Localized Prostate Cancer - OncologyPRO · 2018. 3. 2. · G 6 G7 (3+4) G7 (4+3) G8 G9/T3 Active...
Transcript of Localized Prostate Cancer - OncologyPRO · 2018. 3. 2. · G 6 G7 (3+4) G7 (4+3) G8 G9/T3 Active...
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Localized Prostate CancerHave we finally got it right?
Shingai Mutambirwa
Professor & Chair-Division Urology
DGMAH & SMU
Pretoria
SOUTH AFRICA
ESMO Cape Town 14 Feb 2018
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Disclosures
Advisory boards/Lecturer/Consultant-
Aspen
Astellas
Astra-Zeneca
Bayer
Ferring
Lilly
Pfizer
Sanofi
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The male reproductive system
Rectum
Urinary bladder
Prostate
Seminal vesicle
Epididymis
ScrotumTesticle
Penis
Urethra
Vas deferens
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Incidence of cancer in males
Prostate
Lung
Colorectal
Bladder
Kidney-renal
Mouth Pharynx
Stomach
Percentage incidence of cancer in males.
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Predicted increase in incidence
PROBABLY 50% DON’T NEED TREATMENT!
n over 65 years .
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Worldwide variation in prostate cancer incidence rates
Rates per 100,000 population
1.2
6.6
7
23
40
44
50
60
102
0 20 40 60 80 100 120
China
India
Japan
UK
Switzerland
Norway
Sweden
US White
US Black
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Diagnosis of prostate cancer
• The diagnosis of prostate cancer may
comprise three steps, incorporating a range
of diagnostic and imaging tests
– Early detection of prostate cancer is
performed through DRE and PSA testing
– TRUS-guided prostate biopsy is performed to
confirm the diagnosis and grade the tumour
– Imaging studies – CT, MRI and radionuclide
bone scan – may be conducted if metastases
are suspected
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CT=computed tomography; DRE=digital rectal examination; MRI=magnetic resonance imaging; PSA=prostate-specific antigen;
TRUS=transrectal ultrasound.
American Cancer Society. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-diagnosis. Last accessed
June 2014.
Diagnosis
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Impact of PSA screening on incidence and mortality
• The introduction of PSA screening
in the early 1990s has led to a rise
in the detection of prostate cancer
across Europe, particularly among
men aged
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Prostate biopsy
• TRUS or a transperineal laterally-directed core
biopsy is the standard way to obtain material
for histopathology1
• A 10–12 core systematic biopsy targeting the
far lateral aspect of the peripheral zone is
standard practice for initial biopsy2
• The transrectal approach has limitations in
sampling the anterior regions of the gland2
• The transperineal approach employing a
mapping scheme, allows for more accurate
sampling of the entire gland2
• MRI-guided biopsy may be used to investigate
anterior located prostate cancer1
• Saturation biopsy is the preferred option after
initial negative sampling2
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MRI=magnetic resonance imaging; TRUS=TransRectal UltraSound.
1. Heidenreich A, et al. Eur Urol 2011:59;61–71.
2. Dominguez-Escrig JL, et al. Prostate Cancer 2011;2011:386207.
Transrectal
Transperineal
Diagnosis
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Clinical staging
Nx = loco-regional lymph nodes
cannot be evaluated
N0 = no lymph node involvement
N1-N3 = regional lymph metastasisN+
M+Mx = no metastasis can be
evaluated
M0 = no distant metastasis
M1 = distant metastasis present
1a = lymph nodes other than
regional nodes
1 b = skeletal
1c = other sites
D3 Resistant to hormonal therapy
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Imaging techniques
• Radionuclide bone scan
– Used to determine spread of prostate cancer
to the bones
– A small amount of radioactive material is
injected into a vein and settles in damaged
areas of bone, viewed as ‘hot spots’ on
the skeleton
– Hot spots are suggestive of cancer in the
bone, but may also arise due to arthritis or
other bone diseases
– The detection of possible cancer needs to
be confirmed with other imaging tests such
as X-rays, CT or MRI scans
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CT=computed tomography; MRI=magnetic resonance imaging.
ACS prostate cancer: Detailed guide. Available from: http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-
cancer-diagnosis. Last accessed June 2014.
Characterising the tumour
Please see Module 3: CRPC and its treatment for further information on metastatic spread
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Imaging techniques
• Computed tomography
– Combines X-rays and computer technology to give images
of the soft tissues and bones in the body1
– Can determine spread of cancer into the lymph nodes, or
other organs/structures1
– Not as useful as MRI for looking at the prostate gland itself1
– With addition of a radionucleotide tracer, PET-CT
is the preferred technique for recurrence detection2
• MRI/diffusion-weighted MRI
– Uses radio waves and strong magnets instead of
X-rays to produce 3D images of the prostate and show
whether the cancer has spread to nearby structures1
– MRI is the most accurate technique for staging cancer2
– Diffusion-weighted MRI detects free water diffusion: the
greater the density of tissues, e.g. tumours, the more water
restriction2
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CT=computed tomography; MRI=magnetic resonance imaging; PET=positron emission tomography.
1. ACS prostate cancer: Detailed guide. Available from: http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-
cancer-diagnosis. Last accessed June 2014.
2. Mayans AR, et al. Arch Esp Urol 2011;64:746–64.
Characterising the tumour
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• Localised– Active Surveillence
– Curative
• Prostatectomy
• Radiotherapy
• HIFU/Cryo?
– Hormonal therapy?
• Locally advanced
– Watchful waiting
– Local control
• Hormonal therapy
• Radiotherapy
• Combinations
• Metastatic
– Palliation - Hormonal therapy
Treatment Options
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Androgens & the prostate gland
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Radical Prostatectomy-
Retropubic,Perineal,Laparoscopic
or Robotic?
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Radiotherapy
EBRT (external beam radiation therapy)
Old EBRT(
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Radical prostatectomy for localised/ locally
advanced prostate cancer
Epstein et al 1996
% patients
progression-
free
0
10
20
30
40
50
60
70
80
90
100
Localised Establishedcapsular
penetration
Seminalvesicle
invasion
Lymph nodemetastases
Focalcapsular
penetration
p
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Focal therapy?
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Conclusion
G 6 G7 (3+4) G7 (4+3) G8
G9/T3
Active
Surveillance
Whole
gland
treatment
Agressive
radical
treatmentSurgery + radiotherapy
Radiotherapy + hormonal
therapy
Today 170 000 new cases/year in the US, 343 000 in Europe
70 % undergo radical treatment
20% have active surveillance which can be stressful
Around 35% patient have overtreatment: they are the target for
focal therapy
Focal
treatment
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10,000,000 men at risk
Death
34,000
CRPC
Fail
Local
Treatment
(30%)
ABI
Chemo
MDV-3100
Hormonal
Management
Local Therapy
Incidence
240,000
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PET +/-MRI vs CT
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Why are biomarkers needed for prostate cancer?
i) for reliable diagnosis of significant prostate cancer and making therapy decisions;
ii) for early prediction of prognosis of the future course of disease, which may lead to
adjusted monitoring and optimized therapy
iii) for prediction of therapy response and thus stratifying potential treatment benefit
iv) the identification of alternative therapeutic targets based on molecular analyses (eg.
target expression and mutational status)
v) developing individualized treatment options and thus improve patient outcomes
vi) standardization of study/cohort design, permitting standardized reporting
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Organisation of Follow Up and Multidisciplinary
Uro-oncology Panel
Full Panel members•Urologist•Medical Oncologist•Radiologist•Radiotherapist
PatientUrologist Follow-
Up
Neuro-surgeon
Medical Oncologist
Follow-Up
Radio-therapist
Radio-logist
Additional:•Neurosurgeon•General Surgeon•Thoracic Surgeon•Pathologist