Prostate Cancer

Prostate CancerThe prostateThe largest sex accessory gland of male reproductive systemIts main function is to secrete a clear, slightly alkaline (pH 7.29) fluid that contributes to the formation of seminal fluid The gland is located in the pelvis, inferior to the bladder, where it surrounds the prostatic part of the urethra continued It consists of 30 to 50 tubuloalveolar glands arranged in three concentric layers: an inner mucosal layer, an intermediate submucosal layer, and a peripheral layer containing the main prostatic glands

The glands of the mucosal layer secrete directly into the urethra; the other two layers have ducts that open into the prostatic sinuses located on either side of the urethral crest on the posterior wall of the urethra The adult prostatic parenchyma is divided into four anatomically and clinically distinct zones

The central zone surrounds ejaculatory ducts as they pierce the prostate gland. It contains about 25% of the glandular tissue and is resistant to both carcinoma and inflammation. The Central ZonePeripheral ZoneThe peripheral zone comprises 70% of the glandular tissue of the prostate. It surrounds the central zone and occupies posterior and lateral parts of the gland. Most prostatic carcinomas arise from the peripheral zone of the prostate gland. The peripheral zone is palpable during digital examination of the rectum. This zone is also the most susceptible to inflammation

Trnasitional Zone The transitional zone surrounds the prostatic urethra; it comprises about 5% of the prostatic glandular tissue and contains the mucosal glands. In older individuals, the parenchymal cells of this zone frequently undergo extensive division (hyperplasia) and form nodular masses of epithelial cells. Because this zone is proximate to the prostatic urethra, these nodules can compress the prostatic urethra, causing difficult urination. This condition is known as benign prostatic hyperplasia (BPH)

The periurethral zone The periurethral zone contains mucosal and submucosal glands. In later stages of BPH, this zone may undergo pathologic growth but mainly from the stromal components. Together with the glandular nodules of the transitional zone, this growth causes increased urethral compression and further retention of urine in the bladder.

Prostate CAEpidemiology :

More common in western countries and rare in East Asia. Blacks are affected more than whites Weak but established familial tendency. It is the most common malignant tumor affecting males. Life time chance of having Ca Prostate is as high as 15% (1 in 6). The chance of having cancer increase with age.

EtiologyGenetic influenceHormonal ChemicalOthers : diet , exercise , weight etc

And none of these is strong enough to be considered as cause-effect factorIn UK there was an area showed increased number in the reported cases of prostate cancer and after research they found it's related to the source of flour - from an area in the US- which has a big deficiency of selenium!

Estrogen , selenium ( soya beans ) and lycopene )tomatoes ) are proved to have protective effect against prostate cancer.

Histology Adenocarcinoma; 95%

Apudoma; 5%, an endocrine tumor that arises from ( APUD cell ) from structures such as the Ampulla of Vater, pancreas, and prostate. They are derived from neural crest cells.

Grading by Gleason Grading System It is the most widely accepted grading system. It depends on the description of the architecture of the prostate gland under light microscopy at low magnification. What is important is how much the architecture of the gland is distorted, and according to the degree of distortion they put 5 grades from 1-5.

How to know the score ?And then the most prevalent architectural derangement is the primary grade , the second most common is the secondary grade , we also might have a tertiary grade Then the primary grade + the secondary grade gives the total grade (score). So that, the least score is 2 (primary grade is one and secondary grade is also one) and the greatest is 10. GRADESCORELow grade2,3,4Intermediate 5,6,7High grade7,8,9,10The most common grade is 6 (more than 80% of the casesClinical presentation90% of prostate cancers are detected by PSA testing screening, abnormal DRE, or incidentally

Can give similar symptoms as BPH, BUT this is a late manifestation.

Symptoms of distant metastasis as presentation are rare.

Prostate Specific Antigen (PSA)Serine protease.Produced in the epithelium of the prostate.Increases with age.Liquefies semen fertilityLow specificity & low sensitivity for prostate CA.Screening and follow-up.The levels of PSA (ng/dl) in an adult average of 50-55 years old (put in mind that as the age increases we accept higher levels of PSA):

If PSA level is less than 4, the chance of tumor is low but not zero. If PSA level is from 4 to 10, the chance of the tumor is 30% which is high. If PSA level is from 10 20, the chance of the tumor is 50%. If PSA level is from 20 50, the chance of the tumor is 78%.If PSA level is more than 50, the chance of the tumor is almost 100%. If the PSA in the gray zone 4-10ng/ml so what to do ??1- PSA velocity: 10 ng/dl

TNM StagingTX: cannot be assesed.T0: no primary tumor.T1 : discovered by chance (TURP).T2: palpable by DRE.T3: extension beyond the capsule.T4: Invasive local.

N0: no lymph node involvementN1: regional lymph nodes.

M0: no metastasis.M1: metastasis.

AJCC stagingStage I:6No nodesNo metastasisStage III:Extends through prostate capsule or into the seminal vesicleNo nodesNo mets

Stage IV: any of the following:Extends to adjacent structures other than the seminal vesicleNode involvementMetastasisTreatmentStage I: radical prostatectomy

Stage II: radical prostatectomy lymph node dissection

Stage III: radiotherapy andorgen ablation

Stage IV: radiotherapy + androgen ablationTreatmentRadical prostatectomy: prostate + seminal vesicles + ampulla of vas deferens

Radiotherapy:External beam radiation therapyBrachytherapy (Radioactive seed implantation therapy)

Androgen ablation: bilateral orchiectomy or GnRH agonistPrognosisThe Cancer of the Prostate Risk Assessment (CAPRA):PSA levelGleason scorePercentage of biopsy cores positive for cancerClincal tumor stageAge at diagnosisFollow-upPSA levels every 6-12 months in the 1st 5 years and then annually

Yearly DRE

Patients receiving androgen deprivation therapy:Monitor for anemiaMonitor calcium, Vit D, and bone densityMovember / No Shave November

Thank you