Reference: Sur Talk 263, Lec Not Onc 114,
2nd commonest malignancy in ♂. Rises steeply with age.
Most adenocarcinoma arising in peripheral prostate.
Local: seminal vesicles, bladder, urethra, rectum
Lymph nodes: iliac, para-aortic
Haematological: sclerotic bone lesions (pelvis, spine,
Symptoms or nocturia, hesitancy, poor stream, dribbling, urinary
obstruction. Weight loss and (especially) bone pain suggests metasteses
Malignancies are hard, irregular, loss of sulcus
↑PSA (can be normal, also ↑ in hypertrophy, prostatitis):
⩾4 then 25%, ⩾10 then 40% chance malig. Can look at time trends.
Diagnosis: transrectal USS and biopsy. 6 cores sampled on
each side of prostate, analysed to give a Gleason score.
Staging: Vital - has it gone through the capsule? CT/MRI,
LFTs. Bone XRs, bone scan, urine flow tests
T0: non palpable, T1: tumour in one lobe, T2: both lobes. T3: outside
prostate to involve seminal vesicles, T4: local structures
N0: no nodes, N1: nodal involvement
M0: no mets, M1: mets
Early stage (T1/T2 and M0)
Active surveillance (monitor PSA, repeat biopsy), radiotherapy, radical
prostatectomy. With good or moderate histology there is the same
overall chances of survival with surgery and radiotherapy except in the
younger group with poor histology where surgery is best.
Radical prostatectomy: prostate and LNs. Incontinence in 25%, impotence
Radiotherapy: 6w. SE: Impotence in 40%, cystitis, proctitis (can become
chronic). Can use brachytherapy (implanting radioactive seeds) w less
morbidity except ↑risk retention due to prostate swelling up.
Locally advanced/mets (T3/T4)
Hormonal: GHRH (leuprorelin acetate, goserelin accetate), i.e. medical
castration. SE: hot flushes, osteoporosis. Relapse at 18m.
Anti-androgen (cyproterone acetate) given simultaneously in first few
weeks due to initially higher Testosterone.
Localized and small bulk:
Well/moderately differentiatd (80% 10YS), Poorly differentiated (70% w
surgery and 15% w other)
Mets and large bulk:
80% respond to treatment but after 1y most patients have PSA evidence
of relapse. Median survival 2-3y.