Prostate Carcinoma

Prostate Carcinoma

Prostate Carcinoma
Prostate cancer is the most common cancer diagnosed and is the second leading cause of death The prevalence of cancer increase with age ,the probability of Ca P developing in men under age of 40 is 1\ 10.000 , for men 40-59 it is 1\103 , 60-79 it is 1\8. Blacks are at higher risk than whites. Positive family history of CaP increase RISK of CaP. High dietary fat intake increase the relative risk of CaP.

ETIOLOGY

The gene responsible for familial Ca P resides on chromosome 1 The region most commonly identified are chromosome 8p,10Q,13Q 17P,18Q.Epithelial stromal interaction under the influence of growth factors Such as :Transforming growth factors –BPlatelets-derived growth factorNeuroendocrine peptide

PATHOLOGY

Over 95% of CaP are adenocarcinoma Of 5% : 90% Transitional cell carcinoma Neuroendocrine carcinoma Sarcoma

The cytologic characters of CaP include : Hyperchromatic ,enlarged nuclei, with prominent nucleoli Cytoplasm is often abundant ,blue-tinged or basaophilic The basal cell layer is absent in CaP ,it is present in normal gland Prostatic intraepithelial neoplasia (PIN) is the precursor to invasive CaP the distinguishing feature of invasive CaP is that the basal Cell layer is absent. 60 -70% of CaP originate in the peripheral zone 10- 20% transition zone 5-10% central zone

TNM STAGING SYSTEM

Grading And Staging


Gleason grade Gleason grade range from 1 to 5 ,gleason score range from 2 to 10 Well differentiated tumor have a gleason score of 2-4 Mod differentiated tumor 5-6 Poorly differentiated tumor 8-10 Gleason score of 7 is grouped with mod differentiated tumor.


Gleason grade 1and 2 characterized by small uniformly shaped gland,with little intervening stroma Gleason grade 3 characterized by variable sized gland Gleason grade 4 has a several histologic appearance, Gleason grade 5 has single infiltrating cell, no gland formation Comedocarcinoma is a variant of gleason grade 5

Whitmore-Jewett

Symptoms: Most patient are asymptomatic in early stage Obstructive and irritative voiding symptoms can result from Local growth pf tumor (urethra ,bladder neck) Bone pain in metastatic disease Symptoms of spinal cord compression (paresthesia,weakness,urinary and fecal incontinence)
CLINICAL PICTURE

SIGNS: DRE: induration Lympadenopathy Lymphedema Signs of metastases

LAB FINDINGS: Azotemia Anemia Alkaline phosphatase elevated in bone metastasis Acid phosphatase TUMOR MARKERS PSA Prostate biopsy is the most commonly employed technique. Increase the sensitivity of cancer detection Indicated in elevated PSA, abnormal DRE


IMAGING TURS: useful in performing prostate biopsy Provide local staging Measure prostate volume CT scan confirm local or distant metastsasis MRI Bone scan is the standard part of initial evaluation Molecular staging Detection of circulating CaP cells in peripheral blood. By using (RT-PCR) revers transcription-polymerase chain reaction)

Differential Diagnosis

Not all patients with elevated PSA have prostate cancer It elevates in : BPH Urethral instrumentation Infection Prostatic infarction Prostate calculi Alkaline phosphatase increase also in paget disease



Pattern of progression Local extension out side the prostate (extracapsular extension)or seminal vesicle invasion and distant metastasis increase with increase tumor volume. Small and well differentiated cancer usually confined to prostate Large volume and poorly differentiated (G 4-5)>4cm often locally extensive ,metastatic to lymph node or bone. Locally advanced Ca P invade bladder trigone , lead to ureteral obst.


Lymphatic metastases most identified to : Obturator lymph node, common iliac, presacral ,and periaortic The axial skeleton is the most usual site of distant metastases (lumbar spine ,femur, thoracic spine,. Ribs, sternum, skull) can lead to pathologic fracture. Visceral metastases (lung,.liver,adrenal gland)

Diagnosis

DRE PSA TRUS Prostate biopsy Grading and staging.

TREATMENT

LOCALISED DIDEASE Radical prostatatectomy :provide removal of prostate ,seminal vesicle,block dissection of obturator and ext iliac lymph node Radiation therapy Cryosurgery

Locally advanced disease Radiation therapy Also indicated in unfit patient Symptomatic metastases ,it lead to relief of pain TUR : in patients with urinary outflow obstruction Bil Orchidectomy


HORMONAL THERAPY: Is the main line of treatment in metastases disease Is used in unfit patient for surgery or radiotherapy Bilateral orchidectomy(removal of testicular tissue) LHRH agonist (zoladex) It causes initial rise in testosterone level for (4-6)weeks Then drop to castration level Antiandrogen (block testosterone receptors) It is used as adjuvant therapy

Organ confined cancer ,10 years free survival range 70-85% Focal extracapsular extension ,free survival 70% at 5 years 40% at 10years High grade ,free survival 15%at 10 years
Prognosis



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