ADENOCARCINOMA OF THE PROSTATE

Transcription

1 Ref : ADENOCARCINOMA OF THE PROSTATE Div. of Urology, Dept. Surgery Medical Faculty, University of Sumatera Utara Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3 rd ed, 2001 Smith s General Urology (Tanagho & McAninch eds), Lange Medical Books, 15 th ed, 2000 The most common cancer in men 2 nd most common cause of cancer related death after lung ca The choice of th/ for localized disease must be based on many factors : - grade & stage - personal preference - age - performance status Prostate tumors are generally androgen sensitive and advanced disease is most often treated by single or combined androgen ablation 1

2 Etiology Risk factor : - age > 50 - family history - ethnic origin African American >> - androgens - diet (>> animal fat) - environmental exposure - insulin-like growth factors Pathology Benign cystadenoma Prostatic intraepithelial neoplasia (PIN) - high grade (2 & 3) 30 40% chance of developing prostat Ca need repeat biopsies Malignant - conventional adenocarcinoma - transitional cell carcinoma - sarcoma - metastatic tumour - hematologic malignancies Conventional adenocarcinoma (small acinar carcinoma) Vast majority (95 97%) is adenoca from acinar epith Majority lesion in peripheral zone, 20 25% from the transitional zone Classically discovered after TURP Patterns of spread Direct extension into the seminal vesicles & extracapsularly through the periprostatic nerve routes Direct extension into the rectum is uncommon Ureteral obstruction 10 35% 2

3 Lymphatic spread is not uncommon hypogastric, obturator, external iliac, presacral, common iliac 90% distant metastate osseous Visceral meta (lung, liver, adrenal) less common Grading & Staging Gleason grade based on the degree of glandular diff and growth pattern Mostofi grade based on the degree of nuclear irregularity. The lesion are graded as well, moderately and poorly differentiated Staging systems The American Joint Committee on Cancer, modified TNM system Signs & symptoms Diagnosis A prostatic nodule or induration of the gland hallmark sign Consist of : - symptom of bladder outflow obstruction - symptom resulting from local extension - symptom from distant metastase (bone pain, low back pain, weight loss) Digital rectal examination (DRE) any palpable irregularity 50% chance TRUS very sensitive but non specific Serum marker PSA Prostate needle biopsy Bone scan CT & MRI 3

4 DRE findings that may indicate cancer : Asymmetry of the gland A nodule within one lobe of the gland Induration of part or all of the prostate Lack of mobility due to adhesion to surrounding tissue Palpable seminal vesicles Treatment for localized disease Radical or complete prostatectomy Radiation th/ : - external beam radiation th/ - interstitial brachyth/ Follow up after treatment for localized disease - serum PSA single most important parameter Treatment for advanced disease Prostate Ca is an androgen-sensitive tumor Methods of androgen ablation : - bilateral simple orchiectomy - diethylstilbesterol - DHT receptor blockade (flutamide, bicalutamide) - LHRH agonist (leuprolide) - aminoglutethimide - ketoconazole Castration - easily accomplished, relatively inexpensive, well-tolerated, almost free of complication - side effects : vasomotor instability, loss of libido, ED LHRH agonist - long term effects of bone mineralization - as effective as castration with similar side effects, administered subcutaneously 4

5 Antiandrogens - act by blocking DHT receptor - not as effective as castration or LHRH th/ - do not lower the serum testosterone level do not cause impotence or decreased libido - side effects : diarrhea & liver function abn wr07 5