Prostate Cancer. David Wilkinson MD Gulfshore Urology

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1 Prostate Cancer David Wilkinson MD Gulfshore Urology

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3 What is the Prostate? Male Sexual Gland Adds nutrients and fluids for sperm This fluid is added to sperm during ejaculation Urethra (urine channel) runs through the middle of the prostate

4 What is Prostate Cancer? 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 areas of the body

5 Prostate Cancer Facts 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

6 Probability of Developing Invasive Prostate Cancer at Various Ages Birth to % (1 in 12,833) 40 to % (1 in 44) 60 to % (1 in 7) Birth to Death 17.15% (1 in 6)

7 Prostate Cancer Detection 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 effective Now 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

8 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

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

10 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 unecessary biopsies

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

12 Prostate Health Index (PHI) 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)

13 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)

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

15 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

16 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

17 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)

18 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

19 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

20 Diagnosis of Prostate Cancer Staging

21 Transrectal Ultrasound Most often used for prostate biopsy Not recommended as a routine test for the early detection of prostate cancer

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24 MRI of prostate 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

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27 UroNav Prostate biopsy 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

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30 Biopsy and Gleason Score: Good and Bad Grades 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

31 Prostate Cancer T1 disease 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

32 Prostate Cancer T2 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

33 Prostate Cancer T3 Has spread beyond the prostate T3a extra capsular extension T3b tumor invades seminal vesicle(s)

34 Prostate Cancer T4 Cancer has invaded local organs Bladder invasion Invasion into surrounding pelvic side wall May cause pain in joints and back

35 Treatment Options Dependent upon Stage of the disease Patient s age and health Patient s personal preference

36 Watchful Waiting/Active Surveilence 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

37 Hormone Therapy: Background 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

38 Cryosurgery 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

39 Radiation Therapy 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 Brachytherapy Seed implantation High dose rate (HDR) Cyberknife Gamma Radiation Created by neurosurgeon for inoperable brain tumors Used with prostate, colon, breast Mixed results for prostate

40 Surgery for Prostate Cancer Radical Prostatectomy Retropubic Perineal Laparoscopic Robotic

41 Goals of Radical Prostatectomy 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

42 Nerve-sparing Prostatectomy Preserves nerves responsible for erections Nerves run alongside prostate

43 Laparoscopic Surgery Minimally invasive surgery Ability to operate through small keyhole incisions Camera and instruments fit through the keyhole incisions Better visualization than open surgery

44 Advantages of Robotic Lap 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

45 What is the da Vinci Surgical System? Powered by state-ofthe-art robotic technology Surgeon is in control and operates at the console Assistant surgeon is next to the patient

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

47 The Surgeon Directs the Instruments The surgeon s hands are placed in special devices called masters that direct the precise instrument movements

48 Stereoscopic Camera

49 Wrist and Finger Movement Traditional laparoscopic instruments are straight and do not bend EndoWrist instruments move like a human wrist Allows increased dexterity, maneuverability, and precision

50 Small Instruments through Keyhole Incisions da Vinci Surgical System EndoWrist Instruments are small and are able to fit through keyhole incisions A wide range of instruments are available

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52 Robotic-Assisted Surgery Access

53 Benefits of da Vinci Prostatectomy 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

54 HIFU 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)

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57 Questions & Answers