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Where are most of the glands in the prostate?
- In the peripheral zone.
- then the central and finally the transitional has the least 5%.
What part of the prostate surrounds the prostate?
The transitional zone
What is the prostate's function and what does it have to do so?
Its function is to produce and expel secretions and because of this they have glands and fibromuscular tissue.
Where are most of the prostate cancers found?
Peripheral zone of the prostate
What are the bad things of the digital rectal exam to detect for prostate cancer?
- Dectection is only for about 1.5-7%
- detects at the most advanced stages
- there is a lot of inter examiner variability (what may seem normal for one may not be normal for another person)
- leads to increased biopsies and risk of infection and bleeding
- can't distinguish between a clinically indolent and aggressive carcinoma
If the digital exam is positive then what is the next step?
Well we can use a transrecal US and biopsy. The device is placed against the anterior wall of the rectum which allows for assessment of the peripheral zone of the prostate and we can do a core biopsy at the same time
What percentage of prostate cancer is found through screening and what have been the advantages of screeing?
- It can extend the life of the patient if the cancer is found when he is asymptomatic vs symptomatic.
- and there has been a decrease in the mortality.
What is PSA and how can it help us determine if the patient has cancer or not?
- PSA is a serine protease that is normally produced by the prostatic glandular epithelium and functions in th liquefaction of the seminal cogulum.
- PSA from 4-10 does not distinguish between benign land non-neoplastic but it does tell us that there is an increased risk of cancer 20-25%..
- If the PSA value is greater than 10 then there is a greater than 50% chance that there is prostate cancer and this value increases as the PSA value rises
We have a patient with a PSA value of 7.. What does this tell us and what is the differential?
So because the PSA is from 4-10 then we know that there is an increased risk for cancer but its not above 10 which means that the risk for cancer is about 20-25% vs 50%. So differential is: prostate cancer, glandular hyperplasia, prostatitis, trauma and DRE (digital rectal exam).
What is the most common place for BPH (benign prostatic hyperplasia)?
transition zone around the urethra
What is cystoscopy good for?
To dx BPH it is not great for cancer dx because only 2.5% of cancers arise in the transition zone
DRE is the best exam we have to combat prostate cancer?
Not really... It is a pretty bad exam that is why we also need PSA.
Patient comes in for exam, you do the PSA exam as part of the routine exam..
BAD! You need to inform the patient.. This is one of those exams that you need to have patients consent
Patient has a very high PSA. You suspect cancer. How can you tell if the cancer is indolent or aggressive?
You can't with only a PSA. You should probably get a Rectal US and biopsy.
How can you tell the difference between BPH and prostate tumor?
- At the beginning it is almost the same: freq, urgency, hesitancy, incomplete emptying, straining, decease force, dribbling, nocturia..
- The only main difference at the beginning is that there shouldn't be hematuria with BPH but there can be with prostate cancer.
- later in the progression of the disease it is easier to tell
- Late onset BPH: bladder diverticula, hydronephrosis, peylonephritis
- Late onset prostatic cancer: metazoic disease, bone pain- low back, weight loss
How does normal glandular tissue look in normal glandular prostate tissue?
2 cell layers
What propels the secretions from the prostate glands?
fibromuscular stroma of the prostate
How is the glandular tissue of the prostate organized?
- So we have the basement membrane
- basal cells: reserve cells
- columnar secretory epithelial cells and neurorendocrine are like around there also
Histologically which is a pretty good way of knowing if something is BPH or if is prostate cancer?
- If we can see 2 cell layers then it is BPH if it only has 1 layer then it is prostate cancer.
- Cancer will also have a prominent nucleolus in the nuclei
Patient comes in with a huge prostate.. Like huge! Could this be BPH?
No in BPH the prostate is not enlarged but it does weigh more that a normal prostate and therefore the urethra is almost closed off. It can weigh as much as double that of the normal
What are the different types of BPH? what are the differences between them?
- Glandular Hyperplasia and fibromuscualr hyperplasia
- Glandular hyperplasia: cystic dilatations separated by fibrous aroma and lines by epithelium and basal cells
- Fibromuscualr: increased muscle tone and compression of the urethra due to compression of the s.m. around it.
What can we see histologically in BPH?
Stromal and glandualr hyperplasia but his has 2 cell layers
What do we think is the cause of BPH?
Testosterone.. Yup.. So Androgens have the biggest effect on prostate growth. Stromal cells convert testosterone into DHT which binds to nuclear testosterone receptors and has autocrine and paracrine action that leads to cell proliferation. So we need this in the puberty years to make the prostate bigger but it does become more problematic when men get older.
Patient has BPH and wants to know what is his risk for prostate cancer?
BPH is not a premalignant lesion so the same as the rest of the population
So what do we do if a patient has BPH?
because it is a progressive disease that can lead to UTI, bladder damage and kidney damage we need to keep an eye on it to see when we need to start with an actual treatment.
What are the different treatment methods of BPH?
- alpha-adrenergic blockers such as: 5alpha reducatase, finasteride, and dutasteride block the conversion of testosterone to DHT.
- laser PVP and turp where there is a reduction of the prostate tissue
- way to see the grade of the prostate cancer..
- Grade 1: well diff- 2-6 gleason score
- Grade 2: mod diff - 7
- Grade 3: poorly diff- 8-10
- we do average scores to get the grade
What are the treatments for prostatic carcinoma?
- watchful- only TNM 1
- hormonal meds
What are the different hormonal treatments we can do for a patient with prostate cancer?
- orchiectormy: bye bye testicles
- estrogen: yup estrogen
- GnRH analogs (leuprolide): supresses LH-RH synthesis
- Antiandrogens (flutamide): inhibits androgen uptake and nuclear binding
- adrenal androgen sythesis blockade: ketoconazole
Does family history increase the possibility of having prostate cancer?
There could be a hereditary form of cancer
What are some risks of prostate cancer?
- being AA
- living is the US
What are the genes linked to prostate cancer?
HPC1 gene linked to the RNASEL gene
- What are the early and late symptoms of prostate cancer?
- Early: asymptomatic or associated with hematuria or dysuria
- Late: bone pain
What do Apha adrenergic blockers do?
relax the fibromuscular tissue to decrease tone of the stromal smooth muscle.
What are the side-effects of surgical therapy for prostate cancer?
- shortening of penis
- inconticence (urine or stool)
- hernia (ingunal)
complications of radiation therapy in prostate cancer
- increased risk for bladder and rectal cancers
What are the complications of hormonal therapy in prostate cancer?
- hot flashes
- impaired sexual fxn
- prirutus (itching)