Department of Surgery IV (Urology), University Hospital of Guangdong Province, China
2012
I. Overview Zhu Shulun, Department of Urology, Guangdong Provincial Hospital of Traditional Chinese Medicine
l What is the prostate and where is it?
The prostate is a small gland in the body, about the size of a walnut, that grows under the bladder, with the urethra passing in the middle of the gland, as shown in Figure 1.
Figure 1
What does the prostate gland do?
The prostate is one of the parts of the male reproductive system that starts to develop from puberty. As we age, other organs and tissues are aging and shrinking, but the prostate is the only one that keeps growing throughout its life.
The prostate gland has two major functions: first, to control the storage and discharge of urine together with the bladder; second, the secreted prostatic fluid itself makes up the components of semen, while being able to discharge semen into the urethra, forming the ejaculate. As shown in Figure 2.
l What affects the enlargement of the prostate?
The enlargement of the prostate is controlled by the male secretion of androgens, which are equivalent to the nutrients that stimulate prostate enlargement.
Androgens are the nutrients that stimulate prostate enlargement. In men, 90G of androgens are produced by the testes, and the rest of the androgens are produced by the adrenal glands.
The androgens are secreted into the bloodstream and transported along the bloodstream to the prostate tissue, where they are converted into the more potent dihydrotestosterone, which stimulates prostate enlargement in the prostate. The prostate gland also grows larger as we age. The enlarged prostate compresses the urethra and blocks the outlet of the bladder, resulting in various symptoms of uncomfortable urination, such as: weakness in urination, unclean urination, frequent urination, long time to urinate, and increased urination at night after falling asleep. Most of the prostate enlargement is benign lesions. Only a few are malignant and become prostate cancer.
l What is prostate cancer?
As with other parts of the body, there is an orderly renewal of cells in the prostate tissue as well. New cells replace apoptotic cells, and under the supervision of cancer-suppressing cells, the tissue maintains continuous stability and does not grow into cancer cells. If this balance is broken, cancer cells will grow out and gradually produce tumors, such as prostate cancer. So a tumor that originates in the prostate is prostate cancer.
How does prostate cancer metastasize?
Prostate cancer metastasizes in four ways.
1. Blood-borne: metastasizing everywhere along the bloodstream.
2. direct invasion: direct invasion of surrounding tissues, such as the prostate envelope, seminal vesicles, etc.
3. lymphatic metastasis: it appears earliest and metastasizes through lymphatic channels with obvious local lymph node enlargement
4. implantation metastasis: tumor cells are shed and dropped somewhere to grow again.
The onset of prostate cancer is relatively insidious, and in China, most prostate cancer patients are usually in the middle and late stages when diagnosed, losing the time to cure. Therefore, once urinary discomfort occurs, it is important to visit the urology clinic as soon as possible for early detection, early diagnosis and early treatment. (Figure 3)
Figure 3
l What is the incidence rate of prostate cancer?
The incidence of prostate cancer is increasing year by year, and in the United States and the United Kingdom, the incidence of prostate cancer ranks first among male
first among tumors (Figure 4). In the United Kingdom, there are 20,000 new prostate cancer cases and about 10,000 deaths from prostate cancer each year. The incidence of this disease in Asia is much lower than in Europe and the United States, but the incidence of this disease in China is also increasing year by year and has become the number one urological tumor in men.
Prostate cancer rarely develops before the age of 50, but mostly occurs between the ages of 60 and 70. Of course, the older the age
The older the age, the higher the incidence will be. Figure 4
What are the predisposing factors for prostate cancer? (to be modified according to guidelines)
Although the exact predisposing factors are not known. However, some factors may trigger or promote the development of prostate cancer.
The following factors may trigger or promote the development of prostate cancer.
1. Family history: 25% of patients have a family history of prostate cancer. 2.
Ethnicity: High incidence in blacks and low incidence in Asians. 3.
3. living environment: high incidence in urban areas, probably related to environmental pollution, etc. 4.
4. diet: high-fat diet, etc. (Figure 5)
What are the clinical symptoms of prostate cancer?
1. Early prostate cancer has no symptoms, so it is difficult to detect early. 2.
2. As the tumor progresses and compresses the urethra that crosses the middle of the prostate, symptoms of uncomfortable urination will occur.
For example, weakness in urination, increased frequency of urination, unclean urination, increased frequency of urination at night, and even failure to urinate. These symptoms are the same as those caused by benign prostatic hyperplasia.
3. Bloody semen, which may be caused by prostate cancer invading the seminal vesicles.
4. Metastasis occurs in middle and late stage prostate cancer, most commonly bone metastasis, with general bone pain, especially spinal pain.
l How is prostate cancer diagnosed?
1. The first symptom is uncomfortable urination, or bone pain.
2. Transrectal prostate examination: Patients with prostate cancer can feel a hard prostate nodule (Figure 6).
(Figure 6). Figure 6
PSA test: Short for prostate-specific antigen. The PSA test is performed by blood sampling.
The PSA level is usually significantly higher in patients with prostate cancer. However, in 30% of patients with prostate cancer, PSA levels are not elevated.
4. Transrectal prostate ultrasound and pathological examination by puncture: The ultrasound probe is inserted into the rectum through the anus, and a hypoechoic nodule in the prostate can be detected.
5. CT, MRI examination: It can understand the size and shape of prostate cancer and its relationship with surrounding tissues.
6. Whole-body bone ECT scan: to clarify the bone metastasis due to prostate cancer (Figure 7).
7. PET-CT examination: It is expensive, but it can be performed if the economic condition allows. It can be more ready to understand the metastatic lesions of the tumor. Figure 7 (whole body bone scan)
l How is the clinical staging of prostate cancer? (Figure 8 – Figure 11)
Figure 8 (Stage T1) Figure 9 (Stage T2)
Figure 10 (stage T3) Figure 11 (stage T4)
Description.
Stage T1: Very early stage, the tumor is very small, and the tumor cannot be palpated by anal finger examination. Transurethral electrodesiccation of the prostate is often performed for benign prostatic hyperplasia, and postoperative pathology suggests the presence of incidental prostate cancer.
Stage T2: Early stage, the tumor is not metastatic, located in the prostate gland and not growing outward.
Stage T3: middle stage, the tumor grows outward and invades the adjacent tissues of the prostate, such as the seminal vesicles.
Stage T4: late stage, tumor metastasizes distantly, lymph nodes, rectum, bone, liver, lung, etc.
l What is the pathological grading of the prostate?
Prostate cancer can be diagnosed by puncturing the prostate gland, taking part of the prostate tissue and sending it to the pathology department for laboratory tests and examining it under the electron microscope to find cancer cells. The Gleason score is also applied to classify the malignancy of prostate cancer according to the following grading: Figure 12
Low risk Medium risk High risk
(Gleason score 2-4) (Gleason score 5-7) (Gleason score 8-10)
(Note: As the Gleason score increases, the risk level of prostate cancer gradually increases and the prognosis gradually becomes worse)
II. Treatment
Treatment principles: early detection, early diagnosis, early treatment; individual treatment according to individual; integrated treatment of Chinese and Western medicine; regular monitoring and follow-up.
The principles of treatment: early detection, early diagnosis and early treatment; individualized treatment; integrated treatment of Chinese and Western medicine; regular monitoring and follow-up.
For patients with very early stage (T1 stage) prostate cancer or those who refuse active treatment in advanced stage, they should be reviewed every 3 months.
PSA, prostate finger examination, transrectal ultrasound or bone ECT should be reviewed every 3 months, along with dialectical treatment with Chinese medicine.
2. Radical surgery for prostate cancer: Radical surgery is preferred for early stage prostate cancer.
The surgery removes the prostate gland and clears the surrounding lymph nodes to completely cure prostate cancer, and the chance of recurrence is low. In the United States, 60% of this surgery is performed robotically, and in China, laparoscopic radical prostate cancer surgery is mainly carried out at present. The laparoscopic radical prostate cancer surgery carried out in our department takes about 3 hours to operate and bleeds about 50 ml. Figure 12
3. Radiation therapy for prostate cancer: This technology is mainly used in China for middle and late stage prostate cancer to delay tumor progression and relieve pain, etc. This technology is carried out in the radiotherapy department of University Hospital.
4. Cryotherapy, high-energy focusing, particle implantation, radiofrequency ablation and other treatments for prostate cancer: the efficacy is uncertain.
Few of them are carried out at home and abroad. 5.
5. Endocrine therapy: It is suitable for patients with mid- to late-stage prostate cancer, and also for new adjuvant chemotherapy before radical surgery.
Endocrine therapy: It is suitable for patients with intermediate to advanced prostate cancer and also for new adjuvant chemotherapy before radical surgery. By reducing the secretion of androgens and blocking the action pathway of androgens, tumor progression is delayed and the disease is controlled. The main pharmacological treatments are the application of anti-androgen drugs (e.g. Comstock, Flutamide) and luteinizing hormone releasing rush analogs (Norelide injection). Surgical removal of the testes to remove androgen production from the testes is also available to slow down the progression of prostate cancer.
6. chemotherapy and biologic targeted therapy: polyene paclitaxel, etc., are used for advanced prostate cancer where endocrine therapy is ineffective; the drugs are expensive and the efficacy is not exact.
7. Nuclear and phosphate: used for advanced prostate cancer bone metastasis with bone pain and for pain relief treatment.
8. CIK treatment: 100ml of blood is retained from the patient, some immune factors are added in vitro, cultured and then returned to the body to enhance the patient’s immunity, improve the body’s resistance and delay the tumor progression.
9. Chinese medicine treatment: It is the characteristic of our hospital. Through comprehensive treatment of Chinese medicine, we can regulate yin and yang, harmonize qi and blood, support and suppress tumor, achieve control of tumor progression, even turn negative PSA, improve surgery tolerance, promote rapid recovery after surgery, prolong survival time, improve quality of life, and reduce economic burden.
10. Dietary modifications: beans, onions, pumpkin seeds, tomatoes, kiwi, grapes, along with light diet, etc.
11. Regular monitoring and follow-up, regular communication with the supervising physician to understand the progress of the disease, as well as regular participation in the patient meetings of our department. (Figure 13)
Figure 13