Prostatic gland diseases
Asst. prof. dr. Wadhah A. MarzooqFIBMS (uro)
Dr_wadhah_uro@yahoo.com
2020
Objectives
1. Give the student a summary about most common disease of prostate gland.2. Enable the student evaluate pt. with LUTS.
3. Give the student an idea about the head line of treatment of prostatic gland disease
Prostatic carcinoma
AnatomyProstate gland can be divided in to 3 distinct zone
Peripheral account 70% of prost. Size
Central account 25% = =
Transitional 5% = =
Note
• 60-70% of ca. prostate occur at peripheral zone.
• 20-30% occur at the central zone.
• 5-10% occur at the transition zone.
• BPH occur exclusively at transition zone.
Although prostate cancer is one of the most common cancer detected in men, many prostate cancers are indolent and inconsequential to the.
Several risk factors for prostate cancer have been identified, increasing age, African American men tend to present at a later stage of disease than whites, a positive family history, high fat diet.
Additionally, lycopene, selenium, omega-3 fatty acids (fish), and vitamin E intake have been shown to be protective, whereas vitamin D and calcium increase risk
Pathology
Over 95% of the cancers of the prostate are adenocarcinomas.Of the other 5%, 90% are transitional cell carcinomas,
The remaining cancers are neuroendocrine (“small cell”) carcinomas or sarcomas.
Grading
The Gleason grading system is the most commonly employed grading system.Well-differentiated tumors have a Gleason sum of 2–4, moderately differentiated tumors have a Gleason sum of 5–6, and poorly differentiated tumors have a Gleason sum of 8–10.
Staging
The TNM staging system for CaP.T—Primary tumor
• Tx Cannot be assessed
• T0 No evidence of primary tumor
• Tis Carcinoma in situ (PIN)
• T1a ≤5% of tissue in resection for benign disease has cancer, normal DRE
• T1b >5% of tissue in resection for benign disease has cancer, normal DRE
• T1c Detected from elevated PSA alone, normal DRE and TRUS
• T2a Tumor palpable by DRE or visible by TRUS on one side only, confined to prostate
• T2b Tumor palpable by DRE or visible by TRUS on both sides, confined to prostate
• T3a Extracapsular extension on one or both sides
• T3b Seminal vesicle involvement
• T4 Tumor directly extends into bladder neck, sphincter, rectum, levator muscles, or into pelvic sidewall
N—Regional lymph nodes (obturator, internal iliac, external iliac, presacral lymph nodes)
• Nx Cannot be assessed
• N0 No regional lymph node metastasis
• N1 Metastasis in a regional lymph node or nodes
M—Distant metastasis
• Mx Cannot be assessed
• M0 No distant metastasis
• M1a Distant metastasis in nonregional lymph nodes
• M1b Distant metastasis to bone
• M1c Distant metastasis to other sites
Clinical Findings
Early tr …. Asymptomatic.
Local advanced…. LUTS
Distant metastasis…..symptom of metastasis eg. Bone pain, backache.
Examination, most important DRE, any nodule should be considered as ca. until prove otherwise.
General examination, cachexia, LN exam, signs of spinal cord compression.
Investigations.
RFT……azotemia bilateral ureteric obstructionHigh S. ALP….. Bone metastasis
S. PSA (prostate specific antigen)
PSA is a serine protease produced by benign and malignant prostate tissues. It circulates in the serum as uncomplexed (free or unbound) or complexed (bound) forms. Normal PSA values are those ≤4 ng/mL.
PSA velocity (change of PSA over time). 0.75 ng/mL/year
PSA density (standardizing levels in relation to the size of the prostate). 0.12 ng/mL/g of BPH tissue.age-adjusted PSA reference ranges (accounting for age-dependent prostate growth and occult prostatic disease).
and PSA forms (free versus protein bound molecular forms of PSA). 25% free PSA cutoff would detect 95% of cancers
PROSTATE BIOPSY
Prostate biopsy should be considered in men with an elevated serum PSA, a DRE, or a combination of the two.Prostate biopsy is best performed under TRUS guidance using a spring-loaded biopsy device coupled to the imaging probe. Biopsies are taken throughout the peripheral zone of the prostate, rather than just sampling an area abnormal on the basis of DRE or TRUS
IMAGING
TRUS—TRUS is useful in performing prostatic biopsies and in providing some useful local staging information if cancer is detected.
Endorectal magnetic resonance imaging (MRI).
Axial imaging (CT, MRI).
Bone scan.
Antibody imaging. ProstaScint is a murine monoclonal antibody to an intracellular component of the prostate- specific membrane antigen (PSMA
Treatment
• Localized disease.Watchful waiting mean monitoring of the disease without treating it, it is suitable for pt. who don’t want or cant have treatment therapy.
Active surveillance mean that the pt. and urologist defer treatment right away and instead track the disease, it is suitable for pt. with small low risk tumor, and for those at high risk from surgery or radiation.
Radical prostatectomy.
Radiation therapy—external beam therapy.
Radiation therapy—brachytherapy
Cryosurgery and high-intensity focused ultrasound (HIFU).
B. METASTATIC DISEASE.
Initial endocrine therapy.Manipulations for hormone refractory prostate cancer.
Androgen deprivation therapy
Level Agent Route Dose (mg) FrequencyPituitary
Diethylstilbestrol Oral 1–3 Daily
Goserelin Subcutaneous 10.8 Every 3 months
Goserelin Subcutaneous 3.6 Every month
Leuprolide Intramuscular 22.5 Every 3 months
Leuprolide Intramuscular 7.5 Every month
Adrenal
Ketoconazole Oral 400 Daily
Aminoglutethimide Oral 250 Four times a day
Testicle
Orchiectomy
Prostate cell
Bicalutamide Oral 50 Daily
Flutamide Oral 250 Three times a day
Nilutamide Oral 150 Daily