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22.7 Carcinoma of the Prostate

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Prostate cancer is among the most common malignancies and is the second most common cause of cancer related death in men. However, most men die with their prostate cancer rather than from it and management must balance the potential toxicity of active treatment, with the chances of benefit in a disease with a long natural history. The most common type of prostate cancer is adenocarcinoma (95 %)

Tumours are stratified by T stage, Gleason score (GS), and PSA into three prognostic groups of low, intermediate and high risk.

  • Low risk: T1–T2a and PSA < 10 ng/ml and GS ≤ 6
  • Intermediate risk: T2b or PSA 10 – 20 ng/ml or GS 7
  • High risk: T2c–T4 or PSA > 20ng/ml or GS 8–10

Patient can be offered appropriate treatment options according to stage of disease, prognostic risk group and estimated survival taking into account performance status and comorbidity.

Diagnostic Criteria

  • May be asymptomatic in early stages of the disease
  • May present incidentally following examination for benign prostatic hypertrophy or elevated serum prostatic specific antigen (PSA)
  • Prostatic symptoms are associated with advanced stages of the disease, which include: reduced potency, urinary frequency and nocturnal, poor stream, hesitancy and terminal dribbling
  • Very often patients may present with bone pain including backache or pathological fracture
  • Digital Rectal Examination (DRE) typically reveals a hard, irregular prostate. TURP is carried out to both confirm the diagnosis and also as part of the treatment (to relieve obstruction).

Investigations

  • Laboratory: FBC, LFTs, urea, creatinine, serum PSA, ALP
  • X-rays of the painful bone or spine
  • CXR
  • Abdominal and pelvic USS and or CT Scan
  • Pelvic MRI in early stage disease
  • Bone scan
  • Biopsy for histopathology

Staging: TNM

Treatment:

Treatment depends on disease profile and patient factors as noted above. Options include:

  • Watchful waiting
  • Active surveillance
  • Surgery (curative or palliative
  • Radiotherapy (curative or palliative)
  • Hormonal therapy (chemical vs surgical castration)
  • Chemotherapy

Surgery

Early stages can be treated with either radical prostatectomy or radical RT with cure intent. However, surgery may cause postoperative impotence and impaired urinary control. TURP is carried out to both confirm the diagnosis and also as part of relieving obstruction.

Radiotherapy

Radical RT for early stages, EBR up to 70 Gy/35 , given with 3D technic. Palliative radiotherapy is valuable to bone metastases, massive hematuria, spinal cord compression and brain mets,

Hormonal Therapy

Hormonal manipulation is by surgical or medical castration. It is carried out in patients with locally advanced or metastatic disease. Bilateral orchydectomy is a surgical hormonal manipulation and should not be regarded curative surgery.

Pharmacological Treatment:

S: Goserelin 3.6 mg subcutaneous every 4 weeks or 10.8mg every 12 weeks with or without oral bicalutamide 50mg once daily

Note:
Gosereline is not required after orchydectomy but patient may receive Biculutamide.
Treatment with gosereline and bicutamide may be given up to 2 years depending on patient condition and Prostate Specific Antigen (PSA) levels

Chemotherapy

Current recommended chemotherapy drug is mainly:

S: Doctetaxel, 75mg/m2 IV Day1 given every 3 weeks up to 6 cycles. It is mainly reserved in hormonal refractory prostate cancer.

For Bone metastases/osteolytic/tumour induced hypercalcemia:

S: Zolendronic acid IV 4mg over 15min given 4 Weekly

The codes will be shown below

Seconds
First: 170598
Seconds
Second: 180198

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