Prostate Cancer (Part Two)

Diagnosis

Prostate tumor is often discovered through a clinical examination via digital rectal exploration or by a high PSA level (prostate-specific antigen). When a prostate tumor is suspected, it must be confirmed by a biopsy. Other examinations are Ultrasound, traditional Radiography, Computed Tomography (Scanner) as well as Bone Scintigraphy, are done when bone metastases need to be assessed.

Digital Rectal Examination (DRE) is a procedure by which the examining doctor evaluates the size, shape, and consistency of the prostate: irregular, hard, or nodular areas should raise suspicion because they might be caused by the prostate tumor. This examination is assessed with a sensitivity that varies from 44 to 97% and with a specificity between 22 and 69% (Selley 1997).

Prostate adenocarcinoma in 70% of the cases is localized in the peripheral part of the gland and this is the area well palpable by DRE. In about 20% of the cases, the tumor's localization is in the anterior middle part of the prostate called the transitional zone which is the characteristic area of benign prostatic hyperplasia. Only in 5% of the cases the tumor originates from the central zone, but more often the tumor spreads widely in the gland and is considered of the multifocal type.

PSA Dosage determines the blood level of an enzyme produced by the prostate. Normal values are considered those that are below 4 ng/ml, levels from 4 to 10 ng/ml indicate a probability of tumor, whereas values above 10 ng/ml obligatorily make you search for a prostate tumor. But it should be said that PSA is not a perfect test, because some men with prostate tumor do not have high PSA levels, just as many men with a high level of PSA do not have a prostate tumor.

However, PSA is proposed as the primary test for searching for prostate tumors. PSA can also be increased in inflammatory processes or in benign prostatic hyperplasia, or after a digital rectal examination, just as after sexual intercourse shortly before the examination. Likewise, some medications can influence PSA values.(Andriole and Di Paola, 1998).

The level of PSA is directly proportional to increasing age. For PSA values from 4 to 10, 26% of subjects were found with prostate tumor (Postma 2005).

To improve PSA values for the early diagnosis of prostate cancer, other methods of PSA dosage (free PSA and total PSA, age-specific PSA, PSA velocity) have been used, but none of them has been more convincing than total PSA.

There are studies to find more reliable diagnostic methods, but so far these are the ones we mentioned.

Transrectal Ultrasound (TRUS) in prostate cancer. If the digital rectal examination (DRE) provides data on the presence of prostate cancer based also on PSA level results then the doctor seeks to obtain a visual ultrasound image of the prostate via TRUS. We emphasize that the TRUS examination helps in making the diagnosis but does not provide an exact diagnosis as this examination cannot differentiate an inflammation from a malignant process and the diagnosis is questionable without biopsy confirmation. The TRUS examination assists in performing the biopsy puncture, which is carried out under ultrasound guidance. Complications of the biopsy under ultrasound guidance are rare, but infection and hemorrhage may occur in 0.1% to 4% of cases that undergo biopsy puncture.

Transrectal Biopsy via Ultrasound (TRUS):
What can be discovered by prostate biopsy?

1. Prostatitis: many biopsies negative for carcinoma may reveal prostate inflammation known as prostatitis. This is very common in the adult male population.
2. Intraepithelial prostatic neoplasia (PIN).This is a stage that over the years may evolve towards prostatic carcinoma.
3. As mentioned above, almost all types of prostate cancers are adenocarcinomas. They are multifocal in 85% of the cases. Among many classifications for evaluating the diagnosis of prostate cancer, the most accepted is the Gleason classification.

Stages of tumor development:
There are several systems for categorizing the level of prostate cancer development. The most accepted is the TNM system.

• Stage one (T1): the tumor is small, confined to the prostate, and cannot be detected by DRE. This is a cancer that is usually discovered incidentally after a procedure on the prostate for benign prostatic hyperplasia. The biopsy of the removed tissues reveals the cancer.
• Stage two (T2): the tumor is still confined to the prostate but is larger and can be detected by DRE.
• Stage three (T3): prostate cancer has breached the prostate capsule and may infiltrate surrounding tissues and seminal vesicles.
• Stage four (T4): Prostate cancer has metastasized and has reached the lymph nodes, bones, and other organs like the liver or lungs.

Disease progression

Prostate tumor is usually a slowly progressing tumor. For this, information has been provided by a study published in JAMA (the Journal of the American Medical Association). Men with a low grade of prostate tumor (Gleason score of 2-4) have slow tumor progression and survival is good. The opposite happens when the tumor type is evaluated at Gleason 8-10.

Treatment of prostate cancer and therapeutic options:

• Observation and periodic monitoring
• Hormonal therapy
• Radiotherapy
• Radical prostatectomy
• Brachytherapy
• Cryosurgery.

Of course, the treatment method will be determined by the urological oncology specialist, based on a detailed assessment of the patient's condition and age as well as the stage of tumor development. Each treatment method has its own advantages and disadvantages. Ultimately, it is an invasive treatment method.

Hormonal therapy: prostate cancer grows depending on the testosterone hormone produced by the testicles as well as by the adrenal gland (suprarenal). The production of this hormone can be interrupted in two ways.

1. Through a surgical procedure orchiectomy (removal of the testicles).
2. But the testosterone hormone can also be stopped with the use of medications such as leuprorelide or goserelin, which inhibit the pituitary gland and thus reduce hormone production by the testicles. This therapy is usually reserved for tumors with metastases.

Other medications used for androgenic blockade are:

• Casodex (bicalutamide)
• Cyproterone acetate
• Eulexin (flutamide)
• Lutenizing Hormone Releasing Hormone (LHRU, leuprolide/Zoladex-goserelin).

In conclusion, we see that for prostate adenocarcinoma there are many variants

• Preventive
• Diagnostic
• Invasive curative
• Medical curative, etc.

For this reason, we should once again mention the saying of urologists that:
“men die with prostate cancer, but not from prostate cancer“.(Ultrasound Assessment in Prostate Diseases. Prostate Cancer A.Gjokutaj; A.Hoxhaj;E.Enesi;E.Isufi;Sh.Beqiri.)

To prove this, we can recall prominent figures of European art who have themselves announced that they have been treated for prostate cancer and who are currently doing very well and lead active artistic lives.