Hl Diagnostic and staging evaluation

3 • Transrectal ultrasound (TRUS) guided biopsy, with 6-12 core specimens H9 ' Histology: Gleason grade (2-10. low grade -.6) sum of the differentiation score (1 Hsl best 5 worst) of the two most prevalent patterns in the bx; correlates with prognosis

• Imaging: to evaluate extraprostatic spread bone scan: for PSA -10 ng ml. high Gleason grade, or clinically advanced tumor abdomen-pelvis CT: inaccurate for detecting extracapsular spread and lymph node mets endorectal coil MRI: improves assessment of extracapsular spread

TNM Staging & Treatment of Prostate Cancer

Stage

Tumor

Nodes. Mets

Treatment

non-palp., not visible on imaging

NO. MO. Gleason 2-4

Watchful waiting (consider if limited life expect.) Radiation (external beam or brachytherapy; ne/m

2006:355:1583) Radical prostatectomy (: radiation and or hormonal Rx if high-risk features found at surgery)

w in prostate

NO. MO

III

T3 extends thru capsule

NO. MO

Radiation » androgen ablation (see below)

IV

T4 = invades adjacent structures AnyT

Any N. MV

Radiation (for M0 disease) Androgen deprivation (/ama 2005:294 238) orchiectomy

GnRH analogues (leuprolide, goserelin) antiandrogens (flutamide. bicalutamide) 2nd-line: antiandrogen withdrawal, different antiandrogen, androgen synthesis inhib. (ketoconazole. aminoglutethimide). estrogens Chemo (docetaxel) if hormone-refractory (NEjM 2004:351 1502.1S13)

'Bisphosphonates (alendronate, zolendronaie) & palliative radiation for bone mets Prognosis

• PSA level. Gleason grade, and age are predictors of metastatic disease

• In surgically treated Pts. 5-y relapse-free survival 90% if disease confined to organ.

75% if extension through capsule, and 40% if seminal vesicle invasion

• Compared to watchful waiting, surgery 1 prostate cancer mortality & overall mortality in patients 75 (NE}M 2005:3521977); comparisons of surgery and radiation are underway

• PSA doubling time. Gleason, & time to biochemical recurrence predict mortality following recurrence. For local recurrence following RP. salvage RT may be beneficial if low PSA.

• Metastatic disease: median survival 24-30 mos.all progress to androgen independence

Prevention

• Finasteride I total prostate cancers detected by bx. but T number of high Gleason grade tumors (NEJM 2003:349:215)

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