The Prostate - PowerPoint PPT Presentation

Loading...

PPT – The Prostate PowerPoint presentation | free to view - id: 10b7b2-YmM0O



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

The Prostate

Description:

The Prostate – PowerPoint PPT presentation

Number of Views:226
Avg rating:3.0/5.0
Slides: 55
Provided by: dominion
Category:
Tags: keb | prostate

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: The Prostate


1
The Prostate
  • Robert Ball, M.D., F.A.C.S.
  • Clinical Professor of Urology
  • Inova Fairfax Hospital Cancer Center

2
What is the Prostate
  • Round organ/gland with a hole (donut)
  • Lives under the bladder and is the size of a
    large walnut
  • Men urinate and ejaculate through the hole
  • The prostate and its associated gland the
    seminal vesicles produce the seminal fluid (only
    2 of semen is sperm)
  • The prostate has two histological tissue types
  • The glandular tissue which makes the prostate
    fluid
  • The stromal tissue which give the gland shape and
    tone

3
anatomy
prostate
rectum
4
(No Transcript)
5
Enlarged Prostate (EP) Overview
  • Prostate size ? 30 mL
  • Progressive condition
  • Results in varying levels of bladder outlet
    obstruction
  • Major cause of urinary symptoms in older men
  • Most common prostate condition

Hypertrophied detrusor muscle
Obstructed urinary flow
Roehrborn CG et al. In Campbells Urology, 8th
ed. Philadelphia, Pa Saunders 20021297?1336.
6
Symptoms Associated with Enlarged Prostate (EP)
  • Obstructive Symptoms
  • Hesitancy
  • Weak stream
  • Straining to pass urine
  • Prolonged micturition
  • Feeling of incomplete bladder emptying
  • Urinary retention
  • Irritative Symptoms
  • Urgency
  • Frequency
  • Nocturia
  • Urge incontinence

Kirby RS et al. Benign Prostatic Hyperplasia.
Oxford, UK Health Press 1995.
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
Anatomy
bladder
rectum
  • pubis

prostate
16
Prostate Cancer
  • Adenocarcinoma of the Prostate
  • Adeno means gland or glandular
  • Carcinoma means a malignant differentiation of an
    epithelial or endothelial tissue
  • Thus, the typical prostate cancer is a malignancy
    of the prostate glandular tissue
  • A malignancy of the stromal tissue would be a
    sarcomavery rare and really bad

17
Prostate Cancer Risk Factors
  • Genetics
  • One 1st degree relative 2x increased risk
  • Two 1st degree relatives 5x increased risk
  • Three or more 1st degree relatives 10x risk

18
Prostate Cancer Risk Factors
  • Diet
  • High fat diet increases risk
  • High levels of cadmium (tobacco and batteries)
  • High levels of selenium and Vit E decrease risk

19
Prostate Cancer Epidimiology
  • Most common malignancy in American men
  • 2nd highest incidence of male CA deaths
  • 38,000 deaths per year (decreasing)
  • 1/10 men will get significant CAP
  • 1/3 who get CAP will die of it
  • Lung CA is most lethal CA
  • Colon CA is third most lethal

20
Prostate Cancer Risk Factors
  • Age is a disease whose prevalence increases with
    age
  • Rare in men less that 40
  • Common in men over age 80

21
Prostate Cancer Screening
  • PSA and DRE
  • Yearly for most men age 50 70
  • Yearly for African-Americans and all men with a
    family history of CAP at age 40-45
  • Not to be done routinely after age 75 and
    certainly not indicated in men over 80
  • Can be performed q 2 years with PSA lt 1.0

22
Prostate Cancer Detection
  • Prostate biopsy is only way to detect CAP
  • Indications for biopsy
  • PSA gt age specific normal
  • Any abnormal DREno matter the PSA
  • PSA increasing by more than 0.75 ng/dl/year over
    an 18 month period including 3 data points

23
PSA Prostate Specific Antigen
  • Produced only by the prostate glandular cells
  • Not produced by any other cells in the body
  • 33 kd serine protease that liquifies semen
  • exists in free and bound states in the blood
  • Relationship of free and bound serum PSA
    correlates with the risk of CAP
  • - PSA serum levels can vary 10 30 during the
    day

24
Prostate Cancer Detection
  • Caveat about PSA
  • PSA elevation is not specific for CAP
  • 75 of men with a PSAgt 4.0 do NOT have CAP
  • 20 of men with CAP have a PSA lt 4.0

25
Molecular forms of PSA
  • Most (90) of PSA bound to serum protein
    alpha-1-antichymotrypsin and alpha-2-macroglobulin
    s.
  • Remainder of PSA is free floating
  • The ratio of the free / free plus bound when PSA
    gt 4 gives statistical correlate to CAP risk
  • If f/t gt 25 less than 6 risk CAP
  • If f/t lt 10 greater than 56 risk CAP

26
Age Adjusted PSA
  • Age Range (years)
  • 40 49
  • 50 59
  • 60 69
  • gt 70
  • Normal PSA
  • lt 2.5
  • lt 3.5
  • lt 4.5
  • lt 6.5

27
(No Transcript)
28
Gleason Grade
  • Prostate cancers are graded by the difference in
    the glandular architecture
  • Dr. Gleason, a pathologist, came up with a
    numbering system to differentiate CAP
  • Two numbers between 1-5 added together
  • The first number is the predominate gland
  • The second number is the next gland
  • The total of these two numbers yields the Gleason
    grade which is s sum between 2 and 10

29
Gleason Grade
  • Gleason sum
  • 1 1 2
  • 2 2 4
  • 3 2 5
  • 3 3 6
  • 3 4 7
  • 4 3 7
  • 4 4 8
  • 5 5 10
  • Differentiation
  • Well Differentiated
  • Moderately Differentiated
  • Poorly differentiated

30
Prostatic Intraepithilial Hyperplasia
PINDifferentiation of Cells
Cancer
PIN
Normal
cells
Low grade
Mod grade
High grade
Gleason
Grade
6
2
10
Spectrum showing cells becoming more
abnormal/different
31
Stage
32
Prostate Cancer Survival Statistics
  • Prostate CA requires greater than 10 years to
    cause impact on survival
  • However, CAP 15 year mortality 62
  • Therefore patients with less than 10 year
    expected survival may not need treatment
  • N.B. Patients surviving 10 years with CAP have
    60-80 risk of morbidity
  • Bone pain, spinal cord injury, urinary retention,
    renal failure, lower extremity lymphedema and
    infection

33
(No Transcript)
34
Treating CAP With Watchful Waiting
  • It takes CAP at least 10 years to do its dirty
    deed
  • WW appropriate if
  • Life expectancy lt 10 years (older age 72-74)
  • Gleason lt 2 2
  • Microscopic focus of disease
  • Even with above 10 risk of death by CAP

35
Cryotherapy
  • Freezing and thawing prostate kills tumor
  • Outpatient procedure similar to brachytherapy
  • Multiple hollow core probes placed with TRUSP
  • Ice balls form around probes at 25 to 50 C
  • Similar cure rates as radiation therapy,
    approaching 85
  • Possibility of just treating prostate cancer and
    sparing the rest of the prostate in select cases-
    focal therapy
  • Can be performed for primary therapy or after
    radiation treatment failures

36
Radiation Therapy
  • Mechanism of Tumor Kill
  • The higher the dose of radiation the better the
    kill
  • Ionizing radiation causes
  • Destruction of DNA so cells die upon mitosis
  • Superoxide reaction resulting in rupture of cell
    membrane

37
External Beam Radiotherapy
  • Ionizing beam of radiation pointed at prostate
  • Treatment every week day for 8 weeks
  • Radiation dose is limited by the collateral
    damage risks to bladder and rectum
  • Conformal therapy allows increased dosages
  • Is a bona fide treatment alternative,
    particularly for patients gt age 65
  • Does have proven failure rate than RRP

38
Brachytherapy (Seeds)
  • High dose radiation delivered with seeds
  • Can obtain doses 2 3 times external beam
  • Best for small volume tumors Gleason lt 6
  • Outpatient treatment in OR
  • Limited collateral damage to bladder/rectum
  • Can burn urethra
  • Unable to sterilize tumor outside capsule
  • Can be performed in conjunction with or as
    salvage after failed external beam RT

39
Radical Prostatectomy
  • Walsh nerve sparring procedure gives overall best
    chance for cure
  • Cure rates correlate directly with pathologic
    grade and stage
  • Complications of surgery
  • E.D., incontinence, bleeding and rectal injury
  • Related to surgeon experience and patient age

40
(No Transcript)
41
Davinci Robot- Can be used for Radical
Prostatectomy (DVP)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
Comparison Old vs. New
49
Metastatic disease
  • CAP uses androgens as a fuel
  • Removal of testosterone causes apoptosis
  • Hormonal ablation effects will wane with time
  • Not curative
  • 95 of T is produced by Leydig cells of testis
  • Under pituitary control with feed back systems
  • Can remove T by
  • Removing testis
  • Turning off Leydig cells
  • Giving female hormone estrogen (vascular risks)

50
Metastatic CAP refractory to hormones
  • Complete androgen blockade
  • Block androgen receptor from seeing adrenal T
  • Chemotherapy
  • Anti-angiogenesis agents (Thalidomide)
  • Taxol, etoposide, Mitoxantrone, Estramustine
  • Strontium 89 for bone mets pain
  • Investigational Immunotherapy
  • Vaccines and gene therapy

51
Recurrence After RRP
  • Local recurrence
  • Difficult to prove
  • if surgical margin
  • PSA undetectable post op
  • PSA double time lt 1 year
  • External beam RT /- hormone ablation

52
Dr. Ball and Fairfax OR Nurses
53
Dr. Simon Chung Director Robotic Surgery
54
(No Transcript)
About PowerShow.com