Introduction.
Prostate cancer has become a serious health hazard for men, accounting for 9% of all cancer deaths in men. The incidence and mortality rate of prostate cancer increases year by year with age. In addition to age, genetics is the biggest factor. Clinical data also show that many external factors may be related to the development of prostate cancer, including race, high animal fat diet and heavy metal exposure environment.
The discovery of the serum prostate-specific antigen PSA has allowed more patients with early stage disease to be diagnosed and receive early and effective treatment. However, this non-selective diagnostic measure in elderly patients with short life expectancy may result in problems such as overdiagnosis and overtreatment. Even prostate cancer of the same stage requires an individualized treatment strategy based on the patient’s wishes.
Staging of prostate cancer
UICC 2002 TNM Staging
Primary tumor (T)
Clinical
Tx:primary tumor cannot be evaluated
T0:no evidence of primary tumor.
T1:clinically occult tumor that cannot be palpated and cannot be detected by imaging.
T1a:5% of the volume of tissue removed for incidental tumor volume.
T1c:tumors detected by puncture biopsy (e.g. due to elevated PSA)
T2:tumors confined to the prostate.
T2a:tumors limited to 1/2 of a single lobe (≤1/2)
T2b:tumor exceeding 1/2 of a single lobe but limited to that single lobe (1/2-1).
T2c:tumor invades both lobes.
T3:tumor breaks through the prostate envelope.
T3a:tumor invades the pericardium (unilaterally or bilaterally).
T3b:tumor invades the seminal vesicles.
T4:tumor fixation or invasion of adjacent tissue structures other than seminal vesicles, such as bladder neck, external urethral sphincter, rectum, anal levator and/or pelvic wall.
Regional lymph nodes (N)
Clinical
Nx: regional lymph nodes cannot be evaluated.
N0: no regional lymph node metastasis.
N1: regional lymph node metastasis (one or more).
Distant metastases (M)
Mx: distant metastases could not be evaluated.
M0: no distant metastases.
M1: with distant metastases.
M1a: with lymph node metastases other than regional lymph nodes.
M1b: bone metastases (single or multiple).
M1c: metastasis to other organ tissues (with or without bone metastasis).
1. single-lobe or two-lobe tumors detected by puncture biopsy but not clinically palpable or detectable by imaging are designated as T1c.
2, those invading the apical part of the prostate or the prostate envelope but not breaking through the envelope were designated as T2, not T3.
3. metastases not exceeding 0.2 cm are designated as pN1mi.
4, When there is more than 1 metastasis, it is the most advanced staging.
Gleason grading system
Gleason scoring system is the most commonly used pathological grading system for prostate cancer. Cancerous tissues are scored according to differentiation, from well differentiated to poorly differentiated, in the order of 1 to 5, described as the sum of the scores of major grading areas and minor grading areas, forming a cancerous tissue grading constant (2-10 points). For example, 3 + 4 = 7, with the former being the major grading area. Gleason scoring can be performed only if the cancer is larger than 5% of the needle specimens or surgical specimens; cytological specimens cannot be scored.
Diagnosis and staging
The examination process should be decided through a combination of the patient’s age, what treatment he/she can receive and other coexisting diseases. Try to avoid tests that are not determinative of treatment. The following are simple guidelines for diagnosis and staging.
Prostate cancer diagnosis and staging guidelines
1. Abnormal DRE test or elevated PSA predicts prostate cancer. There is still no definite conclusion on how to define the PSA value, but we still take 2.5-3ng/mL as the normal standard for relatively young patients; (Grade C recommendation)
2. The diagnosis of prostate cancer relies mainly on histopathological diagnosis to determine it (level B recommendation). Further biopsy and staging studies are recommended only when the results may have an impact on the patient’s treatment approach; (Level C recommendation)
3. Transrectal ultrasound-guided systemic puncture biopsy is the most common diagnostic approach taken in patients suspected of having prostate cancer. At least 6-10 stitches of systemic puncture are performed, and the number of stitches can be increased appropriately in cases of large prostate volume; (Grade B recommendation)
Shifting bands are not recommended at the time of first biopsy due to the low positive puncture rate. (Grade C recommendation)
Repuncture should be performed for exclusion when there is high suspicion, including abnormal DRE, persistently elevated PSA, or tissue with suspicious malignancy in the first puncture result. (Level B recommendation)
The need for three or more puncture biopsies is determined specifically on an individual patient basis. (Grade C recommendation)
4. Paraprostatic local anesthetic injection helps to reduce the patient’s pain during the operation; (Grade A recommendation)
5. T-stage indicates the local condition of the primary tumor, which is determined mainly by DRE and MRI. The number and location of positive prostate puncture biopsies, pathological grading of the tumor and PSA can assist in staging.
6. N-stage indicates the lymph node situation, only through lymph node dissection can we get an accurate picture of lymph node metastasis. n-stage is important for patients who are ready for radical therapy, staging below T2, PSA for 10 years, and can receive standard treatment for patients with treatment related complications.
(Grade A recommendation)
Radiation therapy
Life expectancy >10 years, acceptable for patients with treatment-related complications Presence of surgery
contraindications. patients with 5 to 10 years of life expectancy and poor tumor differentiation (recommended for combination
treatment) (Grade B recommendation)
Endocrine therapy
Patients requiring symptom relief who are not candidates for drug therapy. (Grade C recommendation)
Anti-androgen therapy is not recommended because of its poor outcome relative to watchful waiting treatment.
(Grade A recommendation)
Combination therapy
NHT + RP: No benefit from this. (Grade A recommendation) NHT + radiotherapy: better
local control but does not prolong life. (Level B recommendation) Endocrine therapy
(2-3 years) + radiotherapy: better for patients with poorly differentiated tumors than
radiotherapy alone. (Grade A recommendation)
T3-T4
Watchful waiting treatment
Asymptomatic patients with well-differentiated or intermediate tumors and a life expectancy of less than 10 years.
(Grade C recommendation)
Radical prostate cancer surgery
Patients with life expectancy >10 years and stage T3a are eligible. (Grade C recommendation)
Radiation therapy
Patients with a life expectancy of 5 to 10 years with stage T3 Dose increase to 70Gy or more can be beneficial.
If ineffective, combined endocrine therapy is recommended. (Grade A recommendation)
Endocrine therapy
PSA >25ng/mL in symptomatic patients with vast T3,T4 stage. Superior to watchful waiting.
(Grade A recommendation)
Combination therapy
Radiotherapy + endocrine therapy is more effective than radiotherapy alone. (Grade A recommendation)
NHT + RP: No benefit from this. (Grade B recommendation)
N+ M0
Watchful waiting treatment
Asymptomatic patients. May be based on patient’s wishes.
May not have an impact on patient survival time. (Grade C recommendation)
Radical prostate cancer surgery
Not usually considered. (Grade C recommendation)
Radiation therapy
Generally not considered. (Grade C recommendation)
Endocrine therapy
Standard treatment. (Grade A recommendation)
Combination therapy
Generally not considered. May be based on patient preference. (Level B recommendation)
M+
Watchful waiting treatment
Generally not considered. Compared to endocrine therapy, may shorten survival time and bring
more complications. (Level B recommendation)
Radical prostate cancer surgery
Generally not considered. (Grade C recommendation)
Radiation therapy
Generally not considered. (Grade C recommendation)
Endocrine therapy
Standard treatment. Symptomatic patients. (Grade A recommendation)
Combination therapy.
Generally not considered. (Grade C recommendation)
Follow up of prostate cancer
Primarily based on measurement of serum PSA, special medical history and DRE. except for special circumstances, routine imaging is not recommended for patients with stable disease.
Guidelines for follow-up of patients after curative treatment
Curative treatment of prostate cancer is defined as radical prostatectomy and radiotherapy, including external or brachytherapy, or a combination of these treatments.
1. Measurement of serum PSA in asymptomatic patients together with DRE adjuvant is the routine follow-up, which needs to be performed at 3, 6 and 12 months after treatment, and then every 6 months until 3 years when it is changed to annual.
2.Patients with radical prostate cancer, if serum PSA is higher than 0.2ng/mL can be considered to have tumor residual or recurrent disease; (Level B recommendation)
3.Patients after radiotherapy, persistent PSA elevation can be considered as reliable evidence of tumor recurrence; (Grade B recommendation)
4, DRE palpation of new nodules or elevation of serum PSA is a sign of tumor recurrence.
5. TRUS or biopsy should be considered to demonstrate local recurrence only if the results may have implications for treatment modality. In most cases, TRUS and biopsy are not required before second-line treatment; (Level B recommendation)
6. Metastases can be detected by pelvic CT/MRI or bone scan. For asymptomatic patients, if serum PSA 5ng/mL to confirm the effect of treatment; (Level B recommendation)
7, Fully inform patients of possible side effects as well as the pros and cons before deciding on chemotherapy; (Grade C recommendation)
8. For HRPCa patients who have developed metastases, polyene paclitaxel 75mg/m2 every 3 weeks is effective in improving survival; (Grade A recommendation)
9. For HRPCa patients with symptomatic bone metastases, polyene paclitaxel or mitoxantrone combined with prednisone or hydrocortisone is recommended. (Grade A recommendation)
Analgesic treatment for patients with HRPCa
1. Bisphosphonates are recommended for patients with bone metastases, and zoledronic acid is effective in patients with bone pain and reduces the occurrence of bone-related events; (Grade A recommendation)
2. Radionuclides, external radiation and appropriate analgesic treatment can be considered in the initial stage of bone pain caused by bone metastases. (Grade B recommendation)