Carcinoma of the prostate
It is the second leading cause of cancer death in men; the prevalence of CA
prostate is increasing with age.
Risk factors:-
1 – Age, 2 – Racial - black men.
3– Family history.4– Diet, 5 – Obesity.
6 – Minerals and vitamins ( lycopene , selenium , omega-3 fatty acid (fish ) are
protective decreasing the risk while vitamin D and calcium increasing the risk .
7– Previous vasectomy is a risk factor.
Pathology
Over 90% - adenocarcinomas , 5% - are transitional carcinomas .
Approximately 70% - peripheral zone, 20% in the transitional zone and 10% in
the central zone.
Grading & Staging
The Gleason score or Gleason sum is obtained by adding the primary and
secondary grades together , well differentiated tumors has Gleason sum 2-4 ,
moderately differentiated 5-6 and poorly differentiated tumor has Gleason sum
8-10.
Staging
TNM staging system for CaP
Tis-Cacinoma in citu
T1 – Detected from elevated PSA alone , normal DRE and normal TRUS,or positive
biopsy .
T2 – Tumor palpable by DRE or visible by TRUS on one or both sides , confined to
the prostate.
T3 – Extracasular extension or seminal vesicle involvement.
T4 – Tumor direcly extends into the bladder neck, sphinicter , rectum , levator
muscles or into pelvic side walls .
N0 – No regional lymph node metastasis.
N1 –Metastasis in a regional lymph node or ondes .
M0 – No distatnt metastasis .
M1a – Distant metastasis in nonregional lymph nodes.
M1b – Distant metastasis to bone.
M1c – Distant metastasis into other sites.
Symptoms
1-Most -early asymptomatic.
2- irritative or obstructive voiding symptoms can result from local growth of the
tumor into the urethra , bladder neck or into the trigone
3-metastasis - symptoms of cord compression Signs
Physical exam including DRE may reveal induration , lymphdema of lower
extremities , signs of cord compression may be elicited ( weakness or parasthesia
of lower extremities and hyper reflexic bulbocavernosous reflex .
Laboratory findings
Anemia , uremia , high level of alkalie phosphatase , elevated serum acid
phosphatase may be elicited
Tumor markers
PSA ( prostatic specific antigen ) is a protein produced by the prostatic tissue
both benign and malignant , it circulate in the blood either free or bound , PSA
is elevated in : -
1- BPH, 2- CaP , 3- ,prostatitis , 4 – Urethral instrumentation , 5 –
Catheterization , 6 – DRE 7- Prostatic infarction .
Prostatic biopsy
It is performed when there is high PSA, DRE finding of hard nodule or induration
and is best done under TRUS ( Trans rectal ultrasound ) .
Imaging
TRUS , Endo recal magnetic resonance ( MRI ) , axial imaging ( CT , MRI ) , Bone
scan .
Differential diagnosis
All causes of induration of the prostate .
BPH , Chronic granulomatus prostatitis , previous TURP , Prostatic biopsy ,
prostatic stones ,
Treatment
A ) Localized disease :-
–
Watchful waiting for early stage cancer.
–
Radical prostatectomy.
–
Radiation therapy (external beam radiation).
–
Brachy therapy, it means implantation of radioactive seads into the prostatic
tissue under TRUS guidance.
–
Cryosurgery and high intensity focused ultrasound (HIFU ) .
B ) Metastatic disease :-
Endocrine therapy , Most prostatic carcinomas are hormone dependant
( Testosteron ) and About 80% of meatstatic CaP may respond to androgen
deprivation which includes:
1-Physiological castration (bilateral orchidectomy).
2-Pharmacological castration (using anti androgens-flutamide,Gonadotrophine
releasing hormone agonists e.g. Goserline ,boserline).