Prostate Cancer

Epidemiology

2nd commonest malignancy in ♂. Rises steeply with age.
Associations: Testosterone, FH

Pathology

Most adenocarcinoma arising in peripheral prostate.

Spread

• Local: seminal vesicles, bladder, urethra, rectum
• Lymph nodes: iliac, para-aortic
• Haematological: sclerotic bone lesions (pelvis, spine, skull)

Clinical

Symptoms or nocturia, hesitancy, poor stream, dribbling, urinary obstruction. Weight loss and (especially) bone pain suggests metasteses
Differential: Benign hyperplasia
PR: Malignancies are hard, irregular, loss of sulcus 

Investigations

• ↑PSA (can be normal, also ↑ in hypertrophy, prostatitis): ⩾4 then 25%, ⩾10 then 40% chance malig. Can look at time trends.
• Diagnosis: transrectal USS and biopsy. 6 cores sampled on each side of prostate, analysed to give a Gleason score.
• Staging: Vital - has it gone through the capsule? CT/MRI, LFTs. Bone XRs, bone scan, urine flow tests
  

Staging

TNM.
T0: non palpable, T1: tumour in one lobe, T2: both lobes. T3: outside prostate to involve seminal vesicles, T4: local structures
N0: no nodes, N1: nodal involvement
M0: no mets, M1: mets

Treatment

Early stage (T1/T2 and M0)

Active surveillance (monitor PSA, repeat biopsy), radiotherapy, radical prostatectomy. With good or moderate histology there is the same overall chances of survival with surgery and radiotherapy except in the younger group with poor histology where surgery is best.
Radical prostatectomy: prostate and LNs. Incontinence in 25%, impotence 70%
Radiotherapy: 6w. SE: Impotence in 40%, cystitis, proctitis (can become chronic). Can use brachytherapy (implanting radioactive seeds) w less morbidity except ↑risk retention due to prostate swelling up.

Locally advanced/mets (T3/T4)

Hormonal: GHRH (leuprorelin acetate, goserelin accetate), i.e. medical castration. SE: hot flushes, osteoporosis. Relapse at 18m.
Anti-androgen (cyproterone acetate) given simultaneously in first few weeks due to initially higher Testosterone.
Monitor: PSA

Prognosis

Localized and small bulk: Well/moderately differentiatd (80% 10YS), Poorly differentiated (70% w surgery and 15% w other)
Mets and large bulk: 80% respond to treatment but after 1y most patients have PSA evidence of relapse. Median survival 2-3y.