Carcinoma Of The Prostate

Introduction

Carcinoma Of The Prostate us the most commonly diagnosed malignancy
affecting men above middle age.
It is the commonest malignancy of the male genitourinary tract.
About 90% of the cases are adencarcinomas.

Causes

  • Exact cause not known

Risk factors

  • Increasing age
  • Presence of testicles
  • Heredity – Cancer of the prostate in first degree relatives, inheritance of faulty genes e.g. cancer of the breast in mother
  • Ethnicity – commoner and more aggressive in the black race
  • Environment Industrial workers (rubber, fertilizer)
  • Obesity

Clinical Features

  1. Lower urinary tract symptoms
    (LUTS)

    • Daytime frequency
    • Poor stream
    • Excessive straining
    • Nocturia
    • Terminal dribbling
  2. Features of advanced disease
    • Low back pain
    • Paraplegia/Paraparesis
    • Pedal oedema
    • Weight loss
    • Pathological fractures
    • Azotaemia
  3. Digital Rectal Examination (DRE) -Enlarged, assymetrical, hard, nodular prostate with obliteration of the median groove and lateral sulci

Differential diagnosis

  • Benign Prostatic Hyperplasia
  • Chronic Prostatitis
  • Bladder cancer
  • Prostatic calculi
  • Urethral Stricture

Complications

  • Urinary retention
  • Recurrent Urinary tract infection
  • Obstructive uropathy
  • Progressive renal failure
  • Paraplegia/Paraparesis
  • Pathological fractures
  • Lymphoedemal

Investigation

  • Full blood count and ESR
  • Serum, electrolytes, urea and creatinine
  • Transrectal ultrasound
  • Abdominal ultrasound
  • Prostate biopsy
  • X-ray -Lumbosacral spine, chest
  • MRI/CT scan
  • Radionuclide bone scan

Treatment

Objective

  • Cure for early disease.
  • Palliation and improvement of quality of life for advanced disease

Treatment should be in a specialist centre.

Non-drug treatment

  • Active surveillance (Watchful waiting)
  • Radical Prostatectomy
  • Radical radiotherapy
  • Bilateral orchiectomy.
  • Cryoablation therapy
  • Laser therapy

Drug Treatment

Used usually in advanced diseases
1. Leutenising hormone releasing hormone agonist:

  • Goserelin 3.6mg subcutaneously every month or 10.8mg 3-monthly
  • Leuprolide – 3.75mg-7.5mg subcutaneously monthly or 11.5mg – 22mg 3-monthly

2. Leutenising hormone releasing hormone antagonist:-p

  • Degarelix 280mg subcutaneously stat, then 80mg monthly

3. Antiandrogens
Used with LHRH agonist, antagonist, or orchiectomy. Monotherapy is not advised

  • Bicalutamide – 50mg daily orally
  • Flutamide-250mg three times daily orally

For castration resistant prostate cancer (CRPC):
This must be treated in tertiary centres with appropriate facility and personnel.

  • Ketoconazole- 400mg orally three times daily with prednisolone 20mg mane, 10mg evening
  • Dietylstilboestrol-3mg daily
  • Docetaxel 75mg daily to be used with  Prednisolone

For bone metastasis:

  • Zoledronic acid 400mg over 1 hr once per month

4. Radiotherapy-Radium-223.

Notable ADR, caution, and contraindications

Antiandrogens

  • Loss of libido
  • Gynaecomastia
  • Erectile dysfunction
  • Fluid retention
  • Hypertension
  • Thromboembolic disease
  • Loss of libido

Ketoconazole

  • Liver toxicity – monitor liver function

Other drugs for CRPC fraught with ADRs including blood dyscrasias, and reduced quality of life