CARCINOMA OF PROSTATE

• Carcinoma of prostate is the MC malignant tumour in men over 65 years.
• MC cause of bone secondaries
• Carcinoma of prostate occurs in peripheral zone in prostatic gland proper (commonly in posterior lobe)

• Advancing age + increase fat intake
• Genetic alterations is hypermethylation of glutathione transferase (GSTP-1) located on chromosome 11

PATHOLOGY-

• Adenocarcinoma of prostate is the MC form of cancer in males
• They are multifocal and heterogenous

1. Local spread-

• Upward- seminal vesicles, bladder neck, trigone
• Downward- distal sphincter

2. Blood spread-

• Bones- pelvic bones, lumbar vertebrae, femoral head, ribs and skull
• MC site of origin- for skeletal metastases

3. Lymphatic spread-

• Obturator lymph nodes

CLINICAL FEATURES-

• Bladder outlet obstruction
• Haematuria
• Commonly asymptomatic
• Pelvic pain, back pain, arthritic pain
• Renal failure
• Perineural invasion
• Rectal examination- prostate feels hard, nodular, irregular and obliteration of medial sulcus

INVESTIGATIONS-

1. Hb%

• Anemia
• Thrombocytopenia
• DIC

2. Plain X-ray, KUB-

• Shows sclerotic metastases in lumbar vertebrae and pelvic bones

3. Serum acid phosphatase-

• Responsible for acidic pH in the prostatic urethra and normally drained in urine
• Increase acid phosphatase

4. Serum alkaline phosphatase-

• Increase in extensive liver metastasis or bone metastasis

5. Prostate specific antigen(PSA)

• It is a glycoprotein, serine protease elaborated by columnar prostatic acinar epithelial cells.
• Free- 10- 40%, complexed to antiprotease- 60 to 90%
• Formed in prostate and secreted in seminal fluid
• Causes liquefaction of seminal coagulum
• More than 4nmol/ml- carcinoma detected
• 10 nmol/ml- prostatic carcinoma
• 35 nmol/ ml- disseminated carcinoma
• Prostate specific, but not prostate cancer specific
• Most efficient test and for staging and assessing

6. Abdominal and transrectal USG- staging of the disease

7. CT scan or MRI scan

• Staging of the disease
• MRI is ideal for most accurate for local staging

8. Bone scan-

• Increased ALP
• Increased PSA (>20nmol/ml)
• For diagnosing metastasis

I) Early malignancy

a) T1 a-

• Well differentiated associated with very slow growth rate
• Regular follow up with DRE and PSA

b) T1b T1c, T2

• Radical prostactectomy or radiotherapy
• External beam radiotherapy- T1 or low T2 disease
• Branchytherapy- low T1 disease

II) Late malignancy (T3, T4 or any metastasis)

• Androgen ablation is the first line of treatment followed by antiandrogenic measure
• Orchiectomy + flutamide or LHRH + flutamide
• Palliative radiotherapy

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