TaiChing

Embryology:

müllerian duct--> central zone
Five Urogenital epithelial bulb--> others(peripheral. transitional zone)
Prostate Ca--> 2nd in foreigner, 7th in Taiwan....low fat diet

BPH: tansitional zone>> central zone> peripheral zone

Prostate ca: peripheral zone>> central zone> transitional zone
Risk factor: age, race, family history, diet(fat)
S/S: non specific, late symptom: urethral obstruction, lymphedema, bone meta(pain, spine compression, hypercalcemia)
Work up: >50 y/o, DRE, PSA< 4ng/dl, TRUS
AUA flow chart:
PSA: serine protease, secreted from acinar (colunmar epithelium), non-specific
elevated PSA: infection, urine retension, ejaculation, post needle biopsy, post DRE
PSA characteristics: velocity> .75; density>.12
Gleason grading system:
   1,2. uniform, tight, medium-size gland

   3. small gland

   4. incomplete gland

   5. no gland

(image from Campbell welsh urology)

TNM system:
T1 Nonpalpable tumor—not evident by imaging
   a. histologic grade <7
   b. histologic grade >7
   c. Nonpalpable, PSA Elevated
T2 confine to capsule
   a. Palpable < Half of One Lobe
   b. Palpable on Both Lobes
T3 outside capsule
   a. Unilateral extracapsular extension
   b. Bilateral extracapsular extension
   c. Involve seminal vesicle
T4 nearby organ
   a. bladder neck, external sphincter, rectum
   b. levator muscle, pelvic wall
Patient risk group
low risk: T1a or c, PSA<10, Gleason score 2~5, unilateral or <50% core
intermittent risk: T1b or T2a, PSA<10, Gleason 6 or 3+4, Bilateral
high risk: T2b or T3, PSA 10~20 Gleason 4+3, >50% core or perinural invasion, ductal differentiation.
very high risk: T4, PSA>20< Gleason 8~10, lymphvascular invasion, neuroendocrine differentiation
Treatment choice: consider age, life expectancy, comorbidity, stage
1. localized CaP: T1,T2
2. locally advanced Cap: T3, T4
3. Advanced metastatic: distal meta
Watchful waiting:

1. life expectancy <10 years
2. low grade

Active surveillance: suit for low risk patient

Radical prostatectomy: entire prostate, capsule, seminal vesicle

1. life expectancy> 10 years
2. suit for T1,T2
3. complication: incontinence, ED

R/T: acute proctitis/ cystitis as major complication(external beam)
low risk: can be cure!
intermittent risk: neoadjvant R/T
high risk: CCRT

Treatment of choice:
Localized CaP: radical prostactomy with/without nerve sparing (at 5 and 8 o’clock)
Local advanced: radical no suggested, R/T 5 years OS:60~70%

Meta: 1. Hormone(70~80% response): Chemical/Surgical Orchiectomy: LHRH antagonist, androgenR antagonist, 5-alpha reductase inhibitor...easy to relapse in 1~2 years, NOT RECOMMANDED for early stage patients!
         2. C/T: taxotere