Lec5 3rd

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Information about Lec5 3rd

Published on April 30, 2008

Author: Abhil

Source: authorstream.com

Slide1:  Donald Vander Griend Ph.D. Huggins Lecture Series February 12, 2005 QUESTIONS? Email me at dvguofc@yahoo.com Access these lectures on the web: http://ben-may.bsd.uchicago.edu then click on “Presentations” Lecture Outline:  Lecture Outline Jan 15 - The Problem, The Prostate, and The Man Jan 22 - What is Cancer? Jan 29 - The Causes of Prostate Cancer Feb 5 - Diagnosing Prostate Cancer TODAY - Treating Prostate Cancer Feb 19 - Prostate Cancer Metastasis Feb 26 - Hormones and Prostate Cancer March 5 - Emerging and Novel Treatment Techniques - Hope for the Future Treating Prostate Cancer:  Treating Prostate Cancer Early Disease Surgery Radiation and Brachytherapy Cryotherapy Watchful Waiting Risks, Pros and Cons of each Advanced Disease Hormone Therapy Chemotherapy Pain Management If You Recall…Lecture 4 Diagnosing Prostate Cancer:  If You Recall…Lecture 4 Diagnosing Prostate Cancer Diagnosis: Yes or No PSA, DRE, Biopsy Staging: The extent of the disease Tumor-Node-Metastasis (TNM) Classification, Gleason Scoring, Surgical Margin, Bone Scan The Decision:  The Decision Discussion between patient and doctor. Thoroughly discuss various options available. Thoroughly discuss the procedure. Patient should be fully aware of risks and potential complications. Considerations Prior to Treatment:  Considerations Prior to Treatment Patient’s general medical condition and age. Tumor Grade (Gleason Score) and serum PSA. Disease Stage and the likelihood of the cancer being confined to the prostate gland and thus potentially curable. Estimation of outcome compared to other treatments. Side effects from various treatments. Goals of Treatment (In Order of Priority):  Goals of Treatment (In Order of Priority) Cancer Control Preservation of Urinary Control (Continence) Preservation of Sexual Function (Potency) Early Disease: Confined to the Prostate:  Early Disease: Confined to the Prostate If staging parameters indicate a good chance that the tumor has not spread outside of the prostate, then removal or destruction of the prostate gland should be curative. Surgery – Radical Prostatectomy removes the prostate gland. Radiation and Cryotherapy – Destroys the prostate gland. History of the Prostatectomy:  History of the Prostatectomy Hugh Hampton Young (Johns Hopkins) pioneered a systematic technique and performed the first radical perineal prostatectomy in 1904. 1943 - Theodore Millin introduced the retropubic prostatectomy approach. 1983 – Patrick Walsh described a modified “nerve-sparing” retropubic approach to preserve potency. Radical Retropubic Prostatectomy (RRP):  Radical Retropubic Prostatectomy (RRP) “Nerve Sparing” procedure developed by Walsh consisted of modified surgical technique to control blood and enhance visibility within surgical site. Allowed for the identification and potential preservation of the nerves that control erectile function (potency). Two neurovascular bundles on either side of the prostate that control erectile function. The Nerve Bundles:  The Nerve Bundles Cross-Section of Prostate Urethra Rectum Neurovascular Bundles of Walsh Prostate RRP: The Surgical Approach:  RRP: The Surgical Approach Bladder Prostate Urethra Rectum 1.5-4 hours, usually epidural anesthesia. Incision: Begins just below navel and extends to pubic bone. Remaining Urethra is sewn to bladder neck over a catheter. Surgical Approach Pelvic Bone (Pubis) RRP: Complications:  RRP: Complications Severe or life-threatening complications are rare. Incontinence (Urinary Control): complete incontinence is uncommon, although a significant number of patients experience some stress-incontinence. Usually improves with time. Impotence (Erectile Dysfunction): if both neurovascular bundles were spared, potency rates range from 30-86%, depending on institution. Usually improves over time, and other ED treatments can work. RRP: Advantages:  RRP: Advantages Whole prostate - and thus the entire tumor - can be examined histologically. Surgeon has access to regional lymph nodes to test if prostate cancer cells have left the tumor. Surgical margin can be examined. Negative Surgical Margin Positive Surgical Margin Not all of tumor removed OR Radical Perineal Prostatectomy:  Radical Perineal Prostatectomy Bladder Prostate Urethra Rectum Surgical Approach Very similar to Retropubic protocol (nerve sparing, sewing of urethra, etc.) Incision: Between Anus and base of Scrotum. Pelvic Bone (Pubis) Perineal Prostatectomy:  Perineal Prostatectomy Comparison with RRP: Comparable cure rates as well as similar urinary and potency complications. Disadvantages: Cannot access regional lymph nodes Slight increase in risk of rectal injury and associated complications. Emerging Therapy: Laparoscopic Radical Prostatectomy:  Emerging Therapy: Laparoscopic Radical Prostatectomy Eliminates the need for a large incision by using a telescopic instruments called a laparoscopes. Small camera attached to the laparoscope allows the surgeon to view inside the abdomen. Laparoscopic Prostatectomy:  Laparoscopic Prostatectomy Advantages: Less blood loss. No large incision. Shorter hospital stay and earlier return to activities. Disadvantages: Longer procedure Variable surgical margins rates. Slower return of urinary continence. Variable potency rates. The Da Vinci Robot:  The Da Vinci Robot Surgeon operates from a console with a 3-D screen. Grasp controls to manipulate surgical tools within the patient. Robotic arms translate finger, hand, and wrist movements. Very High-Precision http://www.intuitivesurgical.com ? Radiation Therapy (RT):  Radiation Therapy (RT) High-Powered X-Rays that damage DNA and kill prostate cancer cells. External Beam Radiation Therapy (EBRT): X-rays aimed at prostate. Brachytherapy: Radioactive seed implants into prostate. General Procedure: EBRT and Brachytherapy:  General Procedure: EBRT and Brachytherapy EBRT: Map precise area that will receive radiation. Multiple treatments ~5 days/week for ~8 weeks. Each treatment takes about 10 minutes and no anesthesia is required. Brachytherapy 40-100 rice-sized radioactive seeds are implanted into the prostate via ultrasound-guided needles. Anesthesia is required. All radiation inside the pellets is generally exhausted within a year. History of Radiation Therapy:  History of Radiation Therapy 1898 – The first use of newly discovered “X-rays” was to alleviate the pain of pelvic bone metastases. Early use of external beam radiation therapy was limited because of power necessary to reach deep-seated cancers such as prostate cancer. 1950’s – New and more powerful isotopes and machines were discovered and built. Today – Computers and improved radiation technologies allow high-dose and high-precision treatment of prostate tumors. External Beam Radiation:  External Beam Radiation Goal: Maximize damage to the prostate and minimize damage to surrounding tissues (i.e. bladder and rectum) Prostate Seminal Vesicles History of Brachytherapy:  History of Brachytherapy 1909 – Minet first placed a radium tube in a catheter to irradiate prostate cancer. 1970’s – Real interest occurred when Whitmore described an implant technique using I-125. Inconsistent dose distribution was a problem. 1985 – Holm and Ragde used TransRectal UltraSound (TRUS) to position Pd-103 implants and established a national brachytherapy implant course. Brachytherapy: Distribution:  Brachytherapy: Distribution Cross-Section of Prostate Image of Prostate With Radioactive Bead Implants:  Image of Prostate With Radioactive Bead Implants RT: Complications:  RT: Complications EBRT Most symptoms occur during treatments and subside after completion. Diarrhea, rectal irritation, fatigue, frequent and painful urination, blood in the urine. Erectile dysfunction: less common than radical prostatectomy following treatment but slower recovery. RT: Complications:  RT: Complications Brachytherapy High initial dose of radiation that slowly fades over 1 year. Prostate inflammation and swelling, sometimes with severe urinary symptoms. Other, more rare symptoms include persistent urinary and bowel frequency and urgency. Erectile dysfunction: similar to EBRT. Cryotherapy:  Cryotherapy Destroys prostate cells by freezing tissue. Old idea that is making a comeback due to greater precision and better methods of imaging and temperature monitoring. Method: insertion of sub-zero cryoprobes into prostate perineally (between scrotum and anus). As yet unresolved how effective cryotherapy is compared to surgery or radiation. Cryotherapy: The Procedure :  Cryotherapy: The Procedure Prostate Urethra Rectum Cryo- probes Watchful Waiting:  Watchful Waiting A.K.A. observation, expectant therapy or deferred therapy. Diagnosis of an early-stage (T1-T2), low-grade tumor. No medical treatment is provided. Patient receives regular follow-up to monitor tumor. Why Wait?:  Why Wait? PSA and DRE can detect prostate cancer at a very early stage. Average doubling time of a prostate tumor is quite slow (2-4 years). Immediate radical therapy may constitute over-treatment and an introduce unnecessary urinary and potency risks. May be appropriate if the patient is elderly and/or in poor health, and will live out their life spans without the cancer causing problems. May also be appropriate for a younger patient who is willing to be vigilant and accept the risk of the cancer spreading. ? Advanced Prostate Cancer:  Advanced Prostate Cancer If the prostate cancer is no longer confined to the prostate. 12-28% of newly diagnosed prostate cancers extend outside the prostate gland or involve the regional lymph nodes (stage T3 tumors). Transition from cure to disease management. Hormone Therapy:  Hormone Therapy Prostate cells and prostate cancer cells are dependant upon androgens (male sex hormones) for survival and growth. Removal of androgens kills a majority of prostate cancer cells. Adjuvant Hormone Therapy:  Adjuvant Hormone Therapy Hormone therapy (androgen ablation) is a standard method of treating advanced and metastatic prostate cancer. However, for newly-diagnosed advanced cancers, androgen ablation may be performed prior to prostatectomy or radiation in order to shrink the tumor. The effectiveness of this technique is still under debate. Removing Androgens:  Removing Androgens Orchiectomy (castration): surgical removal of the testicles. Oral drug which has the same effect as castration. Blocks testosterone production. Include LHRH agonists and antagonists and oral estrogens. Anti-androgens which block the effects of testosterone. Combination therapies. Results of Androgen Removal:  Results of Androgen Removal Impotence Loss of sexual desire (libido) Hot flashes Weight gain Fatigue Reduced brain function Loss of muscle and bone mass Some cardiovascular risks Hormone-Refractory Prostate Cancer (HRPC):  Hormone-Refractory Prostate Cancer (HRPC) Despite initial response rates of 80-90%, nearly all men with advanced prostate cancer develop hormone-resistant prostate cancer after 18-24 months. These “hormone-refractory” (HR) prostate cancer cells can grow in the absence of androgens. The behavior of HR prostate cancers differ widely between patients. Chemotherapy:  Chemotherapy What is it: using anti-cancer drugs to kill hormone-refractory prostate cancers. More side effects than hormone therapy. Problem: high variability between HRPCs. A large number of studies have been conducted using numerous chemotherapies with very poor response rates (<10%). Difficulty: criteria used to measure response. Recently, newer agents and combination therapies have shown promising results. Management of Prostate Cancer Bone Metastases:  Management of Prostate Cancer Bone Metastases Goal: prevent pain, improve mobility, prevent complications such as fractures or compression. Goal: Maintain acceptable quality of life. Methods: bis-phosphonates, radiation of detected metastatic lesions, surgery. ? I Want to Know More…:  I Want to Know More… Internet: www.urologyhealth.org www.prostate.com www.ucurology.org www.prostate-cancer-institute.org Books: Dr. Patrick Walsh's Guide to Surviving Prostate Cancer. By Patrick C. Walsh, Janet Farrar Worthington Prostate Cancer for Dummies. By Paul H. Lange, et al. The Best Options for Diagnosing and Treating Prostate Cancer: Based on Research, Clinical Trials, and Scientific and Investigational Studies. By James Jr., Ph.D. Lewis

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