Prostatic Carcinoma
:Introduction
Prostate cancer is the second
commonest malignancy in men.
It is particuiany common in elder men
over 70
The risk increases 2-3 times if first
degree family relative is diagnosed
at an early age, suggesting genetic
basis in some patients.
Red meat and unsaturated fats
increase risk while Vitamin E and
lycopene (anti- oxidant found in
tomatoes) appear to have a
protective effect?
Pathology
Most Prostate Cancer are
adenocarcinomas arising in the
peripheral zone of the prostate gland.
Prostate cancer is divided into :
1- Localized disease.
2- Locally advanced.
3- Metastatic disease.
:Clinical Picture
Symptoms:
• Local disease:
o No specific symptoms.
o Raised prostate specific antigen (PSA) on screening.
o Symptoms of BPH.
• Locally invasive disease:
o Hematuria, dysuria, incontinence.
o Hemospermia.
o Perineal and suprapubic pain.
o Obstruction of ureters causing loin pain, and even symptoms of renal failur
o Impotence.
o Rectal symptoms, e.g. tenesmus.
• Metastatic disease:
o Bone pain or sciatica.
o Paraplegia secondary to spinal cord compression.
o Lymph node enlargement.
o Loin pain or anuria due to ureteric obstruction by lymph nodes.
o Lethargy (anemia, uremia), weight loss and.cachexia.
:Examination
In clinically localized disease, prostate
cancer is almost always suspected during
digital rectal Examination
o a hard nodule(s) within the gland.
o Induration of part or the entire prostate.
o Palpable seminal vesicles (normally are not
palpable).
Advanced disease: DRE may reveal a hard,
irregular prostate gland.
Abdominal palpation may demonstrate a
palpable bladder due to outflow obstruction in
either localized or advanced disease.
Differential diagnosis
:includes
Benign prostatic hypertrophy.
Prostatitis (granulomatous type).
Bladder tumors invading the
prostate.
Investigations
A) Prostate specific
antigen
PSA is normal in 30% of small cancers and is
raised in about 25% of men with benign
prostatic hyperplasia.
Other causes of a raised PSA include:
o Prostatitis
o Benign prostatic hypertrophy
o Any procedure traumatizing the prostate e.g.
catheterization, cystoscopy, biopsy.
o DRE does not have significant effects on PSA.
o Finasteride approximately halves the value of
PSA.
B) Other Investigation
Urinalysis .
Serum creatinine level to exclude
renal disease.
TRUS and TRUS guided biopsies.
Imaging of the upper urinary tract
by ultrasound and/or IVU
MRI & CT scan and a bone scan if
suspect metastatic disease .
Management
1- For Localized or Locally advanced
disease:
Watchful Waiting.
Radical prostatectomy: Radical surgery means excision of
the prostate, seminal vesicles and ampullae of vas, and re-
anatomists of the bladder to the membranous
urethra. It can be done by open retropubic or
perineal routes, and laparoscopically.
Complications include:
• Impotence in up to 80% of men
• Incontinence in up to 20% of men
• Mortality rata is 1-2%.
Radiotherapy
Brachytherapy
2- For androgen dependent metastatic
disease:
Treatment often involves:
Surgical castration, removing 90% of androgens
(10% from adrenals). Surgical castration with
anti-androgen, flutamide, to achieve complete
androgen blockade.
Medical castration by monthly or three-monthly
depot injections of luteinising hormone releasing
hormone agonists (LHRH analogue). Combining
an anti-androgen with androgen LHRH analogue
is essential when stating treatment to avoid the
initial stimulatory effect of the latter.
3- For androgen
independent metastatic
cancers:
Treatment
options include:
Chemotherapy
external beam radiation
Thank You
