Prostate Cancer 2015-5-7

8/19/2019 Prostate Cancer 2015-5-7

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Prostate Cancer: Diagnosis and Staging

Roman Kleynberg, MD; Mitchell Gross, MD, PhD | May 7, 2015

•27 of 27

Prostate cancer is the most common noncutaneous cancer among men,[1] accounting for an

estimated 233,000 new cancer cases (1! of a"" new cancer cases# in 201, with an estimated2$,%0 deaths in the same year (5! of a"" cancer deaths#&[2] 'ccording"y, diagnosis and staging of

rostate cancer are critica""y imortant&

)n this image, transrecta" u"trasonograhy (*+-# shows a hyoechoic area (arrow# a"ong the

"eft erihera" .one of the rostate, which is suggesti/e of rostate cancer&

)mage courtesy of Medscae&


2/27

*he anatomy of the human ma"e is shown& hich of the fo""owing statements is false with regard

to the human rostate g"and

'& )t is "ocated inferior to the "adder and anterior to the rectum

& )t functions as art of the ma"e reroducti/e system and aids in the formation of

sermato.oa

4& )t consists art"y of smooth musc"es, which aid in the eu"sion of semen during

e6acu"ation

& )t is homo"ogous to the -8ene (araurethra"# g"and found in women

9& 'side from nonme"anoma s8in cancer, cancer of the rostate g"and is the second "eading

cause of cancer:re"ated deaths in 'merican men

)mage courtesy of reamstime ; Peter6unaidy&


3/27

'nswer< & )t functions as art of the ma"e reroducti/e system and aids in the formation of

sermato.oa&

*he rostate is a comonent of the human ma"e reroducti/e system[3]= howe/er, sermatogenesis

occurs in the seminiferous tuu"es of the testes&[3,] *he rostate manufactures aroimate"y 20:30! of the semina" /o"ume,[5] and the semen assists in carrying serm from the testes through the

enis during the e6acu"atory hase&[]

)n this image, a c"inician inserts a g"o/ed and "uricated finger into the rectum during a digita"recta" eamination (+9# to a"ate the rostate for any unusua" "ums or irregu"arities& *he

resence of a rostate nodu"e is an indication for iosy&



4/27

)n your c"inic, a ma"e atient notices the grah (shown# of estimated rostate cancer cases and

deaths& >e as8s you what the "ifetime incidence of rostate cancer is for a ma"e from the genera" ou"ation&

hich of the fo""owing is the most accurate resonse

'& etween 1 in 3 and 1 in 5

& 1 in 5

4& etween 1 in ? and 1 in 7

& 1 in 10

9& 1 in 2

)mage courtesy of the @4)&


5/27

'nswer< 4& etween 1 in ? and 1 in 7&

*he grah in s"ide shows the estimated incidence of and morta"ity from rostate cancer er

100,000 men er year for the eriod from 1$$1 to 2011&[7] An the asis of 200$:2011 data, the

"ifetime ris8 of rostate cancer in the genera" ma"e ou"ation is aout 15&0! (1 in ?&?7#& [2] *heincidence of rostate cancer increases with age (3?&3! of new cases are in men aged ?5:7

years# and in men with a fami"y history of rostate cancer& "ac8 men are a"so affected moreoften than men of other races are (223&$ new cases er 100,000 men#& Prostate cancer is the fifth

"eading cause of cancer death, and 3?&%! of rostate cancer deaths occur in men aged 75:%

years& eath rates are a"so higher in "ac8 men than in ma"es of other races (%&$ deaths er100,000 men#&[2]

)mage courtesy of the 4enters for isease 4ontro" and Pre/ention (44#&


6/27

' 5$:year:o"d ma"e atient undergoing *+- is found to ha/e an etensi/e hyoechoic area

(arrows# in the right erihera" .one& efore roceeding further, the c"inician discusses the ris8sand enefits of otaining a rostate iosy with the atient&

hich of the fo""owing is not a common com"ication of a rostate iosy

'& Be/er and ain

& >ematosermia

4& >ematuria

& rinary tract infection

9& @one of the ao/e= a"" are otentia" com"ications



7/27

'nswer< 9& @one of the ao/e= a"" are otentia" com"ications&

Be/er, ain, hematosermia, hematuria, and urinary tract infection are a"" otentia" com"ications

of a rostate iosy&[%] )n *+- (shown#, an u"trasound roe is inserted into the rectum to assess

the rostate when rostate:secific antigen (P-'# "e/e"s are e"e/ated or irregu"ar nodu"es arenoted on the +9&[?] *he standard P-' reference range is 0&0:&0 ng;mC& @orma" P-' "e/e"s for

secific age ranges are 0:2&5 ng;mC for age 0:$ years, 0:3&5 ng;mC for age 50:5$ years, 0:&5ng;mC for age ?0:?$ years, and 0:?&5 ng;mC for age 70:7$ years&[$] *+- can a"so re/ea"

rostatitis and enign rostatic hyer"asia&



8/27

*he *+-:guided rostate iosy from this atient re/ea"ed the histo"ogy shown (hematoy"in:

eosin, D300#& *wo distinct differentiations of rostatic tissues are noticea"e when the s"ide is/iewed from the right ha"f to the "eft&

hich of the fo""owing E"eason /a"ues (or scores# can most accurate"y e a"ied to this tissue

'& E"eason /a"ues 1 and 2

& E"eason /a"ues 2 and 3

4& E"eason /a"ues 3 and

& E"eason /a"ues and 5

9& E"eason /a"ues 1 and 3

)mage courtesy of the @4) ; Atis raw"ey, M&


9/27

'nswer< 4& E"eason /a"ues 3 and &

*he standard aroach for grading rostate cancer deends on a E"eason /a"ue, which is

determined through atho"ogic e/a"uation of a rostatectomy secimen and is common"y

estimated from rostate iosy tissue&[10] Prostate cancer atterns are assigned a numer from 1 to5 (ie, from we"" differentiated to /ery oor"y differentiated#= the E"eason /a"ue is created y

adding the most common attern grades and the highest:grade atterns& *he histo"ogic features ins"ide % re/ea"ed a E"eason /a"ue of 3 (moderate"y differentiated cancer# on the right and a

E"eason /a"ue of ("ess we"":differentiated cancer# on the "eft& *he atientFs E"eason /a"ue is

therefore 7 (3 G #&

)mage courtesy of i8imedia 4ommons ; @4)&


10/27

'n %:year:o"d asymtomatic man resents to his doctor for fo""ow:u& >is medica" record

shows that 1 year ago, a rostate iosy erformed y another hysician re/ea"ed rostate cancer (E"eason 3 G 3 H ?# in one of 12 cores, occuying 5! of the core "ength& >is current P-' "e/e"

(5&$ ng;mC# is essentia""y unchanged from 1 year ago& *he atient reorts no recent hea"th

changes& >e has no recent urinary com"aints, one ain, or weight "oss& >is re/ious medica"history consists of congesti/e heart fai"ure (e6ection fraction, 20!#, ersistent atria" firi""ation,

and "i/er cirrhosis& >e is current"y ta8ing warfarin, metoro"o", sirono"actone, ena.eri",

furosemide, and "actu"ose& *he atient is aferi"e, and his "ood ressure is 132;%2 mm >g& >is u"se rate is ?5 eats;min and irregu"ar& *he hysica" eamination yie"ds no ertinent findings&

hich of the fo""owing is the most aroriate net ste in the e/a"uation of this atient

'& +eferra" for radica" rostatectomy

& 4omuted tomograhy (4*# of the adomen

4& one scan

& +eeat *+-:guided iosy

9& Monitoring (sur/ei""ance#

)mage courtesy of i8imedia 4ommons&


11/27

'nswer< 9& Monitoring (sur/ei""ance#&

*he atient is an o"der man with mu"ti"e medica" comoridities whose "ife eectancy is

roa"y "ess than 10 years& *he 2012 - Pre/enti/e -er/ices *as8 Borce (-P-*B#

recommendations note that screening and treatment tria"s ha/e shown no enefit in men o"derthan 70 years&[11] *he 201 @ationa" 4omrehensi/e 4ancer @etwor8 (@44@# guide"ines on

ear"y detection of rostate cancer note that /ery few men o"der than 75 years enefit from P-'testing= the @44@ suggests eing cautious with screening tests in men o"der than 70 years and

recommends such testing on"y in hea"thy men in this age grou who ha/e few or no

comoridities&[?] *he @44@ indicates that c"inicians cou"d consider a higher P-' cutoff "e/e" (Ing;mC# in men o"der than 70 years who may resent with high:ris8 cancers or a cutoff of 3

ng;mC at 75 years&[?] *he image shows the 201 @44@ guide"ines for ear"y detection of rostate

cancer and indications for iosy&[?]

-ource of image information< @44@&[?]


12/27

' ?3:year:o"d man resents to his internist with a screening P-' "e/e" of 1&2 ng;mC& An +9,

the c"inician notices a distinct"y irregu"ar rostatic order&

)n /iew of the otentia" for a rostatic ma"ignancy, which of the fo""owing is the most

aroriate net ste for diagnostic uroses

'& @uc"ear medicine one scan

& 9ndorecta" magnetic resonance imaging (M+)#

4& *+-:guided rostate iosy

& etermination of P-' dou"ing time

9& +adica" rostatectomy



13/27

'nswer< 4& *+-:guided rostate iosy&

An the asis of the c"inica" findings, the est net diagnostic ste is to otain a *+-:guided

rostate iosy&[?] *he hyoechoic "esion /isi"e in this image, high"ighted in "ue in the

erihera" .one of the g"and, is suggesti/e of cancer& ith the de/e"oment of the P-' screeningtest in the ear"y 1$$0s, rostate cancer has een diagnosed ear"ier in its course& [12] Prostate cancer

is most common"y susected on the asis of e"e/ations on P-' screening tests, anorma"itiesnoted on +9, or oth&[?,12] Most rostate cancers are diagnosed without any anorma"ities on

eamination&



14/27

' ?2:year:o"d asymtomatic man has no ast medica" history and a smooth:surfaced rostate on

+9& >owe/er, his P-' "e/e" is 25 ng;mC& *+-:guided iosy re/ea"s rostate carcinoma(shown# confined to the rostate with a E"eason /a"ue of %&

hat is the most aroriate net ste for this atient

'& M+)

& 4*

4& one scan

& Monitoring (sur/ei""ance#



15/27

'nswer< 4& one scan&

*he tumor is c"inica""y staged as *1c@JMJ ())'#= it was identified y need"e iosy that was

otained ecause of the high P-' "e/e" (I20 ng;mC#, and noda" sread and distant metastasis

cannot e assessed with the information gi/en& [10] *he atient a"so does not ha/e *2, *3, or *c"inica" disease& *herefore, a one scan is the est net ste for staging wor8u&[13] *he isotoic

one scans shown re/ea" diffuse metastases and demonstrate a KsuerscanK aearance (intensesymmetric acti/ity in the ones with diminished rena";soft:tissue acti/ity[1]#= note the asence of

rena" ecretion of radioacti/e tracer& '"most a"" rostate cancer atients are initia""y diagnosed

with *1c disease, and a"most none ha/e any symtoms re"ated to the rostate or to rostatecancer&[15]



16/27

*he ta"e shown "ists issues associated with +9 and P-' screening&[12] 'nnua" P-' screening is

common ut high"y contro/ersia" for asymtomatic men o"der than 50 years& 9ar"y surgery orradiation may "ead to com"ications such as imotence, incontinence, and death from infection&

*he -P-*B no "onger recommends routine P-' screening&[11] >owe/er, the 'merican 4ancer

-ociety ('4-# recommends that men discuss testing with their c"inicians starting at age 50 yearsif they ha/e an a/erage ris8 of cancer and ha/e a "ife eectancy of at "east another 10 years (or

starting at age 5 years if they ha/e a high ris8Lfor eam"e, "ac8 men and men with a

rother;father;son who was diagnosed with rostate cancer efore age ?5 years#&[12] *he 'mericanro"ogica" 'ssociation (''# recommends that men discuss testing with c"inicians starting at

age 55 years and does not recommend routine P-' screening in men o"der than 70 years or any

man whose "ife eectancy is "ess than 10:15 years& [1?]


17/27

*wo years ago, a ?$:year:o"d man resented with worsening com"aints of urgency,

incontinence, nocturia, and wea8 urinary stream& 't that time, his P-' "e/e" was 3&3 ng;mC, andhe was started on tamsu"osin& Binasteride was recent"y added to he" contro" his symtoms=

howe/er, the symtoms ersisted& ' +9 did not re/ea" an en"arged rostate or any masses& '

surauic trans/esica" rostatectomy was erformed& *issue ana"ysis incidenta""y re/ea"ed rostate cancer in 2! of the rostate tissue with a E"eason /a"ue of & @o "ymh node

in/o"/ement was found& Burther imaging did not re/ea" any metastasis&

hich stage is this atientFs cancer

'& -tage )

& -tage ))

4& -tage )))

& -tage )

)mage courtesy of i8imedia 4ommons ; -te/en Bruitsmaa8&


18/27

'nswer< '& -tage )&

4"inicians use rostate cancer staging not on"y to categori.e the ris8 of the cancer sreading

eyond the rostate ut a"so to e/a"uate the otentia" for administering "oca" theraies, inc"uding

surgery and radiation&[3,10,12,17] -taging a"so em"oys the E"eason /a"ue for grading& )n stage )disease, rostate cancer is confined to the rostate& *he ta"e shown detai"s the tumor:node:

metastasis (*@M# staging system for rostate cancer, which e/a"uates the si.e of the tumor, thein/o"/ement of "ymh nodes, and the resence of any metastasis&[3,10,12,17] ' tumor that is not

c"inica""y aarent is staged *1= a tumor that is confined to the rostate is staged *2= a tumor that

etends eyond the rostate casu"e is staged *3& [3,10,12,17]


19/27

Prostate cancer is categori.ed into four stages on the asis of the *@M system, the atientFs P-'

"e/e", and the E"eason /a"ue&[3,10,12,17]

*a"e adated courtesy of @4)&


20/27

' 7:year:o"d man resents to an urgent care c"inic with a com"aint of right:side e"/ic ain& >e

a"so com"ains of ac8 ain that has een increasing in se/erity o/er the course of the ast year&+adiograhy of his e"/is is erformed (shown#&

hich of the fo""owing "esions are e/ident on this e"/ic radiograh

'& Asteo"astic metastases

& -c"erotic metastases

4& Asteo"ytic metastases

& oth osteo"astic metastases and sc"erotic metastases

9& @one of the ao/e



21/27

'nswer< & oth osteo"astic metastases and sc"erotic metastases&

ony metastasis is common with rostate cancer= it resents as mu"ti"e osteo"astic "esions, as

seen on s"ide 20&[1%] Asteo"ytic rostate metastases can occur as we""& *umors from the rostate,

reast, "ung, thyroid, and 8idney are the cancers that most common"y metastasi.e to one&[1%,1$] Metastases that resent as mied "ytic:sc"erotic "esions tyica""y originate in the "ung and reast&

' radionuc"ide isotoic one scan after in6ection of methy"ene dihoshonate (MP#technetium:$$m (shown# is the standard imaging moda"ity used to assess for otentia" one

metastases from rostate cancer&[10] Mu"ti"e areas of increased radionuc"ide tracer acti/ity from

metastatic rostate cancer are resent on this one scan&



22/27

' +9 erformed on a 73:year:o"d man re/ea"s a norma":si.ed and moi"e rostate, ut a

nodu"ar mass within the orders of the rostate g"and is a"a"e (arrow#& >is P-' "e/e" is 15&5ng;mC& -oon thereafter, the atient undergoes *+- e/a"uation, and a iosy re/ea"s

adenocarcinoma of the rostate with a E"eason /a"ue of $& 4* does not re/ea" any sread of the

cancer outside of his rostate&

hat is the stage of this atientFs rostate cancer

'& -tage )

& -tage ))

4& -tage )))

& -tage )



23/27

'nswer< & -tage ))&

)n stage )) rostate cancer (shown#, the tumor has ad/anced and is of a higher grade as comared

with stage ) disease& >owe/er, it does not etend eyond the rostate& [3,10] *he tumor can e

a"ated on +9, and it can often e seen on *+-& -tage ))) disease in/o"/es etension of the rimary tumor outside of the rostate casu"e&[3,10]



24/27

' 72:year:o"d man with a P-' "e/e" of 1%&5 ng;mC undergoes a rostatic iosy= histoatho"ogic

eamination re/ea"s rostate cancer with a E"eason /a"ue of 7& M+) is erformed for staging uroses& *he aia" *2:weighted image (left # shows a "ow:intensity "esion rimari"y in/o"/ing

the erihera" .one at the ase with o"iteration of the rectorostatic ang"e (arrowhead #&

efiniti/e surgery re/ea"s etracasu"ar etension of the cancer ut no semina" /esic"e or "ymhnode in/o"/ement&

hat is the stage of this atientFs rostate cancer

'& -tage )

& -tage ))

4& -tage )))

& -tage )

)mage courtesy of Medscae ("eft#, reamstime ; Peter6unaidy (right#&


25/27

'nswer< 4& -tage )))&

-"ide 2 showed a "esion in the "eft erihera" .one of the rostate with etracasu"ar etension&

*he surgica" atho"ogy confirmed the etracasu"ar sread (*3a@0#, indicati/e of stage )))

disease& -tage ))) rostate cancer in/o"/es etracasu"ar in/asion that may in/o"/e the semina"/esic"es ut has not sread eyond the semina" /esic"es& [3,10] )t a"so inc"udes tumors with

documented sread to the semina" /esic"es (*3#& -tage ) disease (shown# may inc"ude *(with etension to the "adder or rectum, resu"ting in a g"and that aears KfiedK on hysica"

eamination# or in/o"/ement of neary "ymh nodes&[3,10]

)mage courtesy of the @4)&

http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page2http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page2


26/27

' 70:year:o"d man resents with ad/anced rostate cancer with diffuse osteo"astic ony

metastases (arrows# to the sine, e"/is, and femur, as seen on this anteroosterior adomina"radiograh&

hich of the fo""owing are common symtoms of ad/anced or recurrent rostate cancer

'& Coss of aetite and weight "oss

& ac8 ain and ony ain (without fractures#

4& -uression of the one marrow

& 4omression of the sina" cord

9& '"" of the ao/e

)mage courtesy of i8imedia 4ommons&

http://commons.wikimedia.org/wiki/Category:Bone_metastasis#mediaviewer/File:Osteoplastic_bone_metastasis_prostate_cancer_01.jpghttp://commons.wikimedia.org/wiki/Category:Bone_metastasis#mediaviewer/File:Osteoplastic_bone_metastasis_prostate_cancer_01.jpg


27/27

'nswer< 9& '"" of the ao/e&

'd/anced rostate cancer is often associated with "oss of aetite, weight "oss, ac8 ain and

ony ain (without fractures#, suression of the one marrow, and comression of the sina"

cord&[20] *his 4* scan at the "e/e" of the 8idneys indicates etensi/e ara:aortic "ymhadenoathy(arrows# secondary to ad/anced rostate cancer&

http://reference.medscape.com/features/slideshow/prostatecancer#page=27

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