Diagnosis

Prostate cancer

Etiology

Cause [3fp]

• Sporadic mutations in oncogenes

• Genetic factors (BRCA1 or BRCA2)

• Family history (prostate cancer, Lynch syndrome)

• Inflammation

• Infections: chlamydia, gonorrhea, or syphilis

• Environmental exposure:

  • Iionizing radiation

  • Chemicals

Pathophysiology [3fp]

1. The prostate is roughly 3 cm long and weighs approximately 20 g

2. The prostate produce one-third of the total seminal fluid and nourishes the sperm

3. The prostate gland requires androgen (testosterone) to function optimally

4. Prostate cancer typically begins with a mutation in normal prostate glandular cells

5. Usually low-grade with relatively low risk and limited aggressiveness

6. The cancer cells grow and multiply forming a tumor nodule

7. Prostate cancer commonly metastasizes to the bones and lymph nodes.

Type:

• Adenocarcinoma (95%)

• Squamous

• Transitional cell

• Sarcoma

• Metastasis

Risk factors [v9n][3fp]

• Age

• Ethnicity

• Diet (saturated fat and red meat, lower intake of fruits/vegetables/vitamins/coffee)

• Obesity

• Physical inactivity

• Hyperglycemia

Epidemiology

Incidence per 100.000 [3fp][q4r][ryq][5dv]

Approach

• Digital Rectal Examination

• Blood test: PSA

• Urine stix

• Bladder scan

• Uroflow

• Transrectal ultrasound

• MR pelvis

• PET-CT

• Transrectal biopsy

The Gleason Scoring System [3fp]

• Based on the microscopic arrangement, architecture, or pattern of the prostate gland

• Patterns are graded from 1 (normal) to 5 (presence of only abnormal cancer cells)

• Low-grade tumors: Gleason score ≤ 6

• Intermediate-grade = 7

• High-grade ≥7

Treatment

Management strategy consider the following: Cancer severity (TNM, Gleason score), patient preferences, life expectancy, pretreatment general functional, genitourinary symptoms, expected post-treatment functional status [v2i][3fp]

1. Watchful waiting: Localized prostate cancer in advanced age

2. Active surveillance: PSA monitoring, repeat prostate biopsies, repeat MRI

   the goal is to delay curative intervention without missing the window for a cure

3. Radical prostatectomy: If localized and potentially curable disease

   • Laparoscopic, robotically-assisted, classic retropubic and perineal prostatectomy

4. Radiation therapy: Results comparable to surgery

   • Conventional radiation therapy

   • Three-dimensional (3-D) conformal radiation therapy

   • Intensity-modulated radiation therapy

   • Temporary and permanent brachytherapy

   • Proton-beam radiation

   • Stereotactically guided radiation

5. Hormone therapy: Androgen deprivation therapy

   • Surgical castration: Orchiectomy

   • Medical castration: Luteinizing hormone analogues or antagonists, antiandrogens

6. Recurrence:

   • Watchful waiting

   • Brachytherapy

   • Prostatectomy

   • Cystoprostatectomy

   • Cryotherapy

   • Hormone ablation

7. Metastatic prostate cancer (incurable):

   • Bisphosphonates

   • Rank ligand inhibitors

   • Hormonal treatment

   • Chemotherapy

   • Radiopharmaceuticals

   • Immunotherapy

   • Focused radiation

8. Metastatic hormone-sensitive prostate cancer (incurable): Androgen deprivation

   • Combined androgen blockade

   • Intermittent androgen suppression

   • Androgen suppression plus abiraterone acetate with prednisone

   • Androgen suppression plus enzalutamide

   • Androgen suppression plus docetaxel

   • Relugolix

9. Metastatic hormone-resistant prostate cancers: the last stage of metastatic disease

   • Radiation therapy

   • Non-chemotherapy palliative options:

     Megestrol, Nonsteroidal antiandrogens, Corticosteroids, Ketoconazole, Radiation therapy, Bisphosphonates, Suramin, Estrogen

   • Other therapies:

     • Sipuleucel-T (Provenge)

     • Abiraterone acetate (Zytiga, Yonsa)

     • Enzalutamide (Xtandi)

     • Cabazitaxel (Jevtana)

     • Mitoxantrone

     • Apalutamide (Erleada)

     • Rucaparib (Rubraca)

     • Olaparib (Lynparza) 

     • Niraparib/abiraterone (Akeega)

Differential diagnoses

Benign prostatic hyperplasia, Bladder cancer, Deep venous thrombosis, Medullary compression, Prostatic abscess, Prostatitis, Pulmonary embolism, Renal cell carcinoma, Tuberculosis, Urinary tract infection, Urolithiasis