substantial risk of under treatment of

biologically significant disease using the focal ablation, emphasizing the need for careful patient selection based on estimated life expectancy and a thorough pretreatment biopsy scheme.

So what happened?HIFU didn’t workExternal Beam Radiation didn’t workAndrogen Deprivation Therapy didn’t workChemical castration didn’t workNow what?

Distant metastasisHematogenous spread of prostate cancer cells is common

with tumor growth preferentially occurs in bones of the axial skeleton, where red marrow is most abundant

Metastatic lesions in bone are frequently symptomatic, causing pain, debility, and functional impairment

Radionuclide bone scan with technetium-99m advised in patients with PSA levels >10 ng/mL

Radionuclide Bone Scan

Bone Scan FindingsMultiple focal areas of increased

radiotracer uptake (hot spots) on RN bone scan are classic for metastatic disease.

Metastases appear as hot spots on RN bone scan due to increased osteoblastic activity.

RN bone scans are very sensitive for detecting osteoblastic activity, but are non-specific, osteolytic & osteosclerotic metastases present similarly.

Fractures, arthritis, and tumors all present as hot spots.

Note: the tracer is cleared through the urine, hence the "hot" bladder.

The SuperscanWith diffuse bone metastases, a "superscan"

may be seen.

This superscan demonstrates high uptake throughout the skeleton, with poor or absent renal excretion of the tracer.

What do you see?

Ivory VertebraNote sclerotic

vertebral body of normal size at L2

Osteosclerotic metastases are most common from prostate & breast cancer

Other possibilities include lymphoma, vertebral hemangioma, or Paget's disease.

Osteosclerotic vertebra decreased in height likely to be a compression or healing vertebral fracture.

What do you see?

Femoral FindingsThe distal femur demonstrates

an eccentric, sclerotic lesion with periosteal reaction at the edge of the lesion in the form of a Codman triangle.

A Codman triangle is an aggressive pattern of periosteal reaction, but aggressive is not synonymous with malignant.

Codman triangle occurs with malignant bone tumors and metastases, but also with osteomyelitis and/or hemorrhage.

The EndManifestations of advanced prostate cancer

include: anemia, bone marrow suppression, weight loss, pathologic fractures, spinal cord compression, pain, hematuria, ureteral and/or bladder outlet obstruction, urinary retention, chronic renal failure, urinary incontinence, and symptoms related to bony or soft-tissue metastases.

Life expectancy now 9 months to 2 years