Page 283 - Medicine and Surgery

P1: KPE
BLUK007-06 BLUK007-Kendall May 25, 2005 18:6 Char Count= 0

Chapter 6: Genitourinary oncology 279

(TURBT). Follow-up 3 months later has a 50% re- Prostate cancer
currence rate and regular follow-up is needed, usu-
Definition
ally for 5–10 years. Those at higher risk of recurrence,
Adenocarcinoma of the prostate.
e.g. rapid recurrences, multiple, large and in partic-
ular flat lesions, and stage Tis or T1, require further
Prevalence
treatmentwithadjuvantintravesicaltherapy.Bacillus
Second most common malignancy in men. Causes 11%
Calmette-Guerin (BCG), i.e. the live attenuated form
of cancer deaths (>8000 pa).
of Mycobacterium bovis, instilled into the bladder at
intervals is very effective, although other agents are
also used. Age
ii Localised,muscle-invasivedisease(T2,butalsohigh- >50 years (40% > 70 years, 60% > 80 years)
grade T1) is optimally treated by a radical cystec-
tomy–malesaretreatedbycystectomywithproximal Sex
urethral and prostate removal, females require cys- Male
tectomy with the whole urethra removed and an ileal
conduit with urinary diversion (ureters to ileum). In Geography
males it is possible to use a piece of ileum to form Varies by population (90x). Most common in Afro
abladder substitute ‘substitution urethroplasty’ be- Caribbeans, common in Europe, rare in Orientals.
cause the sphincter is below the prostate. However
this is a major operation and patients may be medi- Aetiology
cally unfit. Predisposing factors include age, ethnicity, family his-
iii Locally advanced disease (T3 and T4) is life threaten- tory,genetic factors and diet, with a diet high in ani-
ing and requires radical cystectomy in combination mal fat, low in vegetables showing an increased risk, but
with radiotherapy or chemotherapy. omega fatty acids (found in oily fish), selenium and vi-
Radical radiotherapy may be used where surgery is
tamin E appear to be protective.
contraindicated, or post-surgery. Morbidity results
from radiation cystitis and proctitis leading to a small Pathophysiology
fibrosed rectum. In females radiation vaginitis and/or The cancer is commonly androgen-dependent, but
anasensatevagina,andinmalesimpotenceoccursdue there is no evidence that its growth is driven by a
to nerve damage. hormone imbalance in an individual. However, popu-
Chemotherapy is increasingly used with surgery, or lation studies have shown that men with higher testos-

may be used alone as a palliative measure. Neoad- terone levels appear to be at greater risk of prostate
juvant chemotherapy (i.e. chemotherapy before cancer.
surgery) may be advised in those thought to be non-
resectable (as they may render the tumour resectable), Clinical features
or more conventional post-surgery chemotherapy Bladder outflow obstruction occurs late, when tu-
or radiotherapy. Most regimens are cisplatin based. mour has extended to the transurethral area. The
tumour may cause irritative as well as obstructive
symptoms, i.e. urinary urgency, frequency, nocturia,
Prognosis hesitancy and slow flow.
Depends on stage and grade at presentation and the age In most cases it is diagnosed either on rectal exam-
of the patient. Recurrence is common and may be of ination as the finding of an asymmetric prostate, a
a higher grade (25%). Some patients appear to have a nodule or a hard, irregular craggy mass, often alter-
few,minorrecurrences,whereasothershavewidespread, ing the median groove. Increasingly, prostate cancer is
invasive recurrences. T1 has an 80% 5-year survival and diagnosed because of the finding of a raised prostate
T4 has 10% 5-year survival (but very age dependent). specific antigen (PSA).