Prostate


 * **Epidemiolgy:** || In the United States the most common form of cancer among males is prostate cancer. One out of every six males will develop prostate cancer at some point in their life. In the United States in 2008 about 186,660 men will be diagnosed with prostate cancer out of these men about 28,660 will die as a result of carcinoma of the prostate. The chance that a man will develop prostate cancer increases with each decade of life. Over 65% of prostate cancer is diagnosed in men 65 years and older. African American men have a higher rate of prostate cancer than white men of a similar age. [1] ||
 * **Etiology:** || It is unclear what the cause of prostate cancer is; however, there are some risk factors that increase the chance of a patient developing prostate cancer. These are: increased age, being of the African American race, family history of prostate cancer (father or broth with prostate cancer), and an increased amount of testosterone has been shown to increase the prostate tumor growth rate. [1] ||
 * **Signs & Symptoms:** || Prostate cancer typically to not show signs and/or symptoms in the early stage.[1] As the malignancy progresses there may be symptoms are more associated with blockage due to tumor growth which include:


 * A frequent need to urinate, especially at night.
 * Difficulty starting or stopping a stream of urine.
 * Difficulty urinating
 * A weak or interrupted urinary stream.
 * Inability to urinate standing up.
 * A painful or burning sensation during urination or ejaculation.
 * Blood in urine or semen.
 * Pelvic discomfort [1]

Symptoms of more advanced staged prostate cancer include:


 * Dull, incessant deep pain or stiffness in the pelvis, lower back, ribs, or upper thighs; arthritic pain in the bones of those areas.
 * Loss of weight
 * Loss of appetite
 * Fatigue
 * Nausea and/or vomiting
 * Swelling of legs
 * Weakness or paralysis in the legs [1] ||
 * **Diagnostic Procedures:** || Complete history with physical exam including a digital rectal exam (DRE). Blood work including complete blood chemistry and Prostate-specific androgen (PSA). Core biopsies should be taken of all six quadrants of the gland for the most accurate diagnosis. [1] ||
 * **Histology:** || Adenocarcinoma is the most common histology. [1] ||
 * **Lymph node drainage:** || ===== Prostate cancers spread through a lateral lymph pathway. First nodes involved are the obturator nodes and then the external iliac nodes. The second common drainage pathway is the internal iliac path, which includes the junction of the internal and external iliac nodes. =====



[3] || G1: Well-differentiated (slight anaplasia, Gleason 2–4) G2: Moderately-differentiated (moderate anaplasia, Gleason 5–6) G3–4: Poorly-differentiated/ undifferentiated (marked anaplasia, Gleason–10) [4] ||
 * **Metastatic spread:** || Distance metastases are not commonly seen at the time of diagnosis. In advanced prostate cancer, it primarily spreads to the bones then to the lungs and liver. [1] ||
 * **Grading:** || GX: Grade cannot be assessedG1: Well-differentiated (slight anaplasia, Gleason 2–4)
 * **Staging:** || There are two types of systems used for prostate staging. The most common staging system that is recommended by the American Joint Committee on Cancer (AJCC) is known as the TNM staging system. The TNM evaluates the size of the tumor, the regional lymph node involvement, and distance metastasis. The other non-common staging system is known as the Whitmore-Jewett. [4]

Prostate staging (AJCC 7th Edition, 2010) [4] TX: Primary tumor cannot be assessed T0: No evidence of primary tumor T1: Clinically nonapparent tumor neither palpable nor visible by imaging T1a: Tumor incidental histologic finding < 5% of tissue resected T1b: Tumor incidental histologic finding > 5% of tissue resected T1c: Tumor identified by needle biopsy T2: Tumor confined within prostate T2a: Tumor involves one-half of one lobe or less T2b: Tumor involves more than one-half of one lobe T2c: Tumor involves both lobes T3: Tumor extends through the prostate capsule T3a: Extra capsular extension T3b: Tumor invades seminal vesicle T4: Tumor is fixed or invades adjacent structures other than seminal vesicles
 * Primary tumor **

NX: No regional lymph nodes involvement N0: No regional lymph node metastasis N1: Metastasis in regional lymph nodes
 * Regional lymph nodes (N) **

M0: No distant metastasis M1: Distant metastasis M1a: Non-regional lymph node(s) M1b: Bone M1c: Other site || Pelvic lymphadenectomy: A surgical procedure to remove the lymph nodes in the pelvis. Radical prostatectomy: A surgical procedure to remove the prostate, surrounding tissue, and seminal vesicles. Transurethral resection of the prostate (TURP): A surgical procedure to remove tissue from the prostate using a resectoscope inserted through the urethra.
 * Distant metastasis (M) **
 * Radiation side effects: || Early side effects include dysuria (difficult urination), diarrhea, abdominal cramping, rectal discomfort, and infrequent rectal bleeding. The late effects include persistent proctitis, rectal bleeding, and ulceration. The incidences of these side effects were higher on those with larger volumes of the pelvis that were irradiated. Less common side effects include sexual impotence (erectile dysfunction) and incontinence. [1] ||
 * Prognosis: || Primary tumor stage, pretreatment PSA level, and pathologic tumor differentiation are the strongest prognostic indicators.[1] Prognosis also depends on the stage of the cancer, the patient’s age and health. Patients with Gleason score of 7 have a relatively poor prognosis. Elevated PSA values after radical prostatectomy or 6 months after definitive irradiation are sensitive indicators of persistent disease. ||
 * Treatments: || ** Surgery **

Uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing.
 * Radiation Therapy **

Removes hormones or blocks their action and stops cancer cells from growing.
 * Hormone Therapy **

Uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.
 * Chemotherapy **

New clinical trials include: cryosurgery, biologic therapy, high intensity focused ultrasound, proton beam radiation therapy. [2] || Bladder 6500 Cauda equina 6000 Colon 4500 Femoral Head 5200 Kidney 2300 Liver 3000 Rectum 6000 Small Instestine 4000 Spinal Cord 4700 Stomach 5000 || [2] Prostate Cancer Treatment. National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page4. Accessed June 11, 2012. [3] [] Revision received July 1, 2010. Accessed June 14, 2012. [4] Hoppe TR, Phillips LT, Roach M. Leibel and Phillips Textbook of Radiation Oncology. 3rd Edition. Philadelphia: Saunders, Elsevier. 2010 || Figure 1. Examples of IMRT and 3D-CRT treatment plans. [4]
 * TD 5/5: || **Organ Whole (cGy)** [1]
 * Reference** || [1] Chao C. //Radiation Oncology Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002.

Figure2. Patient positioning for brachytherapy. [4]

Figure 3. Example of prostate seed implant seed positioning. [4] Back to Week 4