PROSTATE CANCER

PROSTATE CANCER

In adult males,prostate cancer is the most common neoplasm (after skin cancer ) andthe second most common cause of death due to cancer over the age of 65 years. In most of these older men, the disease is noclinically apparent, only 10 % of men over 65 yr develop clinical evidence of the disease.95% of tumors are adenocarcinoma, arise  primarily in peripheral zone.

AETILOGY

The cause of prostate cancer is not known but many factors appear to be involved :

1.Genetic

2.Hormonal

3.Dietary

4.Environmental carcinogenic Influences

TYPES OF CA PROSTATE

A. Microscopic latent cancer found on autopsy.

B. Tumors found incidentally during TURP (T1a and T1b) or following screening by PSA measurement ( T1c) .

C. Early localized prostate cancer ( T2) .

D. Advanced local prostate cancer (T3 &T4)

E. Metastatic disease

TYPES OF CA PROSTATE

IT should be noted that only last two groups cause symptoms and such tumors are not  curable. Only screening or the treatment of incidentally found tumors can result in cure  of the disease.

SCREENING-

  Age >50 yrs.

–  Done by TRUS, PSA measurement, andDigital  rectal examination.

–  The cancer detection rate using PSA measurement is between2-4%  

–  Approx. 30% of men with elevated will have prostate   cancer confirmed by biopsy

–  Unfortunately, 20% of men with clinically significant cancer will have PSA

normal

SPREADING

Local spread may involve the seminal vesicle, bladder neck, triagone, ureter, rectum.

Heamatogenous spread :

particularly to bone eg.pelvic, lumber vertebr, femoral head, rib,skull etc.

Lymphatic spread :

– Lymph nodes around int illiac vein, or ext illiac lymph nodes.

– From retroperitonial nodes,mediastinal or occasionally supra claviculer nodes may involve

CLINICAL FEATURES

Only advanced disease (T2-T4) give rise to symptoms but even advanced disease may be asymptomatic :

                             – BOO

                             – Urinary infection

                             – haematuria

                             – pelvic pain or bone pain

                             – anaemia , pancytopenia

                             – renal failure

DRE :  nodules can be palpated, irreguler hard, obliteration of median sulcus  rectal mucosa may be fixed,  bleeding on withdrawal of fingers.

INVESTIGATIONS

Prostate specific antigen :

–  is elevated in serum of approx.60%  of men with prostate cancer.

–  lacking in sensitivity and specificity in the diagnosis of early   localized pros.cancer.

–  normal value is <4ng/ml.

–  PSA >10 is suggestive of cancer but >35 is almost diagnostic of advanced ca.

–  useful to assess prognosis

B. Biopsy :

– the diagnosis is established by TRUS guided biopsy in most instances.

– because the great majority of pts have biopsies due to an elevated PSA and no abnormal finding on TRUS,  symptomatic biopsies of base,middle and apex of the prostate concentrating on peripheral zone with six biopsies per side of prostate are required

c. Ultrasonography :

– TRUS remains the most accurate  method of staging the local disease.

– can be used in early detection of tumoror guiding biopsy needle in PZ of prostate .

– TRUS alone for screening is not recommended.

D. Radiological  exam :

– CXR may reveal metastasis in eithe lung or XR OF bones may reveal osteosclerotic lesion.

– osteolytic lesion is also common.

E. Bone scan :

– If the PSA is > 20 nmol / L, then a bone scan should be performed

F. General blood test

– Normal in early disease.

– Anemia may be present due marrow invasion or renal failure.

– Thrombocytopenia.

G. Liver function test :

 If extensive metastasis to liver, Alkaline phosphate will be raised

Treatment

Incidentally diagnosed Tla & Tlb disease.

– More than 70 yrs : conservative Rx.

– Less than 70 yrs : conservative or radical prostatectomy.

Localised Tlc & T2  disease :

– In elderly pt : TURP with or without hormone therapy.

– In younger pt : Radical prostatectomy or radical radiotherapy.

3. Localised advanced T3 & T4 disease :

– Early androgen ablation :

– Drug

– Surgery.

4. Metastatic disease :

– Androgen ablation will provide symptomatic relief

5.Redical prostatectomy

6. Radical radiotherapy

7. Brachytherapy :

– Radioactive seads are permanently implanted into preostate.

– Becoming popular in low grade low volume T1 disease

8. Orchidectomy :

– is performed to carry out androgen ablation in the treatment of local

advanced disease ( T3 or T4 ) or metastatic disease.

– Bilateral orchidectomy ( total or subcapsular ) will eliminate the major source of testosterone production