Table Of Contents
Carcinoma of the Prostate
Prostate cancer is an adenocarcinoma that is usually located in the peripheral zone of the prostate. It commonly spreads to bones and lymph nodes. Localized cancer is often asymptomatic since it develops in the periphery of the prostate and may not cause obstructive symptoms. ****Prostate specific antigen, digital rectal examinaiton and biopsy (gleason grade) are used to predict the pathological stage. Local prostate cancer can be treated by radical prostatectomy, radiation therapy and active monitoring. Treatment of advanced disease is palliative and hormone ablation remains the first-line therapy
Prostate cancer is the most common cancer in men over the age of 65 years (accounts for 25% of cancers in men) and has a lifetime risk of 1 in 6. It is the second most common cause of death due to cancer in men after lung cancer. The average life expectancy after diagnosis is approximately 5 – 10 years (it is very slow to progress)
Metastasis of prostate cancer
| Site of spread | Description |
|---|---|
| Local spread | Grows upwards to involve the seminal vesicles, bladder neck, trigone and ureter. Spreads distally to involve distal sphincter. May spread directly to the rectum. |
| Hematogenous spread | Spreads to pelvic bones and lower lumbbar vertebrae. Leads to osteosclerosis (osteoblastic lesions) |
| Lymphatic spread | Spreads via internal and external iliac nodes. May enter retroperitoneal lymph nodes, mediastinal lymph nodes and supraclavicular nodes |
Tumor staging (TNM)
| Stage | Description |
|---|---|
| T1 | Incidentally found tumours in a clinically benign gland after histological examination. |
| T2 | Suscpicious nodule on rectal examination confined within the prostate capsule and involving one lobe (T2a). T2b involves both lobes |
| T3 | Tumour extends through the capsule. T3a is ui- or bilateral extension. T3b involves he seminal vesicles. |
| T4 | Tumour that is fixed and invading adjacent structures other than seminal vesicles (rectum or pelvic side walls. |
Age adjusted upper limits for PSA
| Age | PSA levels (ng/mL) |
|---|---|
| 50 – 59 years | 3.0 |
| 60 – 69 years | 4.0 |
| > 70 years | 5.0 |
- Risk factors
- Older age
- Obesity
- Family history (5-10% of cases have a strong family history(
- Signs and symptoms
- May be asymptomatic
- Symptoms of bladder outlet obstruction (BOO)
- Haematuria and hematospermia
- Impotence
- Pelvic pain
- Rectal pain and tenesmus
- Bone pain
- Malaise
- Anaemia or pancytopaenia
- Renal failure
- Digital rectal examination
- Irregular induration (stony hard)
- Assymetrical
- Nodular
- Obliteration of median sulcus
- Adhesions to surrounding tissue (fixed)
- Differentials
- Benign prostate hyperplasia
- Prostatitis
- Urinary tract infection
- Renal stones
- Bladder cancer
- Investigations
- Prostate specific antigen (PSA): a serine protease produced by normal and malignant prostate epithelial cells. Poor specificity and sensitivity for prostate cancer 33% of men with PSA 4 – 10 ng/mL have prostate cancer
- 10 ng/mL is susggestive of cancer
- 35 ng/m is suggests advanced cancer
- Markedly raised when > 16 ng/ml
- Urinalysis: to differentiate urinary tract and bladder abnormalities
- Transrectal ultrasound of prostate (TRUS) + biopsy: estimate size and grade tumour if present. Also examines the upper renal tract for signs of dilation
- Hypoechoic areas in the peripheral prostate
- Transurethral resection of prostate (TURP): if there are symptoms of BOO. A histological sample can also be obtained
- MRI: can be used in place of TRUS biopsies for monitoring known cancer
- X-ray of the Pelvis and Lumbar spine: for bone metastases
- Shows osteosclerotic regions
- Radionuclide bone scans: for bone metastases
- Alkaline phosphatase: for bone metastases
- Elevated
- Prostate specific antigen (PSA): a serine protease produced by normal and malignant prostate epithelial cells. Poor specificity and sensitivity for prostate cancer 33% of men with PSA 4 – 10 ng/mL have prostate cancer
- Differentials for a raised PSA
- Prostate cancer
- Benign prostatic hyperplasia
- Digital rectal examination
- Prostatitis
- Urinary tract infection
- Ejaculation (previous 48 hours)
- Vigorous exercise (previous 48 hours)
- Urinary retention
- Instrumentation of the urinary tract
- Treatment
- Watchful waiting: suitable in 45% of cases. Patients are asymptomatic, have local cancer with no spread discovered on PSA screening. They are more likely to “die with prostate cancer” from another cause rather than to “die from prostate cancer”
- Radical prostatectomy: for localized disease in men with a life expectancy > 10 years. involves removal of the prostate + distal sphincter mechanism and seminal vesicles.
- Radiotherapy
- External beam radiotherapy
- Brachytherapy
- Androgen ablation (androgen suppression): main treatment for non-localised disease. It can take 24 – 36 months for response.
- Andorgen receptor blockers e.g. bicalutamide, flutamide, enzalutamide
- Lueteinizing hormone releaseing hormone antagonists e.g. gosereline, leuprorelin, triptorelin, degarelix. Covered initially with an androgen receptor blocker to prevent a surge in testosterone.
- Bilateral orchidectomy (can be offered to all men with metastatic disease as an alternative to anti-LHRH agents)
Summary of treatment of prostate cancer
| Category | Treatment |
|---|---|
| Localised prostate cancer (T1/T2) | Conservative treatment for men > 70 years. Radical prostatectomy and radical radiotherapy (external beam and brachytherapy) in younger men may be considered. Transurethral resection may be performed with or without hormone therapy in elderly patients with outflow obstruction |
| Localised advanced prostate cancer (T3/T4) | Androgen ablation in elderly men. Multimodal approach involving androgen ablation, surgery and radiotherapy in younger men. |
| Metastatic disease | Androgen ablation for symptomatic relief. Systemic chemotherapy in young fit men. |
Complications of treatment
| Treatment | Complications |
|---|---|
| Radical prostatectomy | Stress incontinence, erectile dysfunction |
| External beam radiotherapy (EBRT) | Urinary frequency, urgency, urge incontinence, diarrhoea, radiation proctitis |
| Luteinising hormone releasing hormone antagonists (LHRH antagonists) | Osteoporosis, urinary and sexual dysfunction, loss of fertility, fatigue, hot flushes |
| Androgen antagonists | Sexual dysfunction |
