Marion Swall, MIV

USC School of Medicine

Epidemiology
Prostate cancer is the most common cancer & #2
cancer killer in American men
Approx 190,000 cases will be diagnosed annually
Approx 27,000 deaths will occur
Clinically ranges from a well differentiated tumor to an
aggressive cancer with substantial invasive and
metastatic potential.
Screening
Prostate cancer used to be detected by digital rectal
examination (DRE) findings of asymmetric areas of
induration or frank nodules
Now, prostate cancer is usually detected by an elevated
serum PSA & is asymptomatic at presentation
PSA >10 ng/mL Prostate biopsy is uniformly
recommended. 50% probability of cancer
PSA 4 to 10 ng/mL Prostate biopsy is advised. Specificity is
lower, 20% probability of cancer
PSA > 2.6 ng/mL & if PSA Velocity is 0.75 ng/mL per year
Prostate biopsy is advised
PSA velocity >2 ng/ml per year is high risk for life threatening
cancer

Diagnosis
Prostate biopsy is the gold standard
Transrectal ultrasonography (TRUS) biopsy is a relatively
simple procedure done in the office


Transrectal ultrasound in sagittal plane
demonstrating hyperechoic biopsy tracts (arrows)
evenly spaced throughout the gland.
Staging
Staging is critical to guide treatment options given
high morbidity of therapy.
Endorectal coil MRI & TRUS with staging biopsy can
be used to assess the local extent of disease.







US shows an extensive, hypoechoic T3
tumor with capsular irregularity on the
right and posteriorly (arrowheads)

US also suggests infiltration into the rectal
wall (arrow).
Staging Continued
Endorectal coil MRI
provides a more accurate
estimate of seminal vesicle
involvement or
extraprostatic extension

Endorectal MRI in a patient with extensive
prostate carcinoma showing a bulge in the
capsular outline on the right side. This is a
stage T3 tumor.
Treatment Options
Depending on stage, management includes:
Radical Prostatectomy
External Beam Radiation Therapy
Brachytherapy,
Androgen Deprivation Therapy (ADT)
Chemotherapy
Active Surveillance
Ablation
Or the new ablation therapy HIFU
HIFU or Hooey?
High-Intensity Focused Ultrasound (HIFU ) pulses energy into an area about
the size of a grain of rice creating a sharply delineated point of increased
temperature, melting cell membrane lipids and denaturing proteins.
HIFU is currently approved in Europe and South America
Targeting is planned to avoid the urinary sphincter, rectum, and the
neurovascular bundles
Complications include urinary incontinence (6%), UTI (7%), obstruction
(14%), pelvic pain (6%) & significant erectile dysfunction in 57%.
Failure-free survival rates at five & seven yrs were 66 & 59% in T1 & T2 cancers
However, pathologic involvement is often more extensive than on imaging
Studies suggests that there is a substantial risk of under treatment of
biologically significant disease using the focal ablation, emphasizing the need
for careful patient selection based on estimated life expectancy and a thorough
pretreatment biopsy scheme.

So what happened?
HIFU didnt work
External Beam Radiation didnt work
Androgen Deprivation Therapy didnt work
Chemical castration didnt work
Now what?
Distant metastasis
Hematogenous spread of prostate cancer cells is common with tumor
growth preferentially occurs in bones of the axial skeleton, where red
marrow is most abundant
Metastatic lesions in bone are frequently symptomatic, causing pain,
debility, and functional impairment
Radionuclide bone scan with technetium-99m advised in patients with
PSA levels >10 ng/mL
Radionuclide Bone Scan
Bone Scan Findings
Multiple focal areas of increased radiotracer
uptake (hot spots) on RN bone scan are
classic for metastatic disease.
Metastases appear as hot spots on RN bone
scan due to increased osteoblastic activity.
RN bone scans are very sensitive for
detecting osteoblastic activity, but are non-
specific, osteolytic & osteosclerotic
metastases present similarly.
Fractures, arthritis, and tumors all present
as hot spots.

Note: the tracer is cleared through the urine, hence the
"hot" bladder.

The Superscan
With diffuse bone metastases, a "superscan" may be
seen.

This superscan
demonstrates high uptake
throughout the skeleton,
with poor or absent renal
excretion of the tracer.
What do you see?
Ivory Vertebra
Note sclerotic
vertebral body of
normal size at L2

Osteosclerotic metastases
are most common from
prostate & breast cancer
Other possibilities
include lymphoma,
vertebral hemangioma, or
Paget's disease.
Osteosclerotic vertebra
decreased in height likely
to be a compression or
healing vertebral fracture.

What do you see?
Femoral Findings
The distal femur demonstrates an
eccentric, sclerotic lesion with
periosteal reaction at the edge of the
lesion in the form of a Codman
triangle.
A Codman triangle is an aggressive
pattern of periosteal reaction, but
aggressive is not synonymous with
malignant.
Codman triangle occurs with
malignant bone tumors and
metastases, but also with osteomyelitis
and/or hemorrhage.
The End
Manifestations of advanced prostate cancer include:
anemia, bone marrow suppression, weight loss,
pathologic fractures, spinal cord compression, pain,
hematuria, ureteral and/or bladder outlet obstruction,
urinary retention, chronic renal failure, urinary
incontinence, and symptoms related to bony or soft-
tissue metastases.
Life expectancy now 9 months to 2 years