Prostate cancer

Objectives: 1-To enumerate pathological types of cancer prostate 2-To diagnose cancer prostate. 3-To outline the lines of treatment of cancer prostate. In the western world carcinoma of the prostate is the most prevalent malignant tumor in men. Incidence: Prostate Cancer is rare before 50 years. The incidence increases with advancing age. Pathology: Prostate Ca arises from lining epithelium of prostatic glands. The posterior lobe (Peripheral zone) is the site of malignant transformation. Occasionally, it arises as malignant transformation of benign prostate. The most prevalent microscopic picture is Adenocarcinoma (95%) with varying degree of differentiation from well differentiated to anaplastic according to Brodel classification. Other rare tumors include transitional cell carcinoma originating from terminal partd of prostatic ducts or columnar cell Ca from the prostatic utricle Tumor spread: 1Local to seminal vesicle, bladder, terminal parts of the ureters. posterior spread to the rectum is limited by the strong fascia of Denonviller . 2lymphatic to the pelvic lymph nodes 3Hematogenous to bones ( pelvis , lumbosacral spine , femurs ) , or to viscera eg; lung and liver Stages: Whitmore alphabetical system: Stage A: microscopic malignant focus Stage B: malignant nodule confined to the prostate Stage C: extracapsular extension Stage D: D1 lymphatic D2 distant metastases Clinical picture:

Symptoms: 1The majority of early cases are asymptomatic , obstructive symptoms occurs late 2uncommonly , patient may complain of hemaspermia , hematuria 31/3 of cases presents with symptoms due to metastases like bone aches, nerve lesions, loss of weight & malaise. Signs: Digital rectal examination (DRE): Any alteration in shape, consistency or surface of the prostate in a man over the age of 50 years should raise the suspicion of cancer Loss of symmetry, induration (nodules) which feels hard, not raised above the surface. The bladder may be full (chronic retention). Investigations: Laboratory findings: 1)Anaemia may reflect extensive metastatic involvement of the bone marrow 2) Elevated urea & serum creatinine may occur due to bladder outlet obstruction, bilateral ureteric obstruction by the tumour or malignant pelvic lymph nodes. 3) Liver function tests may be abnormal in cases with hepatic secondaries 4) Serum Alkaline phosphtase may rise in patients with bone metastases Tumour markers Serum level of prostate specific antigen (PSA). Is sensitive in 95% in detecting prostate cancer. Normal range 0-4 ng/ml Radiologic Examination: Plain X-Ray & IVU: Characteristic osteoblastic metastases in the bony pelvis & spine. The IVU will assess the renal fuction and any obstruction to the upper tract. The cystogram may show a basal irregular filling defect in large tumors US -Abdominal ultrasound -Transrectal ultrasound (TRUS) is very useful in assessing the size of the prostate, any hypoechoic areas. It is also used to guide needle biopsy. Radioisotope bone scans Superior to radiography in detecting early osseous metastases.

Bone scan TRUS biopsy (transrectal ultrasound guided biopsy) Differential diagnosis 1Benign prostatic hyperplasia 2Other causes of prostatic nodules: prostatic calculi Infarction T.B prostatitis
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Osteoblastic bone metastases must be differentiated from Pagets disease. In the latter, the X-rays show subperiosteal cortical bone thickining and the PSA is normal. Treatment of prostatic carcinoma Depends on

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Patient age & general condition Stage and grade Histologic picture of the tumour A) Organ confined tumor *1-In radical prostatectomy we remove: the prostate, the seminal vesicle, the ampulea of the vas deferens. It can be done through a retropubic or perineal route. The complications include urinary incontinence, impotence 2- Radiotherapy is nearly as effective as radical surgery

3-Stage A disease is Incidental Ca discovered during examination of TURP chips for benign prostate. B) Locally advanced and metastatic tumor: Hormonal therapy. Prostate cancer is androgen dependandt and it melts (good response) on androgen deprivation therapy 1-Cathetration (surgical or medical) 2-Androgen blockers.

Stage A B C D

Treatment modality No Treatment Life expectancy approaches age matched population 1radical prostatectomy * 2-radiotherapy (external Or Interstitial) 3-watchful expectancy Radiotherapy Hormonal R/( androgen ablation) -orchiectomy -estrogens