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This professor weaken. Yeah, thank you. Thank you. Yeah, first of all, I would like to apologize for getting coming over bit late. Uh But let's start, let's instead of wasting time. But my apologies though because 10 minutes are wasted. Now, the the topics we discussed last time that we will talk about anatomy of prostate continental diseases, banana. Um And out of which I think prostate cancer and BPH are the two important topics and I'm going to be talk about prostate cancer today, but I'm not going to talk about the treatment in detail because somebody else has done it in the past, but we can always discuss the treatment in questions and answer session. So we'll straightaway go to prostate cancer. Now, if you look at prostate cancer incidents, it's the second most frequent cancer in men worldwide, not just in western countries and the the mortality worldwide correlates with increasing gauge uh and, and as well as incidents. So it is old man's disease basically more commonly diagnosed in the sixth decade. All right. For African American men, the incidence rates are higher when compared to white men. Now, why that is the case there are many hypothesis put forth on that. We can discuss that in questions and answers. But basically, they have got a higher incidents compared to um, you know, um, white or other ethnicity. Now, with regard to risk of prostate cancer after the age of 50 or 60 is 7.8 to 12.9%. And deaths after that age group will be 3 to 2.33322 0.5 to 3%. Now, I'm not going into the details of anatomy because we have discussed this in the last lecture. But suffice to, to say that the peripheral zone is the one which is the seat of cancer in 80% of cases. Why this this is the case because these are the most dividing cells in this region. That's why it's more common in peripheral peripheral region. Now, what about the central zone, central zone is this is the central zone, the great colored one and this is this has got only about 5%. This is the gland which remains almost constant in its shape and size throughout throughout the life. Then you have transition zone, which is the seed for benign enlargement of prostate and you can get about 20 to 25% of prostate cancer's there. Now, coming to the etiology of the prostate cancer, now we know that it is definitely uh the disease of uh elderly. It doesn't mean that it does not occur in younger individuals, the Angus pay age patient I have seen uh was 35. So you can get prostate cancer at early age. But this is rare. And you should always remember in medicine where things are rarely correct. Common things are commonly correct. So most of the elderly gentleman, if they come with bladder of obstruction or prosthetic symptoms should always keep in mind about prostate cancer. That's, that's the center, that's a golden rule. Okay. So of course, the ethnicity we have already discussed. Genetic factors are important because man who had prostate cancer is likely to have a son who can develop prostate cancer. And similarly, family history is important. Now, wife, it occurs in families. It could be due to heritage tree, but most importantly, it could be because of lifestyle. We tend to have a particular lifestyle in running in families. So they can have a particular uh precipitating factor which can cause prostate cancer. Now, what are the other factors? Risk factors? Now, if you look at the diet, animals, saturated animal fat and red meat and processed meat as well and lower intake of fruits, vegetables, vitamins, and coffee. So vitamins and coffee is supposed to have preventative effect. And similarly, vitamin D seems to have preventative effect. But if you take calcium, it can actually trigger prostate cancer. Now, you may say why, why vitamin D and calcium have got such opposite effect because vitamin D is responsible for calcium absorption. What vitamin D does is it actually regulate the cellular function which uses calcium and thereby it, it makes the uncle uncle genesis, you know, cancer of genesis less possible. That's the reason you should take vitamin D. Then coming to the obesity metabolic syndrome, reduced physical activity. These are like for any other cancers and prostate cancer can also be caused by obesity and then inflammation. Now, inflammation in general is due to obesity, metabolic syndrome, bad lifestyle, you know, like smoking, drinking alcohol, things like that and, and eating a lot of meat. Those are the ones which can actually lead to increase uh inflammation or in the South, then infections. Now, in this particular context, you need to think about prostatitis, prostatitis. Is it a cause for process against that? Nobody can say that at this point of time because there is no proof but like many other conditions, many other cancers, it could be the cause for prostate cancer. Then you have environmental exposure to chemicals, ionizing radiation. Those are the other causes for prostate cancer. Now coming to the ethnicity, let's just look at this interesting facts. Now, if you take us a which is a good example because there's a lot of mixture of ethnicity in the USA. Now, if you look at American Indian and Alaska, they have got 46.9% incidents. Whereas if you look at native, native and Asian Pacific Islander, 52.4% followed by 93.9 and highest incidence is seen in African American men 1 57.6. Now why? Because it could be because of socioeconomic factors. Some people also say that they have got high testosterone level, but all these are only hypothetical ideas. There is no evidence to suggest that this particular cause. Any particular cause mention is responsible for causation of prostate cancer. Now let's look at family history of uh prostate cancer. Now that why this is important because they found out in Sweden that in particular village, there was a very high incidence of prostate cancer in in in in in this village because most of them were interrelated. So a family history in 20% of cases, it is possible that there are shared genes and also exposure to certain environmental carcinogens and common lifestyle which we have already discussed coming to the gene linkage. Uh you know, this is, this is just a passing remark. This is not, I do not think anyone would ask you specifically to name the chromosome, the number and the type of gene we are talking about. But it is important to know because prostate cancer is the one particular topic in urology that will be that you will you will crisscross on many occasions with other subjects. For example, somebody might come with a spine fracture and then have secondaries due to prostate cancer. So it's very important to know a little bit about prostate cancer, but it doesn't mean that you have to know everything in a thesis manner from eight to Zen, but I have just made a list of things here um just for completion sake. So I'm not going to the details of that. Now, the important thing about, about diet is carbohydrates. Now, why carbohydrates are so incendiary in in relation to prostate cancer because they release carbohydrates, release insulin and insulin like growth factors. This a little bit controversial but it is not surprising that they have got a role in this. And then sex hormones. Again, I am a bit doubtful about this, but as we know, prostate cancer response to androgen withdrawal. And it was also um found earlier in 19 forties that estrogens actually suppressed prostate cancer because the the whole hypothesis was that Angra Jin's actually caused prostate cancer. Uh Now, then we have environmental carcinogens like agent orange, which is used as a herbicide and then Klor Con which is used as insecticide and biphosphonate all which is used in plastic industry. So these there was agent orange, for example, was used in Vietnam war situation and there was a higher incidence of prostate cancer following that indicating that, you know, it was responsible for higher incidents across cancer in these veterans. So it is it is very difficult to rule out anything uh which are carcinogens because they can have their own rule in genesis of cancers. There was a lot of news about vasectomy. Oh vasectomy causes prostate cancer. I don't think vasectomy causes prostate cancer. But what happens is people who had a vasectomy are likely to have more testicular symptoms, like testicular pain, etcetera. And they're likely to be examined by urologist. And in the process are likely to have um, uh, prostate cancer diagnosed as an age isn't condition. So I do not think you can blame vasectomy for prostate cancer. Then there was another paper from Australia that a monks have got higher incidence of prostate cancer because they don't ejaculate. Now that is, that is a bit difficult to um uh account for because how do you know they're not ejaculating? They may not, they may say, well, I'm not exact because I'm monk but I'm a priest but they might be ejaculating and why it's worse. So, but what you can find out is that those who tend to ejaculate are likely to have less prostate cancer because they ejaculate cells die dead and dying cells which are sometimes dangerous. They could become cancerous then ionizing radiation like any other cancer you can have um prostate cancer due to analyzing radiation. Now, I would just like to bring you to the structure of the prostate a sinus. Now, here you have um three layers of cells and secretions are inside as you know, these are compound resumes, glands and you have got these columnar our cells. These are what are called as uh main secretory cells. These are called Luminal cells, then you have got basal cells. Okay. These blue ones are basal cells. Well, they're just blew for the description purposes. And then you have got neuro endocrine cells. Now, previously, people thought that the basal cells were the cells which become cancerous. But now it is becoming clear that it is likely to be Luminal cells. Now, if neuro endocrine cells become malignant, then it is very, it has carried a very poor prognosis. So we don't know how the extraneous factors influence these cells and cause cancer. Okay. But this is important to remember these structures and they could be the, you know, originally we thought it was basal cells, but then it has come back down to Luminal cells. Now, now the next thing you need to know about prostate cancer is glisten pattern scale. The glisten grading is very important because glisten grading is the one which is used in assessing the prognosis of the patient. Now, in most of the cancers, you take cell as the characteristic feature, sell like nucleus of the cell cell wall and the cytoplasm, you take those into consideration. Whereas in glisten pattern, you you look at glandular pattern, the architecture of the prostate. Now, if you look at this, this this is this resembles more like original prostate gland. So it is well differentiated. So you have got small uniform glands. Whereas here you have got more space between the glands because the architecture is slightly altered and then you go to three, you have got, you know, distinctly infiltration of millig rinse cells and also the the glands are distorted because of architectural lost. So there you become moderately differentiated cancers to the prostate. Now, if you go further down, you will see that the there are masses, irregular masses of glands with intervening stromal cells and then the last 1/5 is lack of occasional glance. So Glisson was in, in I think it was in 19 seventies. He was, he inherited a huge number of slides, having prostate cancer uh uh labeled on them. And he was asked to come out with something which made sense with regard to histology because you couldn't use grade one, grade two grade three type of classification for prosecutors. So he came out with this listen pattern and it still holds good. So that's the important thing then we have what is called as grouping. So in grouping, you have, for example, you need to group like low grade intermediary grade and high grade. Now if you look at here in this table, just adjusting to this, you will see that group very low, for example, less than listen, six. Um they are very low, so low grouping, that means they have a good well behaved cancer. Then you have got intermediary which is seven Gleason court 73 plus four or four plus three. I will explain to you what is this three plus four and four plus three then high and very high. So group four and grew five, we've got glisten eight and Gleason nine plus 10. Now, what Glisan said was that you need to look at two types of cells of one very high and one slightly lower. And then you combine them and come out together. For example, you can have well differentiated small uniform glands which will, which will take score three. Then you may have find another area which is infiltrated with abnormal glands and irregular margins, then it might become four. So then you will say three plus four where three is in majority and four is in minority. If it is four plus three, that means four in is in majority and trees in minority. So it is very simple but it has got a lot of um prognostic significance. Why? Because if you have got a Glisson score 73 plus four, it is likely to behave as glisten four. Okay. And the same with Gleason 74 plus three even though it is four plus even. Sorry, in this case for it is going to behave as four. But in the other previous 13 plus four, it is likely to be a four even though three is in higher concentration. Okay. We'll discuss this more if you have any questions. Now, let's look at myths of uh prostate cancer. Mid number one, prostate cancer is old man's disease. I have already told you that it is common in old man, but it doesn't mean it is not seen in younger patient. So you should be aware that if a 40 year old man comes with the bladder probst ruction or prosthetic symptoms, you shouldn't forget to examine the prostate. And if you feel that there may be malignancy, you should do PS PSA test. So these are very important if you have no symptoms, you don't have prostate cancer, That's wrong because prostate cancer could be a symptomatic. It's a slow growing cancer. So there's no need to worry about. It is not, it is actually it's, it's a cancer. There's nothing called slow fast, bad, good cancers. They're all cancers, they all have the same label. So you have to be very careful in dealing with this. Prostate cancer does not run in my family. So the arts aren't great that I will get it. This is again a wrong assumption if there's a family history that is, that should be taken as significant, but it doesn't mean that you will not get, you will get it or you will not get it. Ps PSA test is a cancer test. It's not a cancer test. It is prostate specific. Yes. Is prostate related test. The high PS PSA level means that you have got prostate cancer and low PS PSA. That means that you don't have prostate cancer. There's nothing like that. PS PSA is only a relative. It depends on the person who is seeing the patient and decides how he wants to, he or she wants to deal with that vasectomy's caused. PCR. We have already discussed this. You can't have a baby after prostate cancer. Now, you can have by assisted conception unless you have a very extensive radiation. It may affect your natural ability to have Children, but your testicles will be intact unless you are treated by hormone therapy, sexual sexual activity, increase the risk of developing prostate cancer. That is the wrong and then surge surgery and relation are the best way to treat prostate cancer. That is also wrong because you can treat the patient's with observation or focal therapy, which will look at later. Now, let's look at the clinical manifestations of uh prostate cancer. Now, let's first talk about a symptomatic prostate cancer. So, anyone who comes with hematuria's to men, I'm talking about should be assessed for a prostate cancer. Okay, hematospermia, 15% of hematospermia patient's can have prostate cancer. Somebody who develops sexual dysfunction may have prostate cancer. Why? Because the nerves might have been affected because they run very close to the prostate dysuria pain while passing urine could be a manifestation of prostate prostate cancer, irritated urinary symptoms, cystitis like symptoms. You should check ps and make sure that you don't have um, anything suspicious. Okay, unexplained weight loss pain while passing urine, which we have already discussed painful ejaculation, unexplained weight loss, back pain. All these are causes of uh silent um prostate cancer. Okay. Then we come to symptoms, they're essential symptoms of prostate cancer. Could be similar to BPH. Uh mainly lower unit have symptoms that means they can have obstructive or irritated symptoms. And then you can have incidental detection after prostatic resection. The patient comes with BPH PS PSA is normal, but then the patient undergoes turp transfer through sectional prostate and then you examine the prosthetic chips and the chipping shell prostate cancer. So this is incidental detection of prostate cancer, then secondary is causing neurological symptoms. The first symptom could be a weakness of the bladder, weakness of legs. And then when you do the X rays, you see these osteo osteo plastic and osteoblastic uh born secondaries weight loss anemia in back pain. You should always keep prostate cancer in mind. Now, the examination of the patient now, obviously abdomen is very important because you want to rule out retention and general assessment, whether it is a weight loss, Emaciation, anemia, etcetera. Then you need to examine the genitalia like we do in BPH and then rectal examination, a baseline estimation of prostate volume, any abnormal areas and neurological neurological examination if you indicate. Now, the rectal examination is typically done in Nietzsche's position or in left lateral position and you need to get the consent of the patient and explain the purpose of the examination and what you are likely to find out. You need to do all that before putting your finger in the rectum. Okay. Now, diagnosis of prostate cancer. Now, once you have um, uh, the clinical diagnosis, suspicion, it's no good telling the patient that he definitely has prostate cancer. Until you have got the histological diagnosis. You have no business to tell somebody that they have got prostate cancer. What he could do, what you would say to the patient is that we need to rule out prostate cancer. That's how I would put it rather than. Well, I think you have got prostate cancer and I would like to do more tests about this prostate biomarkers, ps PSA and prostate health index. This is coming recently and then imaging and biopsy of the prostate. So this is how you make a diagnosis of Prosek Wincey. Now a world or two about prostate specific condition. Now, what is prostate specific condition? It's a, it's an enzyme which is there in the semen. It's a proteus member of uh Calik Crime family and it is synthesized in prostate. The other organs which could synthesize PSEA like substance are breasts in women and also kidney. So it's not just prostate but these organs also, but they are in miniscule. Okay. And it is exclusively synthesized in the prostate gland and it is confined to the prostate land. So if you find higher levels of PS A in the blood, that means there is a leakage of PS PSA into the circulation from the prostate, what is its function. It liquefies seminal fluid and thereby allowing sperm to swim freely in the female. General tracked. No. Um So as I said, it can break the extracellular matrix and come get into the circulation. Now, most of the patient's with prostate cancer are likely to have higher levels of BS A. Now commonly used to cut off his four nanogram per milliliter. And the if, if you are talking about PS PSA uh between 4 to 10 and then uh the digital rectal examination should. So something suspicious, you are likely to have a positive prostate cancer diagnosis in 25% of the cases. If BSA levels are higher than 10 nanogram, then the bop C is likely to be um more than 67%. Now, what are the other causes of PS PSA arise, benign enlargement of prostate because the gland increase in size prostate cancer, of course prostatitis and urinary tract infections in men. Instrumentation, for example, you catheterized and then you check PSA it is likely to go on in these cases. So you should keep all these factors in mind when you determine PS PSA levels. If somebody had sex or ejaculated, that also can increase the PS PSA levels. Similarly riding a bicycle and then taking medicines like testosterone can increase PS A fire. All for reduct ear's can actually decrease PS A old age and stress can also increase PS A. So if you look at the old age, here is the age related PSL levels. So less than 50 it is likely to be between zero and 2.5 between 50 59. It's likely to be between zero and 3.5 and 60 69 and 0.00 to 4.5 and 70 about 0 to 6.5. So we need to take all these factors into account when you talk about PS A. Now, in addition to PS A, there are lots of other things you can do. One is called PS A velocity and PS A. Um then you can actually check PS PSA doubling time, PS psa density and then free and total PS A ratio. So all these are relatively useful. They're not diagnostic, but they actually tell you more about what you are likely to get. There are specific information's in relation to each of them. For example, PS PSA velocity and Dublin time is likely to tell you how fast the prostate cancer is growing. The and then PSA density will tell the amount of prostate cancer that could be there and then free and total will tell you whether the rise in PSA is because the prostate cancer or because of BPH. Now, nowadays, we have got ice A forms of PSA which are being used in prostate health index. This is not widely available, but it is likely to be available and take over the place of PS A in the future. Now emerging studies. You are like you the most important imaging study of of this decade and lost decade is multi parametric magnetic resonance imaging and you know for detection of tea staging and monitoring purposes in active surveillance. France, regular auto sounded to guide the Bobbsey need a bone scan to check bonus secondaries. PSM. A pet CT is used for secondaries after the treatment and CT scan in selected cases when you're suspecting lymph nodes due to prostate cancer. Now, the biopsy of the prostate is done transrectally, transperineal early or transfer you literally depending on the requirement. Now, transrectal used to be very popular but now it is replaced by transperineal. Um Now why transparent, nearly useful because you can actually map the prostate and you can take tissues from specific areas of prostate and thereby you can actually map the cancer in the prostate. That's why transperineal biopsies preferred mood transfer. Italy is not used routine liberty. It is used when you resect the prostate and you can have a diagnosis of prostate cancer. Now, what are the lists of the biopsy? A person can bleed can have infection, urine retention, erectile dysfunction and hematospermia. Uh then we come to staging of the prostate cancer. So you, of course, as you can see here, T one which is confined to prostate. Uh Here it is tumor is, are located to one side. For example, that's T A and T one B is incidental during the reception of prostate and T one C is identified by needle bob. See. So these are actually confined. The T one is always confined to the prostate. T two is also confined to the prostate, but it involves half a lobe or less and T to be, is more than half and then t to see when it involves both lobes. Now, T three is when you're the cancer extend through the prosthetic capsule, bladder neck. So it is a little bit difficult to use surgical treatment as the procedure. So you can do surgical procedures for T one and T two but T three, you have to select your case is very carefully. And if you take T four, you have got, the tumor has spread um tissues next to prostate like a seminal vesicles um or sorry RT four A which has spread to the neck of the bladder and then to the sprinter or to the T four B is tumor has spread to the floor. Okay. Now, nodal status young O2, 3. N is any no, no N zero is no spread. Anyone is regional lymph nodes yen to is one or more lymph nodes and, and significant more than two centimeters um in, in diameter but less than five centimeters and entry is more than five centimeters. Now, M zero is metastases. This medicine, for example, boney metastases is um one if the bone scan is negative, then it is um one sorry um zero. Now, management. Now, as I told you, this is not a management discussion, this is mainly diagnosed diagnostic psa prostate cancer because the treatment itself is a huge chapter and it needs a special another lecture. But I will just to take you through the steps in the management. So once you have made a histological diagnosis, the next thing is to check the general condition of the patient's life, likely life expectancy, associated medical conditions, morbidity, sexual function, bowel function, and all these are very important. And then you discuss the case in Multidiscipline team meeting and then come out with a particular choice or choices and then discuss that with the patient and relatives and look at their provinces and biases and then treatment and follow up. That's how you do it. Now there is a risk assessment. So you, you, you need to know when you should do more investigations and when you should do less investigations, I think this is for you to read the slides. So I'm not going to take in, in in detail is very clear. Now, the National Cancer Group in America, they have put the stable eloquently and it is self explanation. It. Now a surgical anatomy of the prostate. I have showed this diagram before. The most important thing is the nerves and vessels here in the grew and the important structures. You've got bladder here, you've got bladder neck and you have got the rectum. So you can easily land up in problem if you are, you do not remember these relationships and the same thing here. Now, just a word or two about active surveillance. So if somebody has got a very small focus of prostate cancer, you can actually do uh you know, active surveillance, uh expectant line of treatment. So again, it has been shown in various series that these patient's do quite well and it can only interfere if the disease has progressed. Now, surgical procedures for prostate cancer include radical prostatectomy, which is the definitely treatment for T one and T two lesions. And in certain research criteria where you can operate on higher grades transferred to the section of prostate. If there's obstructive symptoms, then you, you the patient has been under control, good control of the disease. Then you can do translate resection to facilitate the relief of obstruction. Then uh procedures for obstructive uropathy, that means you may have to stand the kidneys, bilateral subcapsular. Architect Ammi was a very uh commonly used treatment in eighties. Now, it is used, it still has got value and is used in various parts of the world spinal decompression procedures. If somebody has got compression, you may have to decompress and then catheterization, radiotherapy, external beam, radiotherapy with new adjuvant hormone therapy, bracket therapy and focal therapy. You have quote, you know the the here comes the question whether it is focal or multifocal. So if there is a cancer which is focal, you could do high intensity ultrasound. You could do Puerto dynamic therapy, bracket therapy, cryotherapy, and uh nano knife um thing. So locally at once you, you may, you may have to consider total prostatectomy a nodal dissection. But this is again in research interest and you should be done in recognized centers and then near joint hormone therapy followed by radiotherapy. Then you should know about biochemical reckons across the cancer. That means PSS stands rising after it has been brought to less than one. Uh, less than less than zero. I mean, minus, sorry, not less than less than one where you know, like somebody who had PSF 0.1 and certainly starts having a rise in PS A. Then you need to re re validate and see do investigations to see whether and then metastatic prostate cancer. So in brief, this is about the prostate cancer diagnosis and principles of management. Uh, now we'll take questions. Hello. Yes, Professor Lincoln A. Hmm Yeah. Any questions please? Shall we go through questions? Are there any questions? Um, right here in the chat. No one has asked for a question. You can ask question. Any questions sheriff, any questions, sir, any questions guys, professor, we've got like 10 minutes for questions. Anyone so you can ask whatever questions you got. I went fast because I wanted to catch up with questions. That's why I went past because questions are more important as well. You can always follow the slides. Yes. Uh would you go then with the uh dragging system of uh the back of the slide other treatment one where we see the PMM. Uh Can you, can you ask question again? Yes. Can you go back to the management part by the spread of the two levels was just, but in the management packed before the management point, I don't know what you asked. The last part of the question I didn't understand. Not a management. This is, this is just the principles of management because management itself needs another lecture. You know, and I saw somebody has given a talk on surgical management of prostate cancer. Is that right? Hello? No, nobody has given because I was going through the previous sessions and then I saw somebody giving talk about robotic prostatectomy and all that. But anyway, let's let's deal with your question. It doesn't matter. Ask the question again, please. Can you talk a bit slowly? Uh the spreading of the cancer? Yeah. So the spread of the cancer, how it is spread, you mean? Yeah. Yeah. Okay. So any cancer in the body spreads in a particular way and prostate cancer is no exception. The first and the foremost thing is what is called a pin. Have you heard the word pin? Pin? Sure. No, sir. No. Okay. Pin means prosthetic intraepithelial neoplasia. So before the cancer starts, there are a few cells which become abnormal and in pro it is, it is called in situ carcinoma in situ cis, that's the usual thing that happens. So in prostate cancer there called a spin prosthetic intraepithelial neoplasia. So the first thing is it is like, let me tell in very simple language, all in sheep's clothing. That means it is very difficult to see this cell by microscope because it looks like a normal cell only if you stay in it appropriately and especially and look at it very carefully, then you might see pin. So the first stage is the pin and then it spreads in the epithelium. So it is local spread. So you you are likely to have a focus or four chi four sigh of tumour in the prostate. Then it can invade the capsule and once it invades the capsule or once it gets into the blood vessels, it is likely to spread through lymphovascular route. And the the first report of secondaries is operator nerves, uh sorry, operator lymph nodes, those are internal iliac lymph nodes. So they get in ward and then you you can have either jump, that means the next group may completely escape and may go to the further up the lymph node. So that's the next way of doing it. And the third way of spread is through the bones into the bones actually. So you can have secondaries in bones, particularly axial skeleton, why axial skeleton? Because axial skeleton has got veins which have free communication with prosthetic veins. So the prosthetic cancer cells can easily go and launch in the axle uh scalp system and then of course, lungs and brain and other things are very, they are advanced secondaries. Does that answer your question? Yes, sir. Uh Any other question? So as a, as a, as a basic doctor, what I would expect a doctor to know GP for example, should know is how to recognize prostate cancer and how to investigate the basic and then refer the patient to a specialist. That's, that's the level of knowledge I would expect in an undergraduate student. And that's exactly what I have told. Now, if you are interested in more about treatment, I'm quite happy to take another lecture for you guys. You need to, you need to come back and tell me you want another one on the management. Okay. I will, I will, I will tell uh Hannah and I'll tell cheri to organize that. All right, any other question you should challenge me, you should ask more questions. Come on otherwise. So what happens when people don't ask questions? You? I, I had another question I ask, ask, please ask uh you said about the neurological examination uh as the incidents of uh prevalence can occur when uh prosthetic cancer can reach to the brain and cause you're in the practice like it's a be considered as a spread of cancer for a long distance. So prostate cancer is a very protracted disease is a protracted disease. That means it goes very slowly to start with. There are cancers, there are prostate cancers which can be quite fast in spread like field fire. But that's rare with prostate cancer, prostate cancer when you have diagnosed, it has been already there for, for months and years. And that's the thing you need to understand, but it does not spread. You know, I've not, I've not seen that many cases of brainy metastases of prostate cancer. We see lung metastases, but we don't see brain mets very rare actually. But having said that it can happen, the most common spread is to the bones, axial skeleton and living rooms. So those are the things. Now, I do not expect you to assess uh spread um inpatient because that comes afterwards, when you have made a diagnosis of prostate cancer, then you would like to stage the disease. That's when the secondary is coming to exist. That's when you think about secondaries. Oh, this patient has got prostate cancer. How far this disease has advanced in this patient? Has it gone to the lymph nodes? Has it gone to the bones? Has it gone? Now, that is likely to be easily available to you even without doing tests by PS PSA because PS A, once you have diagnosed prostate cancer, PS PSA is very valuable because PS A will go up with tumor volume. So if somebody has got a high tumor volume, you will have higher PS PSA. Whereas if somebody has got localized small focus tumour, ps psa is likely to remain steady because as you know, cancer cells, they synthesize BSA and release into the circulation. So I, I do not, I, I would not expect an undergraduate student to talk more about secondaries. I would be more interested in that person talking about the diagnosis, local diagnosis of prostate cancer. Anything else? All right. Thank you very much, doctor. There's no other questions. I've put the link in for the next lecture in the group. Everyone, if anyone can, can look for the next lecture, you please call me feedback. Yeah, you could book me for because you're going to have holidays now, aren't you? It's doctor. Um, there's a link in the group that you can check through the appointments and if you have any difficulties, just please text Hannah privately and she can sort everything out for you. Yeah, that's fine. All right, lovely. Useful. I was lovely. Was lovely. Thank you very much and I went very fast. Uh Sorry about that, but it's my own for it actually because I thought it was three o'clock. My uh no problem. Thank you very much for the lecture and I do thank everyone for attending and there's no other questions I think we can, can, we can end the meeting? Uh good.