Urology: Prostate Cancer

Prostate Cancer

Types of Cancer

  • Adenocarcinoma (> 95%)
  • Neuroendocrine Tumor
  • Urothelial (Transitional Cell) Carcinoma
  • Basal Cell Carcinoma
  • Lymphoma

Location

  • Most Common Site: Posterior Lobe
  • Most Common Site of Metastasis: Bone
    • Osteoblastic Lesion with High Alk-Phos
    • Lymphatic Spread

Presentation

  • Usually Asymptomatic at Time of Diagnosis
  • Nonspecific Lower Urinary Tract Symptoms (LUTS)
  • Hematuria

Prostate Specific Antigen (PSA)

  • Causes of Increased Level:
    • Benign Prostatic Hyperplasia (BPH)
    • Prostatitis
    • Prostate Cancer
  • Changes After Prostatectomy:
    • Should Be Zero by Week 3
    • If Not: Suspect Mets

Screening

  • Normal Risk: PSA at Age 50-55
  • High Risk: PSA After Age 40-45, Every 1-2 Years
  • *No Role for Digital Rectal Exam (DRE) in Screening

Diagnosis

  • Primary Diagnosis: Transrectal US-Guided Biopsy
    • Can Also Use MRI to Guide Biopsy
  • Generally Perform x12 Core Biopsies to Increase Detection Rate
  • Gleason Grading System Used to Describe

Gleason Grading System

  • Based Solely on Architecture of the Cancer Cells
  • Higher Score Indicates Higher Risk of Metastatic Disease & Poor Outcomes
  • Gleason Grade: For the Individual Cells
    • Scored: 1-5 (Most-Least Differentiated)
  • Gleason Score: For the Specimen
    • Addition of the Grades for the Two Most Predominant Patterns
    • Combined Scores: 2-10 (2-5 are Generally Not Diagnosed as Cancer)
    • *The Preferred Grading System
  • Gleason Grade Group:
    • Provides Greater Risk Stratification
    • Does Not Replace the Gleason Score but Should Be Given in Addition
    • Group 1: Score ≤ 6
    • Group 2: Score 7 (3+4) – Hazard Ration for Death 2.8 Relative to Group 1
    • Group 3: Score 7 (4+3) – HR 6.0 Relative to Group 1
    • Group 4: Score 8 – HR 7.1 Relative to Group 1
    • Group 5: Score 9-10 – HR 12.7 Relative to Group 1

Prostate Cancer 1

TNM Staging
  • TNM
  Clinical T (cT) Pathologic T (pT) N M
1 Not Palpable 1a – Incidental Finding in ≤ 5% of Tissue Resected 1b – Incidental Finding in > 5% of Tissue Resected 1c – Identified by Needle Biopsy *None Regional LN+ Mets 1a – Nonregional LN 1b – Bones 1c – Other Sites
2 Palpable but Confined to Prostate 2a – Involves ≤ Half of One Side 2b – Involves > Half of One Side 2c – Involves Both Sides Confined to Prostate    
3 Extraprostatic Tumor but Not Fixed 3a – Extraprostatic Extension 3b – Invades Seminal Vesicles Extraprostatic Tumor but Not Fixed 3a – Extraprostatic Extension 3b – Invades Seminal Vesicles    
4 Fixed or Invades Adjacent Structures (Other than Seminal Vesicles) Fixed or Invades Adjacent Structures (Other than Seminal Vesicles)    
  • Staging
  T N M PSA G
I   cT1-2a, pT2 N0 M0 < 10 1
II A cT1-2a, pT2 N0 M0 10-19 1
cT2b-c N0 M0 < 20 1
B T1-2 N0 M0 < 20 2
C T1-2 N0 M0 < 20 3-4
III A T1-2 N0 M0 ≥ 20 1-4
B T3-4 N0 M0 Any 1-4
C Any T N0 M0 Any 5
IV A Any T N1 M0 Any Any
B Any T Any N M1 Any Any
  • *G = Group Grade

Management Options

  • Radiation Therapy (RT)
    • External Beam Radiation Therapy (EBRT)
    • Brachytherapy
  • Androgen Deprivation Therapy (ADT)
    • Medical Castration: Leuprolide (GnRH Agonist)
      • Prevent a Transient LH Surge with Flutamide (Antiandrogen)
    • Surgical Castration: Bilateral Orchiectomy
  • Radical Prostatectomy
    • Surgical Resection of the Prostate, Seminal Vesicles & Lymph Nodes

Treatment Approach

  • Confined to Prostate: RT or Radical Prostatectomy
    • *Consider Active Surveillance for Very Low-Low Risk Tumors
    • *Consider Adding ADT for High-Risk Tumors
  • Locally Advanced or Nodal Involvement: RT & ADT
    • May Consider Radical Prostatectomy
  • Metastatic Disease: ADT
    • Also Consider Docetaxel in Metastatic Disease

References

  1. Yoo S, Kim JK, Jeong IG. Multiparametric magnetic resonance imaging for prostate cancer: A review and update for urologists. Korean J Urol. 2015 Jul;56(7):487-97. (License: CC BY-NC-3.0)