Definition
Malignant lesion of the prostate gland.
Key Points
- Prostate cancer is commonly found in older men. Variable clinical course.
- Increasingly found (asymptomatic) by screening using PSA and digital rectal examination. Screening may detect non-lethal tumours. Need prostatic biopsy to make diagnosis.
- Non-metastatic disease has good 5-year survival with radical local therapy.
- Metastatic disease is best managed medically and has a poor outlook.
Epidemiology
Uncommon before 60 years. 80% of prostate cancers are clinically undetected (latent carcinoma) and are only discovered on autopsy. The true incidence of this disease is considerably higher than the clinical experience would indicate.
Aetiology
- Increasing age.
- More common in black men.
- Hormonal factors: growth enhanced by testosterone and inhibited by oestrogens or antiandrogens.
Pathology
- Prostatic tumours are often multicentric and located in the periphery of the gland.
- Adenocarcinoma arising from glandular epithelium.
- Gleason grading (1–5) is used to grade differentiation. The most common and second most common pattern are each graded 1–5; the sum of these gives the Gleason score (2–10).
- Staging: TNM, PSA levels and Gleason grading are all used to calculate ‘stage’.
Spread
- Direct into remainder of gland and seminal vesicles.
- Lymphatic to iliac and periaortic nodes.
- Haematogenous to bone (usually osteosclerotic lesions), liver, lung.
Clinical Features
- Bladder outflow obstruction (poor stream, hesitancy, nocturia).
- New onset erectile dysfunction.
- Symptoms of advanced disease (ureteric obstruction and hydronephrosis or bone pain from metastases, classically worse at night).
- Nodule or irregular firm mass detected on rectal examination.
Investigations
- FBC: anaemia.
- U+E, creatinine: renal function.
- Specific markers: PSA, PSA velocity (3 measurements over 2 years), free : total PSA ratio.
PSA: >10 ng/ml (carcinoma unlikely to be organ confined) – prostatic bx.
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