prostate cancer, PC

Notes
  • It is the 4th most common type of cancer globally and the most prevalent cancer among males.
  • It is more common in blacks than in other populations.
  • PC is mainly an adenocarcinoma (though in rare cases, it can be sarcoma, undifferentiated prostate cancer, squamous cell carcinoma, and ductal transitional carcinoma).
  • Statistics: proportion of PC among the cancers affecting males globally -15%; proportion of PC among the cancers affecting males in Kenya - 17.3% (most of whom are above 65yrs).
  1. Staging ofprostate cancer
  • Normal plasma PSA levels

 

Age Range (Years)

Normal Values

40 – 49

0 - 2.0 ng/mL

50 – 59

0 - 4.0 ng/mL

60 – 69

0 - 4.5 ng/mL

70 – 79

0 - 5.5 ng/mL

  

 

♦Studies have shown that some men with PSA levels below 4.0 ng/mL have prostate cancer while some with higher levels do not have have the same.

♦Generally, the higher the PSA level, the higher is the possibility of prostate cancer.

 ♦Continuous rise in PSA level over time can a sign of prostate cancer

  • Computation of the Gleason Score

 

Histologic patterns (after biopsy)

Pattern 1

Small glands, well-formed, and closely packed (well differentiated carcinoma)

Pattern 2

Well-formed glands which are larger with more tissue between (moderately differentiated carcinoma)

Pattern 3

Tissue still has recognizable glands but some of these cells have left the glands and are beginning to invade the surrounding tissue or having an infiltrative pattern (moderately differentiated carcinoma)

Pattern 4

The tissue has few recognizable glands but many cells are invading the surrounding tissue in neoplastic clumps (poorly differentiated carcinoma)

Pattern 5

The tissue does not have any or only a few recognizable glands (anaplastic carcinoma)

Grades are assigned to the observed patterns of the tumor specimen as

Primary grade

Assigned to the pattern of the tumor that is greater than 50% of the total pattern seen

Secondary grade

Assigned to the next-most frequent pattern that is 5 -50% of the pattern of the total cancer observed

Tertiary grade

There is a small (≤ 5%)

Calculation of the final Gleason score.

There is summation of the pattern-number of the primary and secondary grades

 

 

  • Stage Grouping of prostate cancer

STAGE

STAGE GROUPING

COMMENTS

I

T1 or T2a

NO

MO

PSA <10

Gleason score ≤6

♦T1-  The tumor cannot be felt or seen by imaging or

T2a-The tumor can be detected by digital rectal exam (DRE) or by imaging and it is in one half or less of only one side (left or right) of the prostate

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦PSA – is less than 10

♦Gleason score of 6 or less

IIA

T1

NO

MO

PSA <20

Gleason score of 7

♦T1-  The tumor cannot be felt or seen by imaging

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦PSA – is less than 20

♦Gleason score of 7

T1

NO

MO

PSA 10-20

Gleason score ≤6

♦T1-  The tumor cannot be felt or seen by imaging

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦PSA – between 10 to 20

♦Gleason score of 6 or less

T2a or T2b

N0

M0

Gleason score ≤7

PSA <20

♦T2a-The tumor is in one half or less of only one side (left or right) of the prostate or

♦T2b-The tumor is in more than half of only one side (left or right) of the prostate

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦Gleason score is 7 or less

♦PSA  is less than 20

IIB

T2c

 N0

M0

Any Gleason score

Any PSA

♦ T2c -The cancer is in both sides of prostate

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦ Any Gleason score

♦Any PSA

T1or T2

N0

M0

Any Gleason score

PSA ≥20

♦T1 - The tumor cannot be felt or seen by imaging or

♦T2 - The tumor can be felt by DRE or seen by imaging

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦Any Gleason score

♦PSA of 20 or more

T1 or T2

N0

M0

Gleason score ≥ 8

Any PSA

♦T1 - The tumor cannot be felt or seen by imaging or

♦T2 - The tumor can be felt by DRE or seen by imaging

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦Gleason score of 8 or higher

♦Any PSA

III

T3

 N0

 M0

Any Gleason score

Any PSA

♦T3- The tumor has grown outside the prostate and may have grown into the seminal vesicles

(It can be T3a where the tumor extends outside the prostate but not to the seminal vesicles or T3b where the tumor has spread to the seminal vesicles)

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦ Any Gleason score

♦Any PSA

IV

T4

N0

M0

Any Gleason score

Any PSA

♦The tumor has grown into tissues next to the prostate (apart from the seminal vesicles) e.g. the urethral sphincter, the rectum, the bladder, and/or the wall of the pelvis.

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

♦ Any Gleason score

♦Any PSA

Any T

 N1

 M0

Any Gleason score

Any PSA

♦T-The tumor cannot be felt by DRE or seen by imaging or it can be felt by DRE and seen by imaging but it is localized.

♦N1-The tumor has spread to one or more nearby lymph nodes

♦M0 - The tumor has not metastasized

♦ Any Gleason score

♦Any PSA

Any T

Any N, M1

Any Gleason score

Any PSA

♦T-The tumor cannot be felt by DRE or seen by imaging or it can be felt by DRE and seen by imaging but it is localized.

♦N0 -The tumor has not spread to the lymph node or N1-The tumor has spread to one or more nearby lymph nodes

♦M1-The tumor has spread beyond nearby lymph nodes. It can be M1a where the tumor has spread to lymph nodes outside of the pelvis or M1b where the tumor has spread to the bones or M1c where the tumor  has spread to other organs e.g. lungs, liver, bones or brain

♦ Any Gleason score

♦Any PSA

Symptoms
  • Early PC is often asymptomatic
  • Hematuria
  • Hematospermia (blood in semen)
  • Painful ejaculation
  • Symptoms of bladder outlet obstruction that include;

♦ a sense of incomplete emptying

♦ hesitancy

♦ straining

♦ burning or pain during urination

♦ terminal dribbling

♦ urge to pass urine frequently and more at night.

♦weak or intermittent urine stream

Diagnosis
  • Prostate-specific antigen (PSA);

♦ Screening is recommended annually in men over 50 yrs.

♦ PSA is raised in 25 to 92% of patients with PC and 30 to 50% of patients with BPH.

♦ PSA levels have no cut-off below which there is no risk

  • Digital (finger) rectal examination (DRE)

♦ Induration or nodules are detected

  • Biopsy (including transrectal ultrasonography (TRUS) guided biopsy), histology and staging
  • Bone scanning
Differential
  • Granulomatous prostatitis
  • Prostate calculi
  • Benign prostatic hyperplasia (BPH).
Prevention
  • Routine screening
Management
  • PC shows a very good prognosis once it is detected and treated early.
  • Drugs used for treatment of prostate cancer;

Luteinizing-releasing hormone (LRH) agonist such as buserelin, goserelin, and leuprolide

Anti-androgens: Flutamide, and                                  Bicalutamide

Docetaxel

Estramustine

Diethylstilboestrol (the first line treatment in resource limited settings)

  • Risk categories and their management

Low risk

♦PSA≤10ng/mL

♦Gleason≤6

♦Stage T1/T2a

♦Active surveillance

♦Radical prostatectomy

♦ Radical Radiotherapy

Intermediate risk

♦PSA>10ng/mL

♦Gleason = 7

♦Stage T2b

♦Radical prostatectomy

♦ Radical Radiotherapy

High risk

♦PSA>20ng/mL

♦Gleason ≥8

♦Stage T3a or worse

♦Radiation and androgen deprivation therapy combined

♦Radical prostatectomy

♦Radiotherapy alone

♦Androgen deprivation therapy alone.

  • For castration-resistant prostate cancer (CRPC) (also known as hormone refractory or androgen independent cancer) is treated with:

_Docetaxel 75 mg/m2 weekly

_Prednisosone 5 mg BD.

  • For metastatic prostate cancer the following drugs are used;

Androgen suppression using bilateral orchiectomy or an LHRH

External beam radiotherapy in case of painful bone metastases from castration-refractory disease

Radioisotope therapy with strontium-89 or samarium-153

IV bisphosphonates in case of bone pain resistant to palliative radiotherapy and conventional analgesics.

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