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• Prostate Cancer


  Carcinoma of the prostate
• Prostate cancer is the second most common cause of cancer related death in men older than 50 years of age after carcinoma of the lung with peak incidence between the ages of 65-75 years
• Autopsy studies show that 30% to 40% of men over 50, who had no symptoms of prostate cancer whilst alive, have histological evidence of prostate cancer at the time of death. This percentage rises to 60% to 70% in men over 80 years of age
• Proposed Risk Factors


  • Family history
  • Diet, fat, obesity, alcohol
  • Hormones
  • Smoking
  • Sexual activity (early, multiple partners, STD)
  • Chemicals, toxins, radiation
  • Viruses (Herpes 2, CMV)
  • Vasectomy
  • BPH
• Pathology of Prostate Cancer

  • 70-80% of Ca prostate arise in the outer peripheral glands and hence may be palpable as irregular hard nodules by rectal digital examination and because of its peripheral location Ca prostate less likely to cause urethral obstruction in early stage than nodular hyperplasia
  • Early lesions appear as ill defined mass just beneath the capsule of the prostate. On cut section foci of CA appear as firm gray white to yellow lesions that infiltrate the adjacent gland with ill defined margin
  • Metastases to regional pelvic lymph nodes may occur early. In advance cancers invasion to seminal vesicles, periurethral zones of the prostate, wall of the bladder may occur but the rectum is rarely involved by invasion that is because there is a connective tissue separating the lower genitourinary tract structures from the rectum which prevent the growth of the tumor posteriorly
• Well differentiated adenocarcinomas


  • Composed of small glands infiltrate the adjacent stroma in irregular haphazard fashion
  • The glands in carcinoma doe not encircled by collagen or stromal cells but they appear to have (back to back) appearance
  • The neoplastic glands are lined by a single layer of cuboidal cells with conspicuous nucleoli; the basal layer seen in normal and hyperplastic glands is absent
• Undifferentiated adenocarcinoma


  • Characterized by increasing variability of gland size and configuration, papillary and cribriform patterns, sometimes there is no gland formation but there is a solid cord or sheet of infiltrating malignant tumor cells within the stroma
• Clinical features of Prostate Cancer


  • Often clinically silent especially during early stages
  • 20% of localized ca are discovered accidently during histological examination for biopsy removed for nodular hyperplasia
  • Discovered accidently during routine digital rectal examination as hard firm nodules under the capsule of peripheral glands
  • More extensive Ca may produce signs and symptoms of prostatism due to lower UT obstruction
  • More aggressive tumor may give clinical presentation of metastases. Bone metastases especially to axial skeleton is the most common and prostatic Ca may cause either osteolytic (destructive lesion) or more commonly osteoblastic lesions (bone producing lesions)
• Bone Metastases


  • Spinal mets are painful, may cause lots of reactive bone growth at the site of the met, osteoblastic, may cause bone destruction, osteolytic
• Microscopic (histologic) description


  • Gleason grading is based on the architecture of the tumor, Gleason grades represent a morphological spectrum from well formed glands (pattern 3) to increasingly complicated glandular proliferations (pattern 4) to almost no glandular differentiation (pattern 5)
  • Glandular crowding and infiltrative growth pattern, Nuclear enlargement, nucleolar prominence, Round generally monomorphic nuclei, Amphophilic cytoplasm, Mitoses, Stromal desmoplasia, Intraluminal contents: crystalloids, pink amorphous secretions, blue mucin, Glomerulations, collagenous micronodules (mucinous fibroplasia), Absence of basal cell layer (generally requires immunohistochemical confirmation)
• Gleason system


  Based on architectural pattern, Cytological features not factored in, Overall grade is not based on highest grade component, Score = Primary pattern (1-5)+ secondary pattern (1-5)
• Gleason Pattern 3


  • Malignant glands are lined by cells with relatively scant cytoplasm and which appear atrophic; however, they have an infiltrative growth pattern and exhibit malignant cytological features, such as enlarged nucleoli. IHC confirms the absence of basal cells
• Gleason Pattern 4


  • Malignant cells have prominent nucleoli. The basal layer is absent
• Gleason Pattern 5


  • Prostate adenocarcinoma showing an infiltrative growth pattern. Malignant cells have prominent nucleoli
• Prostate adenocarcinoma


  • Malignant glands are seen surrounding a nerve. Perineural invasion is a relatively common feature of prostate adenocarcinoma
• Diagnostic tests


  • DRE
  • PSA
  • TRUS
  • Prostate biopsies
• PSA


  Prostatic –specific antigen (PSA) is proteolytic enzyme produced by both normal and neoplastic epithelium. It secreted into prostatic acini then into the seminal fluid where it increases the motility of the sperm by maintaining the seminal secretion in a liquid state. Its upper normal limit value is 4ng/L. It is used in the diagnosis of early Ca but it is of limited that due to causes of Raised PSA: Prostatic cancer, BPH, Prostatic infarction, Prostatic manipulation, Prostatic biopsy, Acute urinary retention, Urethral catheterisation
• Age related reference limits for PSA

  • <49y: <2.5 g/l

  50-59y: <3.5

  60-69y: <4.5

  70-79y: <6.5
• Digital Rectal Examination (DRE)


  Used for early detection of prostate cancer
• TRUS and Biopsy


  Used for early detection of prostate cancer
• Increased awareness


  Causes increased incidence of prostate cancer
• Longer life


  Increases incidence of prostate cancer
• Gleason's System


  Grades 1-5, Scores 2-10, Strongest predictor of biologic behaviour, Should be included with other prognostic factors in therapeutic decision making
• Transitional cell carcinoma of the prostate

  3 types are identified: 1. Direct extension/invasion from the bladder, 2. Spread from the bladder along prostatic ducts, 3. Primary TCC of prostatic urethral lining with no lesion in bladder
• Mesenchymal Tumours


  • Phyllodes (Benign & Malignant)
  • STUMP
  • Leiomyoma & Leiomyosarcoma
  • Spindle cell nodule (post operative)
  • Pseudosarcomatous fibromyxoid tumour
  • Solitary fibrous tumour
  • Embryonal rhabdomyosarcoma
• To achieve a good quality of life for men with Prostatic Cancer