CARCINOMA OF THE PROSTATE

Issa J. kiswagala

(MD)

ANATOMY

• It is an accessory gland of male reproductive system.
• It is composed of glandular tissue embedded in fibromuscular stroma. It surrounds the first 3 cm of the urethra.

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• Capsules
• 1. True capsule: Formed by the condensation of the peripheral part of the gland; continues with the stroma of the gland.
• 2. False capsule: Derived from the pelvic fascia.

McNeal Divided Prostate into Three Zones

• Peripheral zone – prone for carcinoma.
• Periurethral transition zone where BPH arises.
• Central zone.

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Note:

• Prostate carcinoma develops in prostatic gland proper.
• BPH develops in submucosal glands.

PHYSIOLOGICAL FUNCTION

• The prostate gland is a male reproductive organ whose main function is to secrete prostate fluid, one of the components of semen. The muscles of the prostate gland also help propel this seminal fluid into the urethra during ejaculation.
• The fluid excreted by the prostate makes up about one-third of the total volume of semen and contains various enzymes, zinc and citric acid.
• One component of prostate fluid an enzyme called Prostate Specific Antigen (PSA) also aids in the success of sperm by liquefying semen that has thickened after ejaculation. This thinning action allows sperm to swim more freely.

CARCINOMA PROSTATE

• It is the most common malignant tumour in men over 65 years (The incidence increases with age).
• Carcinoma prostate occurs in peripheral zone in prostatic gland proper, i.e. commonly in posterior lobe. So prostatectomy for BPH does not confer protection against development of carcinoma prostate.
• Incidence of prostate cancer in men over 80 years is 70%.

CLINICAL FEATURES

• Commonly asymptomatic
• Bladder outlet obstruction and so retention of urine in 5-10% of cases.
• Difficulty in passing urine, painful micturition and sometimes with frequent haematuria is due to involvement of prostatic urethra.
• Pelvic pain, back pain, arthritic pain in sacroiliac joint due to multiple metastasis
• Anaemia secondary to extensive bone marrow invasion and also due to renal failure
• bilateral sciatica with metastasis in the thoracolumbar vertebrae.
• Incidental carcinoma after TURP or after PSA analysis
• Features of renal failure

ON PER RECTAL EXAMINATION

• On the anterior wall of the rectum, prostate feels hard.
• Nodular (nodulated).
• Irregular.
• obliteration of median sulcus.
• Can go above the prostate gland.
• The rectal mucosa is not ulcerated but fixed or immobile

DIFFERENTIAL DIAGNOSIS

Are other causes of retention of urine and other causes of back pain such as:-

• Benign Prostatic Hyperplasia (BPH)
• Bacterial Prostatitis
• Acute Bacterial Prostatitis and Prostatic Abscess
• Nonbacterial Prostatitis
• Tuberculosis of the Genitourinary System

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INVESTIGATIONS

• Hb%,
• peripheral smear. (In metastatic disease, there may be leuko-erythroblastic reaction with bone marrow invasion causing anaemia, thrombocytopenia).
• Prostate specific antigen (PSA): 4 nmol/ml carcinoma is to be suspected, More than 10 nmol/ml is suggestive, 35 nmol/ml: Disseminated carcinoma.
• Prostatic fraction of serum acid phosphatase is increased (This may also increase in Paget's disease of bone, Acute prostatitis, Cirrhosis of liver, Carcinoma prostate). acid phosphatase of 1 to 3 King-Armstrong units-suggestive of carcinoma of prostate.
• Transrectal ultrasound (TRUS) is very useful
• Plain X-ray, KUB, may show dense coarse sclerotic secondaries. Osteolytic or combination of lytic and sclerotic lesions are also often seen.

PRE-REFERRAL TREATMENT

• Baseline investigations
• Manage urine retention
• Pain management
• Refer

TREATMENT

• Surgery is opted with Radical prostatectomy done in early growth with removal of prostate, seminal vesicle, distal sphincter along with reconstruction of the urethra.
• Bilateral subcapsular orchidectomy is done to reduce the testosterone level.
• Radical radiotherapy

PROGNOSIS

• Prognosis is good

FOLLOW UP

Follow-up after prostate cancer treatment depends on the type of treatment.

• If it’s surgery, radiation therapy, hormonal therapy or a combination of these treatments, follow-up visits are usually scheduled:
• 6 to 8 weeks after treatment starts
• every 3 to 6 months for the first 5 years
• once each year after 5 years
• If it’s active surveillance, follow-up visits are usually scheduled every 6 months.

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• During a follow-up visit, ask questions about the side effects of treatment and how he/she is coping. Ask if any bowel, bladder or sexual problems, do a physical exam, including a digital rectal exam (DRE).
• The following tests are often part of follow-up care: Prostate-specific antigen (PSA) test, complete blood cell count (CBC) and blood chemistry tests, Imaging tests.

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