PROSTATE CANCER LETS DEBATE Dr Fred C Tyler

PROSTATE CANCER LETS DEBATE !!!! Dr Fred C Tyler MBCh. B FRCS FCS UROL

Case Presentation • • Mr D N 44 yr referred PSA 6, 49 Low libido, poor erections PMH : Hypertension PSH: Nil Alllergies: Nil Smoking : 20/d OH : social

Case Presentation • Abdo: soft NAD • Genitalia: NAD • PR: BPH • Testosterone 20. 48

Case Presentation • Cystoscopy: Narrow bladder neck , nil else • TRNB Prostate: One tiny focus of Gleason 6/10 ( 3 +3) 0. 5 mm of one core Prostatitis

Prognostic Grouping • Group 1 T 1 a-c NO, M 0, PSA <10, GLS < 6 T 2 a • Group 2 a T 1 a-c N 0 M 0 PSA < 20 GLS 7 PSA 10 -20 GLS <6 T 2 a, b PSA <20 GLS , 7 • Group 2 b T 2 c N 0 , M 0 , Any PSA, Any GLS T 1 -2 PSA > 20 or GLS >8 Group 3 T 3 a-b Group 4 T 4

MR D N • Low risk • Group 1

WHAT NOW !!!!!!

EUA Guidelines • Clinical Stage 1 c 40%-50% of new cases • SPGC 4 study showeds advatage of RP over WW but on; ly 5% of thise patients were PSA screened • Prevalence of under scoring GLS grades

Watchful Waiting • T 1 a well or moderately differentiated if > 10 yrs life expectancy restaging with TURP and TRNB advised • T 1 b to T 2 b standard rx for well or moderately diff tumours in asymptomatic patients with life expectancy < 10 yrs. • NB Criteria – PSA <10. GLS <6, < 2 positve biopsies, < 50% of the biopsy involved.

Radical Prostatectomy • Reduced cancer mortality and risk of metastases in men <65 yr with little or no benefit 10 or more years after surgery • Standard rx if <65 yrs age and who except rx related complications. • Role of Laparoscopic and Robot assisted Radical prostatectomy…. .

Extended pelvic node dissection • No benefit in low risk CAP

Recommendations for Radical Prostatectomy • Neoadjuvant GNRH for 3 months is not recommended for T 1 – T 2 disease. • Nerve sparing surgery may be attempted for Low risk Disease: T 1 c, GLS 7, PSA , 10

Definitive Radiation Therapy • Transperineal Interstitial Brachytherapy – – – T 1 c-T 2 a GLS , 7 (3+4) PSA<10 Prostate vol <50 ml No previous TURP, Good IPSS • Localised CAP: T 1 c T 2 c , N 0, M 0, – 3 D CRT +- IMRT even for young patients who refuse surgery ? ? ? – Low , Intermediate, high risk patients benefit from dose escalation.

Cryosurgery of the Prostate • Low risk CAP : PSA<10, <T 2 a, GLS<6 • Intermediate Risk: PSA > 10, GLS 7, Stage. T 2 b • 5 yr BDFR inferior to RP in low risl patients. • All other minimally invasive options are experimental……….

Our patient…… • 3 months after diagnosis PSA 4. 27 (9%) • 3 months later PSA 3. 39 • 3 months later PSA 4. 51.