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PROSTATE CANCER


Semir A. S. Al Samarrai

 

Introduction:

Cancer of the Prostate (PCa) is currently the second most common cause of cancer death in men.

In developed country PCa accounts for 15% of male cancers compared with 4% of male cancers in developing countries.

Risk Factors:

There are three well-established risk factors for PCa:

A. Endogenous risk factors:

  1. Increasing age.
  2. Ethnic Origin.
  3. Genetic Predisposition.
B. Exogenous risk factors:
  1. Diet.
  2. Patterns of Sexual Behavior.
  3. Alcohol Consumption.
  4. Exposure to Ultraviolet Radiation.
  5. Occupational Exposure.
All those factors play an important role in the risk of developing PCa.

Diagnosis and Staging:

The decision whether to proceed with further diagnostic or staging work-up is guided by which treatment options are available to the patient, taking the patients age and comorbidity into consideration. Procedures that will not affect the treatment decision can usually be avoided.

The introduction of an effective blood test, Prostate-Specific Antigen (PSA), has resulted in more early-stage prostate cancer diagnosis where potentially curative treatment options can be provided. However, if effective diagnosis procedures are inappropriately used in elderly men with short life span, the use of over-diagnosis and over treatment may occur. Consequently, the same stage of prostate cancer may require different treatment strategies depending on an individual patient’s life expectancy. (EAU-Guidelines 2011)

Diagnosis:

1.) An abnormal digital rectal examination (DRE).
2.) Elevated serum PSA measurement above 4 ng/ml could indicate PCa.
3.) Transrectal Ultrasound (TRUS) guided systemic biopsy is the recommended method in most cases of suspected PCa.

Staging:

1.) Local staging. (T-Staging) of PCa is based on finding from (DRE) and possibly Magnetic Resonance Imaging (MRI). Further information is provided by the number and sites of positive prostate biopsies, the tumor grade and the level of serum PSA.

2.) In comparison with DRE, TRUS and Computed Tomography of the Prostate (CT-P), MRI demonstrates higher accuracy for the assessment of uni or bi-polar disease. (T2) or of extra-capsular extension of the prostate cancer (ECE-PCa) and of seminal vesicle invasion or involvement of the prostatic cancer (SVI-PCa)=(T3), as well as the invasion of the prostatic cancer into the adjacent structures (T4). However, the literature shows a wide range in the accuracy of T-Staging by MRI from 50-90%. The addition of dynamic contrast-enhanced MRI (DCE-MRI) can be helpful in equivocal cases.

3.) Skeletal metastasis (M-Staging) is best assessed by bone scan.

Treatment of Prostate Cancer:

1.) Stage T1a: Watchful-waiting as standard treatment for Gleason Score less than 6 and less than 10 years life expectancy. But by younger patients less than 68 years with Gleason Score more than 7 is the Nerve Sparing Radical Prostatectomy indicated.

2.) Stage T1a + T2c (T1a, T1b, T2a, T2b, T2c)

a.) Active Surveillance with PSA less than 10 ng/ml and biopsy-Gleason Score less than 6 and less than 2 biopsies positive and less than 50% cancer involvement o each biopsy and by patient with life expectancy of less than 10 years. 

b.) The radical prostatectomy is indicated than for patient with a life expectancy of more than 10 years who accept treatment related complications like incontinence and impotence.

c.) The radiotherapy is indicated by patients with life expectancy of more than 10 years who accept these treatment-related complications, by patients with contraindication for surgery like multimorbidity, and by patients who are unfit and with life expectancy of 5-10 years and have poorly differentiated prostate cancers.

d.) The hormonal treatment is than indicated by patients with symptoms and needs palliation of these symptoms and is unfit for curative treatment. 

e.) Hormonal Therapy is indicated for patients, who need palliation of symptoms and are unfit for curative treatment. Hormonal treatment in combination with radiotherapy is indicated by high risk patients. The international-literature and the result of this therapy showed increased overall survival compared to the high-risk patients with only neoadjuvant hormonal treatment.

3.) Stage T3:

A. The radical Prostatectomy is indicated with PSA less than 20ng/ml with positive biopsy Gleason Score less than 8 and life expectants more than 10 years. These patients have to be informed that Radical Prostatectomy is associated with an increased risk of positive surgical-margins unfavorable histology and positive lymphnodes and that, therefore adjuvant or salvage therapy such as radiation therapy or androgen deprivation might be indicated.

B. In asymptomatic patients with T3 and well differentiated and moderately differentiated prostate-cancer and life-expectancy of less than 10 years and are unfit for local treatment is watchful and waiting strategy the option of treatment.

C. By T3 with more than 5-10 years of life expectancy. The combination of radiotherapy with hormonal therapy seems to be of benefit.

4.) Extensive T3 T4 :

A. Symptomatic patients with extensive T3-T4,with high PSA-level more than 25-50 ng/ml and PSA-Doubling Time (DT) less than one year are driven as unfit patients but hormonal therapy seem to be of benefit.

B. The overall survival of three years is improved by concomitant and adjuvant hormonal therapy 3 years combined with external beam radiation with dose escalation of more than 74 Gy.

LITERATURE:

1. European Urology 2008 Jan;53 (1): 68-80

2. European Urology 2011 Jan;59 (1): 61-71

3. European Urology 2011 Apr; 59 (4): 572-83

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae