Prostatic Cancer

Dr Messay Mekonnen

Prostatic Cancer

Incidence and etiology• Most common visceral malignancy• Second to lung cancer • Chance of a man acquiring pca during his lifetime is 15%.

Cause ……. unknownGenetic influences…….. 10% believed to be inherited.

…………….. 2-fold risk 1st -degree male relative ……..5- to 10-fold risk 2 or 3 affected 1st -degree relatives

Hormonal factors……. androgen dependenceChemical factors

Workers in the rubber, fertilizer, and textile industries Diet

A diet high in saturated fat Insulin-like growth factor-1

Pca Tumor histology and grading.

– 95% are adenocarcinomas– arising from prostatic acinar cells at the periphery of the gland– SCC and TCC( 1% to 4%) of the prostate occur only rarely

Prostatic Intraepithelial Neoplasia (PIN) – Consists of benign-appearing prostatic glands lined by

cytologically atypical cells.– low-grade and high-grade PIN, based on the prominence of the

nucleoli– 6% of needle biopsy specimens have a finding of high-grade PIN. – 20% to 35% risk of cancer on subsequent biopsy

Pca

Adenocarcinoma.– The Gleason system

ofive grades of glandular morphologyo two most prominent glandular patterns are

graded from 1 to 5.o sum of these two grades will range from 2 to 10o2 representing the most differentiated & 10

representing the most anaplastic tumors

Axiom for Early Detection: If you don’t look for it, you won’t find it‼

aDiagnosis Prostate cancer was usually clinically silent until metastatic disease

Symptom LUTS & metastaticsigns

General Focuesd

Digital rectal examination (DRE).• 50% of suspicious lesions on DRE are proven cancerous on prostate biopsy.

» Size……… enlarged » Consistency……hard » Surface……..Nodular» Mobility……Fixed

Diagnosis– PSA

– a glycoprotein– specific to the prostate, but not to prostate cancer– correlates well with pathologic stage and tumor volume.– levels are affected by androgen levels, prostate volume, race, and

age.

– Transrectal US hypoechoic regions with irregular borders.

– Prostate biopsy• transrectal approach under US guidance • discrete nodules, focal induration, or a diffusely hard

prostate

PSA Prob CaP

0-2 1%

2-4 15%

4-10 25%

>10 50%

Not surprising – if you don’t perform a biopsy, you don’t find disease..

How many biopsied?

How many cancers?

Nobody Almost none

A few A few

Many 25%

Most 50%

pca

Ultra sound

Prostatic Biopsy

Standard sextant biopsies sample the parasagittal regions of the prostate at the apex, middle, and base of the gland

PCA– Prostatic acid phosphatase

• 80% of pts with elevated PAP have metastatic– Bone scanning

useful in detecting metastatic disease 80% are osteoblastic lesions and 5% osteolytic more sensitive than skeletal radiography able to detect lesions up to 6 months before they are apparent on x-ray films.

– CT can assess gross local extension detect nodal metastases >2 cm

PCA

Route of spread.– Local invasion– lymphatic route

the external iliac (obturator group), internal iliac presacral nodes.

– Hematogenous routes bone, lung, liver, and kidneys

PCA

Treatment– Clinical organ-confined (stages I and II)

• Either EBRT, interstitial radiation, or radical prostatectomy

– Locally invasive (stage III and T4, N0, M0) Options include

• Radical prostatectomy • External-beam radiation with or without interstitial brachytherapy • Hormone therapy

• watchful waiting. (aged 75 or older have a life expectancy of <10 years)

Metastatic (N1, M+ in any combination) diseaseAndrogen deprivation remains the primary treatment modality response in up to 90% of patients but does not improve survival.

PCA

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