Carcinoma prostate

N K Hazra

Department of surgery
MTH
 Incidence /epidemiology
• Age – rare < 50, common >70 yrs(45 – 90 – 72) Latent form
diagnosed in 75% over 80 yrs.
• Blacks more than whites more than asians.
• BPH – many have Ca ( merits careful HPE )
• Germ line mutation – 5-10%.
• Inactivaton/loss of p53, Rb, altered E cadherin expression.
• androgen independent ca produced by mutation in
androgen receptor
• methylation changes.
• Low GST – glutathione s transferase
 contd
• Protection – low fat diet, Vit E, Lycopene,
selenium, vit A/D, antioxidant, green tea >
GST?
• Chemoprevention - finastride
 Pathology
• Macroscopic – posterior part of the prostate beneath
its capsule appear as infiltrating hard pale area.
• Micro – adenocarcinoma,
degree of differentiation (Gleesons grade) 2,3,4
– well differentiated 5,6,7
– moderately differentiated
8,9,10 – poorly differentiated
• Spread – local – peri prostatic tissue and adjacent
organs – bladder, urethra, seminal vesicle, rectum
 contd
• Lymphatics – iliac, para aortic nodes.
• Blood borne – pelvis, spine, skull (ostosclerotic), liver,
lungs.
• Staging –
pT2- organ confined a,b in one lobe – less than ½ />
½ lobe, c – both lobes pT3 -
extraprostatic b – seminal vesicle pT4 –
bladder, rectum pNx,
pNo, pN1 - RLN Mx,
Mo, M1 – a)NonRLN b)bone c)other sites
 Clinical features
• Asymptomatic – PSA detect – screening .
• Symptoms of BPH.
• Symptoms of secondary deposits in vertebrae – backache
• Wt loss, anemia, low –poor genl condition.
• DRE – 3 stages locally
a) hard nodule in one lobe
b) cragginess replacing the prostate and
abolishing the sulcus between the two lobes c)
as in b + infiltrating the tissue on either side of the
prostate.
 Special investigation
• PSA – increases with age >4 ng/ml is abnormal
>20 ng/ml – metastatic disease, marker to
follow response to treatment.
• TRUS – can detect small ca, extracapsular
spread.
• Tru cut bx – transrectal – 6-12 cores –
diagnosis & grade.
• Bone scan – bone pain , PSA>20ng/ml.
 Treatment
• Subject to – confined/not confined to organ. Clinical
staging, PSA,
Gleasons score,
Spread
• A - Localized disease :
1) watchful waiting – well differentiated,
anticipated life expectancy <10 yrs. 2)
Radical prostatectomy – trt of choice in young
patients
3) Radical radiotherapy +/- hormoneSS
 Contd trt
• B – Metastatic disease (andrgen suppression)
a) GnRH
agonist – buserlin, goserlin – inhibit release of
lutenizing hormone from ant pitutary ->
reduction in production of testicular hormone
b)
Cyproterone acetate – a steroid androgen
antagonist.
c) Castration - dramatic remission sometimes.
d) Oestrogen administration – stilboesterol
 Contd trt.
• Other palliation –
RT for bone pain/mets.
TURP – BOO.
Nonsteroidal antiandrogen –
flutamide/bicalutamide – often added to block
low levels of androgen produced by adrenal
medulla.
 Complications
• Radical prostatectomy – remove prostate,
seminal vesicle, PLND – anastomose bladder
neck to the urethra distal to prostate.
• Impotence – 50%
• Incontinence
• RALP – robotic assisted laparoscopic
prostatectomy
 Complication contd.
• Radical radiotherapy – lower impotence, no
incontinence
• Proctitis
• Bladder irritation
• Androgen suppression
Stilboesterol –
gynaecomastia, nipple/scrotal pigmentation testicular
atrophy fluid
retention – CCF, thromboembolic
disease – with aspirin
 Contd.
• GnRH agonist – flare of the disease – so a
short 3 wk course of androgen is given.