Prostatic cancer

Background

• Prostatic cancer is a malignancy arising from the prostate gland (mostly adenocarcinoma)
• It arises most commonly in the posterior lobe (peripheral zone)
• Risk factors include; increasing age ( > 50-60 years of age), family history or black race
• It is frequently diagnosed by Prostate-specific antigen (PSA) increase and a biopsy (transrectal ultrasound guided multiple biopsies)

Clinical features

• It often presents with;
  • Asymptomatic in most cases
  • Lower urinary tract symptoms (urinary retention)
  • It can metastasize to the bone (Osteoblastic metastases in bone may develop in late stages, as indicated by lower back pain and increase serum ALP and PSA)

Diagnosis

• Digital rectal examination (DRE)
• Serum labs
  • Prostate-specific antigen (PSA) is not specific for malignancy (can be elevated in benign prostatic hyperplasia)
  • Alkaline phosphatase (suggestive of bony metastases)
• Invasive studies
  • Transrectal ultrasound (TRUS) guided multiple biopsies

Prostate cancer grading (Gleason score)

Prostate cancer staging

Differential diagnosis

• Benign prostatic hyperplasia (BPH)

Treatment

• Treatment is dependent on pathological features, metastasis, and the patient’s life expectancy
  • Androgen deprivation therapy (if a patient is already on maintenance GnRH therapy, external beam radiation therapy is used to treat symptomatic metastasis)

Complications

• Obstructive uropathy

Supplementary tables

• Table 1: laboratory investigations for prostate cancer workup
  

  Test parameter	Significance
  CBC	Anaemia, pancytopenia due to bone marrow involvement or chronic diseases
  PSA	Elevated levels may indicate prostate cancer
  Alkaline Phosphatase	Bone metastasis
  Electrolytes	Kidney function, bladder obstruction
  Liver function tests, Albumin	Ability to treat with anti-androgen medication
  LDH	Prognostic value in metastatic disease; elevated levels associated with lower overall survival in castrate-sensitive and castrate-resistant prostate cancer

• Table 2: comparison of benign prostatic hyperplasia and prostate cancer
  

  	Benign Prostatic Hyperplasia (BPH)	Prostate cancer
  Risk factors	Age > 50 years	Age > 40 years, African American and positive family history
  Affected part	Central portion (transitional zone)	Usually peripheral zone of prostate but can be anywhere
  Examination	Symmetrically enlarged and smooth prostate Can have elevated PSA	Asymmetrically enlarged, nodules and firm prostate Markedly elevated PSA