EARLY DETECTION OF EARLY DETECTION OF CARCINOMA PROSTATECARCINOMA PROSTATE

Dr. U.K.ShrivastavaDr. U.K.Shrivastava

MBBS,MS,FAIS,DHAMBBS,MS,FAIS,DHA

Professor and Head of surgeryProfessor and Head of surgery

AIMST University, MalaysiaAIMST University, Malaysia

Anatomy and Function of ProstateAnatomy and Function of Prostate

Situated in men in lower pelvis, at neck of bladder and in front of rectum, plum sizeIt secretes alkaline fluid 1/3 of fluid in semenFluid 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

AnatomyAnatomy

AnatomyAnatomy

Prostate CancerProstate 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

MODALITIESMODALITIES

• SERUM P.S.A.

• DIGITAL RECTAL EXAMINATION

• TRANS RECTAL ULTRA SONOGRAM

• MAGNETIC RESONANCE IMAGING

SERUM P.S.A.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

PSAPSA

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

P.S.AP.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

PSA DENSITYPSA DENSITY

Introduced by Benson 1992It 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

Recent conceptRecent 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

Prostate hyperplasiaProstate hyperplasia

Ca ProstateCa Prostate

PSA VELOSITYPSA 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

AGE SPECIFIC PSA AGE SPECIFIC PSA REFERENCESREFERENCES

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%

PSA VELOCITYPSA 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

FREE PSAFREE 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 BPHFree PSA low with inverse rise in PSA/ACT seen

in Carcinoma of prostateHigher the free PSA in BPH

FREE PSAFREE 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

FACTORS INFLUENCING FACTORS INFLUENCING SERUM PSA LEVELSSERUM PSA LEVELS

• Prostatitis• BPH and Carcinoma • Biopsy• DRE• TRUS• Cystoscopy• Ejaculation• Variable with age/race/ volume• U T I , vigorous exercise ,any sexual drive

PSAPSA

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

DIGITAL RECTAL EXAMINATIONDIGITAL 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

DREDRE

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

DIGITAL RECTAL EXAMINATIONDIGITAL RECTAL EXAMINATION

PSA/ DREPSA/ DRE

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

TRUSTRUS

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

TRUS TRUS

TRUSTRUS

Limitation that ,most hypo echoic lesions are not cancerIt could be cancer, infarct or even abscessAlways insure during bx for wide area sampling of

prostatic tissues Indications--------- raised PSA abnormal DREPZ 30-50% cancer may be of isoechoicTZ up to 80% may be isoechoic

TRUS guided BXTRUS guided BX

It can be---

Directed biopsy

Sextant biopsy ,now 12 core bx done

Anterior biopsy from TZ

Lateral lobe biopsy

Extended field biopsy

Gleason ScoresGleason 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

TRUS BXTRUS BX

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

MRI (endo rectal coil)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

ALGORITHM FOR EARLY ALGORITHM FOR EARLY DETECTIONDETECTION

DRE PSA DIOGNOSTIC ACTIONNegative < age spec range annual PSA and DRENegative > age spec. range TRUS bx and sextant bx Positive Any value TRUS bx and sextant bx

ADVANTAGEADVANTAGE

Help to pick up significant disease before it becomes symptomaticHelp to monitor men who have higher risk of developing cancerHelp to pick up aggressive cancer early when treatment is feasibleHelp in investigating the prostatic disease when the value of PSA high

DISADVANTAGEDISADVANTAGE

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

CONCLUSIONCONCLUSION

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

PREVENTION PREVENTION AND SUPPLEMENTSAND 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

SupplementsSupplements

• 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

SupplementsSupplements

• Drugs

a Androgen

b Dutastride

Exercise always good

Keep cholesterol low and HDL high