Prostate cancer is a malignant tumor of prostate tissue. There are no specific symptoms, especially in the early stages. Possible disorders (sluggish intermittent urine stream, nocturia, constant urge to urinate, pelvic pain, etc.) are associated with the presence of prostate adenoma or chronic prostatitis in the patient. In the diagnosis of prostate cancer, a finger rectal examination of the prostate gland, PSA determination, ultrasound, biopsy are used. Treatment may include radical approaches (prostatectomy), minimally invasive interventions (HiFu therapy, brachytherapy, cryoablation), remote radiotherapy, hormone and chemotherapy.
C61 Malignant neoplasm of the prostate gland
In a number of countries, in the structure of oncological diseases, prostate cancer is second only to lung cancer and stomach cancer in terms of the frequency of occurrence in men. In modern oncourology, the disease is a serious medical problem, since it is often diagnosed only at stage III-IV. This is due to both the prolonged asymptomatic development of the tumor and the inadequate implementation of measures for early diagnosis. Prostate cancer is more common in men over 60 years of age, but in recent years there has been a tendency to “rejuvenate” the pathology.
Prostate cancer is a polyethological disease with unexplained causes. The main risk factor is considered to be the age of a man. More than 2/3 of cases of malignant prostate tumors occur at the age over 65 years; in 7% of cases, the disease is diagnosed in men younger than 60 years. Another predisposing factor is race: the disease is most common among African Americans and is least common among Asians.
A certain importance in etiology is assigned to the family history. The presence of pathology in the father, brother or other men in the family increases the risk of prostate cancer by 2-10 times. There is an assumption that the probability of a neoplasm of this localization in a man increases if there are relatives with breast cancer in the family.
Among other possible risk factors, there are dietary peculiarities associated with the use of large amounts of animal fats, testosterone therapy, and vitamin D deficiency. Some studies indicate an increased likelihood of a tumor in men who have undergone vasectomy (sterilization). Reduces the possible risks of eating soy products rich in phytoestrogens and isoflavonoids; vitamin E, selenium, carotenoids, a low-fat diet.
Prostate cancer is represented by the following histological forms: adenocarcinoma (large-acinar, small-acinar, cribritic, solid), transitional cell, squamous and undifferentiated cancer. The most common glandular cancer is adenocarcinoma, which makes up 90% of all detected prostate neoplasms.
The Gleason scale is used to assess the malignancy of prostate cancer. According to her, the degree of differentiation of cells in two samples of biopsy material is estimated from 1 to 5 points, in total, the prostate cancer index is obtained:
- 2-6 points – highly differentiated, low-aggressive, slow-growing prostate cancer
- 7 points – low-differentiated tumor of the middle steppe of aggressiveness
- 8-10 points – low-differentiated, fast-growing prostate cancer with a high risk of early metastasis.
According to the TNM system, several stages of prostate cancer are distinguished:
- T1 – the tumor does not manifest clinically, has a diameter of less than 2 cm, is detected by chance. With the substage of T1a, less than 5% of the gland parenchyma is affected, with T1b – more than 5%. The T1c substage is exposed in case of detection of atypical cells in the biopsy.
- T2 is a tumor of 2-5 cm in size without germination of the gland capsule. T2a – less than half of the prostate lobe is affected, T2b – more than half of the lobe on one side, T2c – bilateral lesion.
- T3 – the tumor is more than 5 cm, the capsule of the gland sprouts. T3a – seed vesicles are not affected, T3b – germination into seed vesicles.
- T4 – the tumor grows beyond the capsule, spreads to the neck or sphincter of the bladder, rectum, the levator muscle of the anus, the pelvic wall.
- N1 – single metastases in lymph nodes are detected, N2 – multiple metastases are detected
- M1 – distant metastases of prostate cancer in lymph nodes, bones, etc. are determined. organs.
The neoplasm is characterized by a long latent period of development. There are no specific signs of prostate cancer. The symptoms that occur, as a rule, are associated with the presence of a concomitant pathology in a man – prostatitis or prostate adenoma. There is an increase in urination with difficulty starting miction; a feeling of incomplete emptying of the bladder; intermittent and weak urine stream; frequent urge to urinate, problems with retention of urine.
There may be burning or pain during urination or ejaculation; hematuria and hemospermia; pain in the perineum, over the pubis or pelvis; lower back pain caused by hydronephrosis; erectile dysfunction. It is these complaints that often force the patient to seek medical help. Prostate cancer most often becomes an accidental discovery during an in-depth urological examination.
Continuous dull pains in the spine and ribs, as a rule, indicate bone metastasis. In the late stages of prostate cancer, edema of the lower extremities may develop due to lymphostasis, weight loss, anemia, cachexia.
The scope of the examination required to detect prostate cancer includes a finger examination of the gland, determination of PSA in the blood, ultrasound and ultrasound of the prostate, prostate biopsy. Finger examination of the prostate through the wall of the rectum determines the density and size of the gland, the presence of palpable nodes and infiltrates, localization of changes (in one or both lobes). However, only with the help of palpation it is impossible to distinguish organ cancer from chronic prostatitis, tuberculosis, hyperplasia, prostate stones, therefore additional verification studies are required:
- PSA research. A common screening test for suspected prostate cancer is to determine the level of PSA in the blood. Oncourologists focus on the following indicators: at a PSA level of 4-10 ng / ml, the probability of cancer is about 5%; 10-20 ng / ml – 20-30%; 20-30 ng / ml — 50-70%, above 30 ng / ml — 100%. It should be borne in mind that an increase in prostate-specific antigen indicators is also noted in prostatitis and benign prostatic hyperplasia.
- Ultrasound of the prostate. It can be performed from transabdominal or transrectal access: the latter allows you to detect even small tumor nodes.
- Transrectal prostate biopsy. Performed under ultrasound control. The material is usually taken from 12 points (6 from each lobe of the gland). It is carried out through the rectum, usually under local anesthesia.
- Saturation biopsy. It is carried out by a transpermentional access under spinal anesthesia. During the procedure, more than 12 tissue samples are taken.
- Fusion-prostate biopsy. A special computer program processes prostate MRI data, which allows for targeted tissue sampling from a suspicious area. It is done both through the perineum (spinal anesthesia) and transrectally (local anesthesia).
Additionally, testosterone levels can be determined, abdominal ultrasound, skeletal scintigraphy, lung radiography.
Taking into account the stage of the tumor, surgical treatment, radiotherapy (remote or interstitial), chemotherapy can be undertaken. The use of different approaches is primarily due to the prevalence of prostate cancer.
- Minimally invasive methods. They include HiFu therapy, prostate brachytherapy, cryoablation. They can be used with a low cancer risk or in those patients who cannot perform prostate removal for medical reasons. However, if these techniques are used, the probability of relapse is higher than with a radical approach.
- Radical prostatectomy. The main type of surgical intervention for prostate neoplasm is radical prostatectomy, during which the gland, seminal vesicles, prostatic urethra and bladder neck are completely removed; lymph dissection is performed. Radical prostatectomy may be accompanied by subsequent urinary incontinence and impotence. Modern surgery is gradually moving away from open operations. Laparoscopic and robot-assisted prostatectomy are increasingly becoming a practice.
- Androgen blockade. In order to induce androgen blockade in prostate cancer, testicular enucleation (bilateral orchiectomy) can be performed. This operation leads to the cessation of endogenous testosterone production and a decrease in the growth rate and dissemination of the tumor. In recent years, instead of surgical castration, drug suppression of testosterone production by LHRH hormone agonists (gozerelin, buserelin, triptorelin) has been used more often.
- Drug therapy. Hormone therapy and chemotherapy can be used after prostate removal, as well as in patients who cannot have surgery
Prognosis and prevention
The prospect of survival depends on the stage of the cancer process and the differentiation of the tumor. A low degree of differentiation is accompanied by a worsening of the prognosis and a decrease in the survival rate. At the T1-T2 N0M0 stages, radical prostatectomy contributes to 5-year survival in 74-84% of patients and 10-year survival in 55-56%. After radiation therapy, 72-80% of men have a favorable 5-year prognosis, and 48% have a 10-year prognosis. In patients after orchiectomy and undergoing hormone therapy, the 5-year survival rate does not exceed 55%.
It is not possible to completely exclude the development of prostate cancer. Men over 45 years of age need to undergo an annual examination by a urologist for early detection of neoplasms. Recommended screening for men includes rectal finger examination of the gland, prostate TRUS, determination of PSA in the blood.