Prostate Cancer

Affiliated Hospital of Weifang Medical University

 Excluding skin cancer, adenocarcinoma

of the prostate is the cancer diagnosed most commonly in men and is the second leading cause of cancer-related mortality in men. prostate-specific antigen (PSA)

EPIDEMIOLOGIC CONSIDERATIONS
The projected incidence of

adenocarcinoma of the prostate is 180,400 new cases in 2000, and the disease is expected to result in 31,900 deaths . A number of risk factors for prostate cancer have been identified, age being the most important.

ANATOMY OF THE PROSTATE GLAND

The normal prostate gland consists of a

transitional zone, a central zone, and a peripheral zone. It is oriented with the broad base superiorly, the midsection, and the narrow apex inferiorly.

HISTOLOGIC FEATURES OF PROSTATIC NEOPLASIA

Almost all prostate cancers are

adenocarcinomas. The earliest recognizable prostatic lesion is prostatic intraepithelial neoplasia (PIN).

MOLECULAR BIOLOGICAL FEATURES OF PROSTATIC NEOPLASIA

At a genetic level, the process of

prostatic carcinogenesis is complex, with multiple genetic lesions implicated in the progression from PIN to localized cancer, locally advanced cancer, and metastatic cancer.

SCREENING FOR PROSTATE CANCER

The availability of PSA as a diagnostic

tool, coupled with increased awareness of the disease, has produced a marked increase in the number of new cases diagnosed.

CLINICAL PRESENTATION Common Symptoms and Signs

Before the availability and frequent

application of PSA determinations, the most common presentation of prostate cancer was with symptoms of urinary obstruction or bony pain.

Digital Rectal Examination

Digital rectal examination (DRE), an

essential component of evaluation for prostate cancer, typically reveals a hardened nodule, although either diffuse induration of the gland or a normal gland may be present.

Prostate-Specific Antigen
PSA is relatively specific to prostatic

tissues and has been highly useful for diagnosing and following up the clinical course of prostate cancer.

INTERPRETING PSA TEST RESULTS

Interpretation of the PSA determination

must include both the degree of elevation and the results of other examinations, particularly findings of the DRE.

INCREASING THE SPECIFICITY AND SENSITIVITY OF PSA TESTING

Fewer than 50% of patients with a PSA

between 4 and 10ng/ml will prove to have prostate cancer on subsequent biopsy.

DIAGNOSIS
The diagnostic procedure of choice for

localized prostate cancer is transrectal biopsy, often directed by transrectal ultrasonography

TNM Staging Classification

Histopathologic grade (G)

GX Grade cannot be assessed

G1 Well differentiated (slight anaplasia) G2 Moderately differentiated (moderate

anaplasia) G3 Poorly differentiated or undifferentiated(marked anaplasia)

Primary tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor T1 Clinically inapparent tumor not palpable nor visible by imaging T1a Tumor incidental histologic finding in 5% or less of tissue resected T1b Tumor incidental histologic finding in more than 5% of tissue resected T1c Tumor identified by needle biopsy (e.g., because of elevated PSA level) T2 Tumor confined within prostatea T2a Tumor involves one lobe T2b Tumor involves both lobes T3 Tumor extends through the prostate capsuleb T3a Extracapsular extension (unilateral or bilateral) T3b Tumor invades seminal vesicle(s) T4 Tumor is fixed or invades adjacent structures other than seminal vesicles: bladder neck,external sphincter, rectum, levator muscles, and/or pelvic wall

 Regional lymph nodes (N) NX Regional lymph nodes cannot be

assessed N0 No regional lymph node metastasis N1 Metastasis in regional lymph node or nodes Distant metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis M1a Nonregional lymph node(s) M1b Bone(s) M1c Other site(s)

 StageI

T1a N0 Stage II T1a N0 T1b N0 T1c N0 T2 N0 Stage III T3 N0 Stage IV T4 N0 Any T N1 Any T Any N

M0 G1 M0 G24 M0 Any G M0 Any G M0 Any G M0 Any G M0 Any G M0 Any G M1 Any G

Assessment of Risk for Extracapsular Spread

Extracapsular spread of prostate cancer

affects the choice of local treatment modality and has a negative impact on prognosis.

Assessment of Lymph Node or Distant Metastasis

Most commonly, prostate cancer spreads

to bone or pelvic lymph nodes. Frequently, the pattern of bony metastasis is blastic and is visualized readily by bone scintigraphy.

TREATMENT Localized Disease

The principle goal of therapy for

localized prostate cancer is cure. Several curative options exist, but lack of randomized comparisons among them complicates selection of the appropriate treatment for any given patient.

RADICAL PROSTATECTOMY
Usually, radical prostatectomy is

reserved for patients who have T1 or T2 disease and are suitable candidates for major surgery. PSA level is being used to assess outcome and should remain undetectable after radical prostatectomy.

RADIOTHERAPY
External-beam radiotherapy is a second

curative modality for localized prostate cancer. Often, radiotherapy series include patients with more extensive local disease than do surgical series, rendering problematic comparison of the outcome and complications of therapy.

INTERSTITIAL BRACHYTHERAPY
Radioactive seed implantation using 125I

or 103Pd is another promising treatment option for patients with localized prostate cancer.

CRYOSURGERY
Cryosurgical ablation of the prostate

involves use of cooling probes that cause necrosis of prostatic tissue through freezing.

Metastatic Prostate Cancer

Metastatic prostate cancer is considered

incurable. Control of tumor growth, palliation of symptoms, and maintenance of quality of life are important goals of therapy.

ORCHIECTOMY
Orchiectomy removes the major source

of male testosterone production.

CYTOTOXIC CHEMOTHERAPY
The role of cytotoxic chemotherapy for

patients after progression on androgen blockade is being reevaluated, but recent studies suggest that significant palliation may be derived and objective responses can be obtained. Tannock et al.

 Most patients with disease relapse have

osseous disease only, which renders response assessment difficult. Trials using posttherapy PSA decline as an end point have identified several active agents that are undergoing further testing.

INVESTIGATIONAL APPROACHES
Because no curative therapy for

metastatic prostate cancer exists, the need for better treatment is urgent.

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