PROSTATE CANCER

Prostate cancer is a common malignancy

among the aged male population
Second cause of cancer death in developed
countries
One of the few cancers having a lot of debate
on treatment modalities.

Epidemiology and Aetiology

Hormonal influence :
Normal prostatic epithelium ,
BPH &
P Ca
are under the promotional Influence of
testosterone and its potent metabolite DHT.

To die with P ca !
To die of P ca !
Histopathology:
Adenocarcinoma
More than 95%.
Arises from the epithelium
of prostatic acini or small peripheral
prostatic ducts

Moderately elevated PSA can be present in

non-cancer cases:

BPH

Prostatitis

Transitional cell carcinoma

Less than 4%
Arises from Prostatic urethra, central
prostatic ducts
or direct extension from TCC of the urinary
bladder

In patients where DRE is suggestive of P Ca

Origin

75% : peripheral zone

20% : transition zone

5% : central zone

Aging
Ethnic factors
Family History (Genetic)
? Diet, sexual activity, viral infections

Diagnosis of prostate cancer is on the increase

(Why?)

Increasing awareness of the disease

Increasing use of serum PSA testing for
both symptomatic and nonsymptomatic aging men
Use of more extensive prostatic biopsy
protocols

Prostate cancer is rare before 40ys

The incidence increases with age
Histological prostate cancer!
Clinical prostate cancer!
P Ca is biologically heterogeneous
(low risk ,intermediate & high risk Pca)

For early detection of P Ca in males over 50

Particularly in high risk groups

Level of PSA in patients with histologically

diagnosed P Ca is important for staging of the
disease
-Example:
PSA up to 20 ng/ml : localized disease
20 -40
: Locally advanced
: Early metastatic
> 40 most probably metastatic

Prostate Specific Antigen (PSA)

PSA (with other parameters) is used for the

choice
of the suitable treatment
modality

A tumor marker used for the diagnosis, staging

and follow up of prostate cancer

Periodic estimation of PSA level is essential for

determining treatment response.

Risk Factors

Importance of serum PSA testing:

An enzyme secreted by prostatic acinar cells

Normally present in the seminal plasma
and ,in trace amounts, in the serum
It is prostate specific but not cancer specific.
Normal serum level is up to 4 ng /ml
In younger patients (2.5 ng/ ml)

Staging of Prostate Cancer

Organ confined (localized) P ca (T1 & T2)
T1: Clinically unsuspected, DRE is normal
Diagnosed by: histopathological
examination of
prostatectomy specimen (TUR) or (open)
T1a, T1 b, T1c

In patients with P Ca, PSA level correlates

positively with tumor burden (primary and
metastatic).

based on prostatic biopsy for patients with

normal DRE but elevated serum PSA
T2:
localized P ca palpable by DRE
T2a, T2b

Normal PSA level does not exclude P Ca:

Early disease (small tumor volume)

Poorly differentiated tumor

Locally advanced prostate cancer( T3 & T4)

T3: Capsular penetration seminal vesicle
invasion
T3a, T3b

T4: Direct extension to an adjacent organ

Metastatic Prostate cancer
N+
(and or) M+

Grading of Prostate Cancer

Gleason grading system
Depends on glandular differentiation
Primary grade (dominant) 1 - 5
Secondary grade
1 - 5
Gleason score = Primary + Secondary grade
=
2
10
Gleason score up to 5 : low risk
P Ca
6 : intermediate risk
> 6 : high risk

Spread
Direct spread:
Extra-capsular extension:

seminal vesicles

bladder base

Lower ureters

Vertebrae (lumbar) , ribs , skull

Visceral spread :
Late

lung

An abnormal DRE is defined by:

* Asymmetric enlargement of the gland
* A prostatic nodule
* Firm to hard consistency

Diagnosis Of Prostate Cancer

Early detection in non- symptomatic males
over 50ys
Screening programs
- pros & cons

NOTE!

Clinical Picture
Localized P Ca (T1 & T2)
Non specific symptoms

Other causes of abnormal DRE:

Chronic prostatitis

Prostatic calculi

*
*
*
*

Asymptomatic
LUTS probably due to ( co-existing BPH)
Haemospermia
Haematuria (? co- existing BPH)

Locally advanced prostate cancer (T3 T4)

Same as previous + ? Symptoms of renal
insufficiency:
due bilateral ureteric obstruction
Metastatic prostate cancer

Lymphatic spread:
Pelvic Lymph nodes
Haematogenous spread
Bones: common

Pelvic bones:
pubic rami,
ischium
iliac bones

long bones:
femoral shafts

liver
brain

LUTS
Lower limb oedema (N+ pelvic LN)
Symptoms related to bone metastasis:
- bony pains
- pathological fracture
- spinal compression
(neurological complications)
General Symptoms of advanced
cancer:
- asthenia,
- anorexia,
- loss of weight

Digital Rectal Examination (DRE)

Most prostate cancers arise in the peripheral
posterior
part of the gland, therefore, they eventually
become
palpable on DRE.

Only 50% of patients with abnormal

DRE prove to have prostate cancer

Normal DRE does not exclude cancer

Prostatic biopsy :
Is essential for the diagnosis
Transrectal ultrasound guided prostatic
(TRUS) biopsy
When to do?

Elevated PSA
abnormal DRE
Both

Imaging in the diagnosis of prostate cancer :

1. Ultrasonography (Abdominal or transrectal)
No specific sonographic pattern:

Homogenous, heterogeneous
iso..hypo..or hyper echoec
size of the gland
Post void residual
Effect on upper urinary tract
Assessment of other abdominal organs

2.

MRI

Imaging of Skeletal metastasis

Bone scan:

High sensitivity but low specificity

high false positive result

Conventional Skeletal radiography

Low sensitivity but high specificity

Bone CT
It is, therefore, recommended to start by
a bone scan then conventional x-ray
or bone CT if needed
Treatment of Prostate Cancer
A- Watchful Waiting (Wa Wa)
Active surveillance with delayed selective
intervention

Localized prostate cancer (T1 T2 )

Watchful waiting:
Life expectancy < 10 ys
Low risk tumor (low grade Tr & PSA<10)
Radical
Radical

Prostatectomy:
radiotherapy:
Life expectancy >10 ys
Good performance status

LHRH Agonists:
Medical orchiectomy
(LHRH , ant. Pituitary , Leydig cells)
Initial flare
Reversible androgen deprivation

B- Radical Prostatectomy
C- Radiotherapy:
External beam radiotherapy
Interstitial radiotherapy (Brachytherapy)
( androgen deprivation)
D- Androgen Deprivation Therapy ( hormonal)

Factors affecting the choice of treatment

modality:
Factors related to tumor: Risk stratification

Tumor stage

Gleason grade

PSA level
Factors related to the patient:

Life expectancy

Performance status (general condition

&
co-morbidity)

Patient counselling on side effects of

treatment and quality of life
parameters:
- sexual function & urinary continence

Locally advanced Prostate cancer (T3 4)

Watchful waiting:
no symptoms with life expectancy <10ys
Radiotherapy:
Symptomatic or non symptomatic cases
Life expectancy >10 ys
Hormonal therapy:
Symptomatic cases with short life expectancy
Patient refusing radiotherapy
Metastatic Prostate cancer
Androgen deprivation therapy:

Bilateral orchiectomy

LHRH agonists

Anti-androgens

Oestrogen

Bilateral Orchiectomy
Immediate , sustained , Irreversible
androgen deprivation

Side effects of androgen deprivation

Sexual dysfunction
Diminished muscle mass
Osteoporosis
Diminished cognitive abilities
Depression

Anti androgens
*Monotherapy
*Along with hormonal deprivation (CAB)

Estrogens
Feed back inhibition
Side effects:

sexual dysfunction

gynecomastia

thrombo-embolic com.