Malignant Disorders of the Prostate

PROSTATE CANCER is the # 1 malignancy in men, 2^nd only to lung cancer in male cancer deaths

Prostatic Intraepithelial Neoplasia (PIN) – a histological finding

lesions consist of multiple foci of glands with intra-acinar proliferation of cells that demonstrate nuclear dysplasia

no invasion (unlike cancer); dysplastic cells surrounded by layer of basal cells and intact original basement membrane

high grade PIN is a precursor to prostatic adenocarcinoma and is considered an indication for repeat biopsy in 3-12 mo.

Prostatic Adenocarcinoma (PCA)

95% of all prostate malignancies; 70% of males age 70-80 have histologic evidence of PCA

most men with histological evidence do not develop clinical carcinoma (they die of something else before it progresses)

1/11 white men and 1/10 African-American men will have "clinical" carcinoma of the prostate (contrast to "histological")

RISK FACTORS: family history, environmental factors, dietary factors, high serum testosterone (?)

Symptoms

Early: often asymptomatic Late: uretal obstruction (like BPH), extension of tumor may cause rectal obstruction

Signs

PSA – serum Prostatic Specific Antigen

PSA is a serine protease glycoprotein that is made in detectable quantities only by the prostate

PSA is organ specific but not cancer specific (Ý PSA could be from infection, infarction, BPH, prostatic massage)

normal PSA <4ng/mL; clearly abnormal if >10ng/mL

anything between 4ng/mL and 10 ng/mL should be checked for % free PSA; the % free is lower in men with prostate cancer than in men with BPH

DRE – Digital Rectal Exam

the posterior location of most (~70%) of prostatic tumors renders them easily palpable

Transrectal Ultrasonography

hypoechoic areas are likely cancerous, convenient to biopsy using ultrasonography

Grading

Grade I: well differentiated, uniform neoplastic glands packed in well-circumscribed nodules

Grade V: no glandular differentiation, tumor cells infiltrate the stroma in sheets, cords, and/or nests

Gleason Score is the numerical sum of the 1^st and 2^nd most prominent grades found in the specimen. Used to predict.

Gleason Score	capsular penetration	seminal vesicle invasion	pelvic lymphatic involvement
2-4	18%	3%	6%
5-7	32%	13%	10%
8-10	78%	57%	28%

Staging

Clinical staging – an assessment of whether the tumor is confined to the prostate or not. DRE, CT, MRI, ultrasound, PET, CXR, IVP, bone scan, serum PSA, and pelvic lymphadenectomy are used.

Pathologic staging – after surgical resection; takes into account involvement of lobe(s), surgical resection margins, seminal vesicle(s), peri-prostatic soft tissues, and pelvic lymph nodes.

Stages: T2 within prostate, T3 outside prostate, T4 out to rectum or pelvic wall.

Treatment

No standard treatment; individualized based on age, clinical stage, Gleason score, general health, degree of sexual activity, patient’s wishes, etc.
Surgery: radical prostatectomy (there is a risk of urinary incontinence, impotence, and loss of fertility)
Radiation: used to supplement surgery and/or for palliation of bone metastases
Chemotherapy: yet to be found effective, hormonal ablation is used when patient is symptomatic but incurable by other means

Other Prostate Tumors

Epithelial Neoplasms – include Urothelial carcinoma; involves the urothelium that lines the prostatic urethra

also included (but rare) are: metastases to prostate, Wilm’s tumor, Basal cell carcinoma, Squamous carcinoma.

Soft Tissue Neoplasms – rare

"Other" Tumors of the Prostate – include Lymphoma and plasmacytoma

prostate can be the primary site, but it is usually part of some systemic process