Prostate Cancer Staging - PowerPoint PPT Presentation

1 / 40
About This Presentation
Title:

Prostate Cancer Staging

Description:

Know the reason for staging prostate cancer ... Assess prognosis and aid in planning management ... Poor visualization hypogastric chain (50%) Conclusion ... – PowerPoint PPT presentation

Number of Views:236
Avg rating:3.0/5.0
Slides: 41
Provided by: Libr162
Category:

less

Transcript and Presenter's Notes

Title: Prostate Cancer Staging


1
Prostate Cancer Staging
  • Amy Opperer, D.O.
  • Michigan State University
  • January 21, 2004

2
Objectives
  • Know the reason for staging prostate cancer
  • Know the elements of clinical and pathological
    staging
  • Know the tools available for staging

3
Outline
  • Introduction
  • History
  • AJCC Staging
  • Digital Rectal Exam
  • Serum Tumor Markers
  • Histologic Grade
  • Imaging
  • Lymph Node Evaluation
  • Conclusion

4
Introduction
  • Goal of staging
  • Assess prognosis and aid in planning management
  • Identify clinically localized v. locally advanced
    v. metastatic disease
  • Pathologic stage
  • Best predictor of outcome
  • Local extent (DRE)
  • Serum PSA
  • Tumor grade

Correlate well with pathologic grade
5
Introduction
  • More information
  • Tumor volume
  • Surgical margin status
  • Extracapsular spread
  • Seminal vesicle involvement
  • Lymph node status

These plus tumor grade are most important for
prognosis
6
Introduction
  • Staging tools
  • Digital rectal exam
  • Serum tumor markers
  • Histologic grade
  • Radiographic imaging
  • Pelvic lymphadenectomy

7
History
  • Whitmore (1956) first staging system
  • Jewett (1975) revised
  • American Joint Committee for Cancer Staging and
    End Results Reporting (AJCC)
  • TNM adopted (1975)
  • Modified (1992, 1997)

8
(No Transcript)
9
1997 AJCC Staging
  • Primary tumor
  • Tx Primary tumor cannot be assessed
  • T0 No evidence of primary tumor
  • T1 Tumor not palpable or visible by imaging
  • a ?5 resected tissue
  • b gt5 resected tissue
  • c needle biopsy specimen due to ?PSA

10
1997 AJCC Staging
  • T2 Palpable tumor confined to prostate
  • a one lobe
  • b both lobes
  • T3 Extends through prostate capsule
  • a unilateral or bilateral extracapsular
    extension
  • b invades seminal vesicle

11
1997 AJCC Staging
  • T4 Fixed or invades adjacent structures other
    than seminal vesicles
  • Bladder neck, external sphincter, rectum, levator
    muscles, pelvic wall

12
1997 AJCC Staging
  • Pathologic primary tumor
  • pT2 Organ confined
  • a unilateral
  • b bilateral
  • pT3 Extraprostatic extension
  • a extracapsular
  • b seminal vesicle invasion
  • pT4 Invasion of bladder or rectum

13
1997 AJCC Staging
  • Regional Lymph Nodes
  • Nx Cannot be assessed
  • N0 No lymph node metastasis
  • N1 Metastasis in regional lymph node(s)

14
1997 AJCC Staging
  • Distant Metastasis
  • Mx Cannot be assessed
  • M0 No distant metastasis
  • M1 Distant metastasis
  • a nonregional lymph nodes
  • b bone
  • c other site

15
Digital Rectal Exam
  • Significantly understages
  • Increases with increased clinical stage
  • Partin et al (1993) 52 sensitive, 81 specific
  • 565 organ confined on DRE
  • 52 organ confined
  • 31 capsular penetration
  • 17 seminal vesicle or LN invasion
  • 36 non-organ confined on DRE
  • 19 organ confined
  • 36 capsular penetration
  • 45 seminal vesicle or LN invasion

16
Serum tumor markers
  • Prostatic Acid Phosphatase
  • Pre-PSA era
  • Directly correlate with disease stage
  • gt80 with abnormal (upper ½ normal) have
    extraprostatic disease
  • Not specific

17
Serum tumor markers
  • Prostate-Specific Antigen (PSA)
  • Not sufficient for staging alone
  • Confounding factors
  • Volume of BPH
  • Tumor grade
  • Stage overlap
  • lt4ng/mL?80 organ confined
  • 4-10ng/mL?66 organ confined
  • gt10ng/mL?lt50 organ confined
  • gt20ng/mL?20 LN involvement
  • gt50ng/mL?75 LN involvement, 90 SV invasion

18
Serum tumor markers
  • Other
  • Alkaline phosphatase
  • Not specific
  • Reverse Transcriptase-Polymerase Chain Reaction
    PSA
  • Specific
  • No additional value

19
Histologic grade
  • Strong predictor of biologic behavior
  • Invasiveness
  • Metastatic potential
  • Perineural invasion indicates higher risk of
    non-organ confined disease
  • 75 have capsular penetration
  • Biopsy of seminal vesicles
  • Consider for large palpable tumors

20
Histologic grade
  • Gleason grade
  • Numbered score to identify histologic pattern
  • ?4 has poorer prognosis
  • Gleason score
  • 2 most prominent patterns
  • gt50 Have at least 3 patterns
  • ? 7 has poorer prognosis
  • Primary 4 (43)-more aggressive

21
Histologic grade
  • Gleason 1
  • Atypical adenomatous hyperplasia
  • Uncommon
  • Rarely diagnosed

22
Gleason Grade 1
23
Histologic grade
  • Gleason 2
  • Similar to Gleason 1
  • Well differentiated
  • Less circumscribed
  • ? variation of acinar size and shape
  • Maintain round shapes

24
Gleason Grade 2
25
Histologic grade
  • Gleason 3
  • Most common
  • 3 patterns
  • Cribiform, small acinar, large acinar
  • Prominent variation in size, shape, and spacing
    of acini
  • Irregular arrangements
  • Stromal fibrosis
  • Infiltrative

26
Gleason 3
27
Histologic grade
  • Gleason 4
  • Poorly differentiated
  • Fusion of acini
  • Ragged infiltrating cords and nests
  • Rigid network of epithelium
  • Sheets of cells

28
Gleason 4
29
Gleason 4
30
Gleason 4
31
Histologic grade
  • Gleason 5
  • Fused sheets and randomly arranged acini
  • Displace other tissue
  • Comedocarcinoma
  • Luminal necrosis
  • Signet cell carcinoma
  • Distinct nuclear displacement by clear cytoplasm
  • If gt25, then signet-ring cell carcinoma

32
Gleason 5
33
Gleason 5
34
Imaging
  • Bone surveys
  • Not sensitive
  • Follow up of radionuclide scan
  • Bone scintigraphy
  • Asymmetric areas with intense uptake
  • Most sensitive
  • PSA lt10 and no bone pain
  • Baseline

35
Imaging
  • Magnetic Resonance Imaging
  • Low sensitivity for local extension or LN mets
  • Computed Tomography
  • Low sensitivity for local extension or LN mets
  • Transrectal Ultrasound
  • 50 tumors gt1cm not visualized
  • Most hypoechoic areas are benign
  • No difference in prognosis if seen on TRUS

36
Imaging
  • ProstaScint Scan
  • Indium 111 tagged antibody CYT-356
  • Limited value in pretreatment staging
  • Postitron Emission Tomography
  • BPH and prostate tumors appear similar

37
Lymph Node Evaluation
  • 10 year progression of prostate cancer
  • 31 in node negative
  • 87 in node positive
  • Pelvic lymph node metastasis
  • T stage, PSA, Gleason score
  • 5-12 localized disease (gt20 pre-PSA)

38
Lymph Node Evaluation
  • Pelvic lymph node dissection
  • Relative indications
  • Enlarged nodes on imaging
  • PSA gt20ng/mL
  • Gleason score 8-10
  • Palpable locally advanced
  • Lymphangiography
  • Good visualization obturator nodes
  • Poor visualization hypogastric chain (50)

39
Conclusion
  • Clinical and pathological staging estimate
    prognosis and guide treatment plans
  • Digital rectal exam
  • Serum tumor markers
  • Histologic grade
  • Radiographic imaging
  • Pelvic lymphadenectomy

40
References
  • Bostwick, D.G., Quan, J. Schlesinger, C.
    (2003). Comtemporary pathology of prostate
    cancer. Urologic clinics of North America 30
    (2) 181-207.
  • Carter, H.B. Partin, A.W. (2002). Diagnosis
    and staging of prostate cancer. In Walsh, Retik,
    Vaughan, Wein (ed.), Campbells Urology (pp.
    3055-3079). Philadelphia Saunders.
  • Kozlowski, J.M. Grayhack, J.T. (2002).
    Carcinoma of the prostate. In Gillenwater, J.Y.,
    Grayhack, J.T., Howards, S.S. Mitchell, M.E.
    (ed.), Adult and Pediatric Urology (pp.
    1512-1526). Philadelphia Lippincott Williams
    Wilkins.
  • Lloyd-Davies, R.W., Parkhouse, H., Gow, J.G.
    Davies, D.R. (1994). Color atlas of urology.
    London Mosby.
Write a Comment
User Comments (0)
About PowerShow.com