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280 Chapter 6: Genitourinary system

Table 6.16 TNM staging more sensitive than transurethral route. The tumour
may be hyper, iso- or hypo-echogenic.
T1 Impalpable 24% N0–N3 Regional
Raised serum PSA: >4 ng/mL is abnormal. Benign
node status
T2 Organ confined 13% M0–M1 Metastases prostatic hypertrophy, inflammation or biopsy of the
T3 Through capsule 52% prostate may also cause a raised PSA.
T4 Locally invasive 11% CT abdomen and pelvis to look for local invasion and
lymph node involvement, and a bone scan to look for
Occasionally, it may present with haematospermia,
bony metastases.
especially in older men, or as metastatic disease with Serum alkaline phosphatase (ALP) is usually raised
an occult primary. when there are bony metastases.

Macroscopy Management
This depends on the tumour staging, grade and also on
The tumours usually are in the peripheral zone of the
the patient’s age and co-morbidity, as many of the treat-
prostate and appear as hard yellow-white gritty tissue
ments have significant side effects.
(see Table 6.16).
Organ-confined, low-grade disease:
These tumours tend to grow slowly, in older patients

Microscopy
(>70 years) and those likely to die of co-morbidity be-
Most are well differentiated and consist of small acini
fore the cancer causes significant symptoms or metas-
in a glandular pattern. Immunohistochemical tech-
tasises, it may be reasonable to ‘watch and wait’.
niques have also been developed, which can help identify
Younger patients should have radical treatment with
whether cells are malignant and if they are of prostatic
the intent to cure: radical prostatectomy and/or radio-
origin (e.g. if found in bone or lymph node biopsies).
therapy to the prostate and local nodes. However, rad-
Gleason score: The biopsy material is examined under
icalsurgery is amajoroperation, witha60% incidence
a microscope and a Gleason grade 1–5 (grade 1 being
of impotence (compared to 16% preoperatively) and
most differentiated, grade 5 the least) is assigned to the
anincreaseinurinaryincontinence.Radiotherapycan
two most commonly occurring patterns of cells. These
also cause complications such as acute and chronic ra-
two grades are then added together to give the Gleason
diation proctitis (diarrhoea, urgency, bleeding), and
score (2–10). A combined Gleason score of 2 + 3 = 5,
impotence in 40–50%.
means that there is predominantly grade 2 and 3 disease
Locally advanced (T3 or T4) disease:
present in the biopsy.
Forlocal symptom control TURP, radical prostate-
2, 3,4–Well differentiated, low grade.

ctomy or radiotherapy (external or brachytherapy)
5, 6,7–Moderately differentiated.

may be used, but recurrence and spread will almost
8, 9, 10 – Poorly differentiated, high grade.

certainly occur, so hormone therapy (see below) is
generally advised with or without surgery.
Complications Metastatic or high grade local disease:
Urinary tract infection and renal tract obstruction may Treatment is for symptoms only (palliative). The aim
occur, which can lead to renal failure. is to deplete the cancer of circulating androgens:
Spread may be local or distant: i Bilateral orchidectomy is often declined by patients
Local spread is usually outward through the capsule. duetopsychologicalreasonsandtherearenowother

Lymphatic spread to pelvic and para-aortic nodes. medical alternatives.

Vascular spread, mainly to bone (classically sclerotic ii LHRH agonists are given parenterally and are

lesions), lung and liver. equally effective as orchidectomy, the second choice
is the use of oral anti-androgens, e.g. cyproterone,
Investigations flutamide, or the two classes may be combined.
TRUS (Transrectal ultrasound) and biopsy: Needle iii Oestrogen therapy is less popular now, due to the

biopsy of the outer prostate by transrectal route is excess risk of cardiovascular deaths.