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Jiang Yio 2021-05-10 11:57:31 -04:00
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prostate.adoc
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= Prostate Cancer = 14-2 Prostate Cancer
== Epidemiology == 14-2.1 Epidemiology
Prostate cancer is a common diagnosis, and although metastatic disease develops in a small percentage of affected patients, this translates into a large absolute number of deaths due to prostate cancer. Prostate cancer is a common diagnosis, and although metastatic disease develops in a small percentage of affected patients, this translates into a large absolute number of deaths due to prostate cancer.
@ -15,7 +15,7 @@ Whether black men tend to have biologically more aggressive prostate cancer than
There is no clear causal link between vasectomy and prostate cancer, nor does testosterone supplementation appear to increase the risk of aggressive prostate cancer. There is no clear causal link between vasectomy and prostate cancer, nor does testosterone supplementation appear to increase the risk of aggressive prostate cancer.
== Heredity == 14-2.2 Heredity
Prostate cancer is one of the most hereditable cancers. Clinicians should take a full history of malignancies in the family and be familiar with the link between prostate cancer and germline alterations in BRCA2 and mismatch repair genes, which are enriched among men with metastatic prostate cancer. Prostate cancer is one of the most hereditable cancers. Clinicians should take a full history of malignancies in the family and be familiar with the link between prostate cancer and germline alterations in BRCA2 and mismatch repair genes, which are enriched among men with metastatic prostate cancer.
@ -46,7 +46,7 @@ Guidelines for referral to genetic counseling are frequently changing, but at mi
** two or more relatives with colorectal, endometrial, gastric, ovarian, pancreatic, small-bowel, urothelial, kidney, or bile duct cancer (suggesting Lynch syndrome) ** two or more relatives with colorectal, endometrial, gastric, ovarian, pancreatic, small-bowel, urothelial, kidney, or bile duct cancer (suggesting Lynch syndrome)
** Ashkenazi Jewish ancestry, which could also prompt genetic testing ** Ashkenazi Jewish ancestry, which could also prompt genetic testing
== Anatomy == 14-2.3 Anatomy
Prostate cancer is typically diagnosed via TRUS biopsy using a standard 12-core template to sample the posterior peripheral zone. Prostate cancer is typically diagnosed via TRUS biopsy using a standard 12-core template to sample the posterior peripheral zone.
@ -62,7 +62,7 @@ Anatomic location can help predict pattern of spread and treatment-related risks
* Apical disease poses the problem of having a higher rate of positive surgical margins, harboring an anterior tumor, and incontinence * Apical disease poses the problem of having a higher rate of positive surgical margins, harboring an anterior tumor, and incontinence
** Patients with a bulk of positive specimens from the apex may not be optimal candidates for prostatectomy ** Patients with a bulk of positive specimens from the apex may not be optimal candidates for prostatectomy
== Pathology and molecular pathogenesis == 14-2.4 Pathology and molecular pathogenesis
Prostate cancer can be characterized by its typical IHC profile: cytokeratin 7/20-negative, PSA-positive, AR-positive, and NKX3.1-positive. Prostate cancer can be characterized by its typical IHC profile: cytokeratin 7/20-negative, PSA-positive, AR-positive, and NKX3.1-positive.
@ -102,7 +102,7 @@ Small-cell prostate cancer is a rare subset and classically occurs with rapid vi
*** Neuroendocrine prostate cancer is associated with amplification of AURKA and MYCN, offering the opportunity for targeted therapy *** Neuroendocrine prostate cancer is associated with amplification of AURKA and MYCN, offering the opportunity for targeted therapy
*** Clinically, emergence of neuroendocrine differentiation and small cell transformation should be considered in men who develop castration-resistant disease after ADT for high-grade cancers, especially when visceral involvement is diagnosed and radiographic progression occurs in the absence of an increase in PSA *** Clinically, emergence of neuroendocrine differentiation and small cell transformation should be considered in men who develop castration-resistant disease after ADT for high-grade cancers, especially when visceral involvement is diagnosed and radiographic progression occurs in the absence of an increase in PSA
== Prevention == 14-2.5 Prevention
There are no universally accepted protocols for prostate cancer prevention or screening. There are no universally accepted protocols for prostate cancer prevention or screening.
@ -127,7 +127,7 @@ When clinicians have adopted MRI-targeted biopsies thus far, it has typically be
* Abnormal DRE necessitates referral to urologist for additional diagnostic evaluation (i.e. TRUS biopsy) * Abnormal DRE necessitates referral to urologist for additional diagnostic evaluation (i.e. TRUS biopsy)
* MRI guidance may be useful as first diagnostic step * MRI guidance may be useful as first diagnostic step
== Tumor staging == 14-2.6 Tumor staging
* Clinical T stage is assigned by DRE * Clinical T stage is assigned by DRE
* Pathologic T stage is assigned based on examination of a radical prostatectomy specimen * Pathologic T stage is assigned based on examination of a radical prostatectomy specimen
@ -136,7 +136,7 @@ When clinicians have adopted MRI-targeted biopsies thus far, it has typically be
* T3 tumor extends through the prostate capsula (T3a) or invades the seminal vesicles (T3b) * T3 tumor extends through the prostate capsula (T3a) or invades the seminal vesicles (T3b)
* T4 tumors invade adjacent structures or organs * T4 tumors invade adjacent structures or organs
== Risk stratification == 14-2.7 Risk stratification
Patients with localized prostate cancer can be risk-stratified on the basis of three clinical factors: T stage, Gleason score, and PSA level. Genomic testing of the cancer specimen may provide additional information about risk and progression, but this is not yet prospectively validated for decision-making. Patients with localized prostate cancer can be risk-stratified on the basis of three clinical factors: T stage, Gleason score, and PSA level. Genomic testing of the cancer specimen may provide additional information about risk and progression, but this is not yet prospectively validated for decision-making.
@ -164,6 +164,8 @@ Patients with localized prostate cancer can be risk-stratified on the basis of t
*** PSA concentration > 10 ng/mL *** PSA concentration > 10 ng/mL
** High-risk disease: all patients ** High-risk disease: all patients
== 14-2.8 Management of Prostate Cancer by Risk
Prostatectomy, RT, and ADT all have unique adverse effect profiles. Prostatectomy can lead to urinary incontinence and erectile dysfunction, but it can help improve significant obstructive symptoms. Radiation tends to lead to irritative urine and bowel symptoms. ADT can cause vasomotor symptoms, fatigue, loss of libido, weight gain, muscle loss, and bone thinning, most of which reverse after discontinuation of ADT and recovery of testosterone. Prostatectomy, RT, and ADT all have unique adverse effect profiles. Prostatectomy can lead to urinary incontinence and erectile dysfunction, but it can help improve significant obstructive symptoms. Radiation tends to lead to irritative urine and bowel symptoms. ADT can cause vasomotor symptoms, fatigue, loss of libido, weight gain, muscle loss, and bone thinning, most of which reverse after discontinuation of ADT and recovery of testosterone.
* Management by risk * Management by risk
@ -183,7 +185,7 @@ Prostatectomy, RT, and ADT all have unique adverse effect profiles. Prostatectom
*** Definitive radiotherapy to prostate and pelvic nodes + long-course ADT *** Definitive radiotherapy to prostate and pelvic nodes + long-course ADT
*** Prostatectomy + extended lymphadenectomy + adjuvant radiotherapy + adjuvant ADT *** Prostatectomy + extended lymphadenectomy + adjuvant radiotherapy + adjuvant ADT
== Treatment modalities == 14-2.9 Treatment modalities
Patients with low-risk disease may be offered active surveillance, which uses serial PSA measurements, DREs, and biopsy specimens to detect any presence of higher-risk disease, at which point definitive therapy can be offered. Sequential MRI may also be helpful. This strategy results in less treatment-associated morbidity and similar long-term cancer survival compared with immediate therapy. Patients with low-risk disease may be offered active surveillance, which uses serial PSA measurements, DREs, and biopsy specimens to detect any presence of higher-risk disease, at which point definitive therapy can be offered. Sequential MRI may also be helpful. This strategy results in less treatment-associated morbidity and similar long-term cancer survival compared with immediate therapy.
@ -238,7 +240,7 @@ Patients with preexisting urinary symptoms should avoid brachytherapy and may ex
There is little to no advantages for robotic prostatectomy versus other surgical approaches and for proton therapy versus conventional RT for clinically localized prostate cancer. There is little to no advantages for robotic prostatectomy versus other surgical approaches and for proton therapy versus conventional RT for clinically localized prostate cancer.
== Therapy for recurrent or advanced disease == 14-2.10 Therapy for recurrent or advanced disease
* Pathologic node-positive disease * Pathologic node-positive disease
** Positive lymph nodes at time of prostatectomy indicates aggressive disease at high risk of recurrence ** Positive lymph nodes at time of prostatectomy indicates aggressive disease at high risk of recurrence