Diagnostic and Staging and Classification Systems Worktip ior Prostate Cancer

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Initial tests

Digital rectal examination (DRE)

Prostate-specific antigen (PSA)

Transrectal ultrasound (TRUS) if either DRE

is positive or PSA is elevated


Staging tests

G lea son score on biopsy sped men

Bone scan


Liver function tests

Serum phosphatases (acid/alkaline)

Excretory urogram

Chest x-ray

Additional staging

Skeletal films

tests {depends on

Lymph node evaluation

tumor classification.

Pelvic CT

PSAr and Gleason

1 "In-labeled capromab pendetide scan


Bipedal lyrnpharrgioqrsm

Transrectal MRI

The prognosis for patients with prostate cancer depends on the histologic grade, tumor size, and local extent of the primary tumor. The most important prognostic criterion appears to be the histologic grade because the degree of differentiation ultimately determines the stage of disease. Poorly differentiated tumors are highly associated with both regional lymph node involvement and distant meta-


Table 92-4 Staging and Classification Systems for Prostate Cancer

AUA- Si age ift-pj

AJCC-IHCC* Ofcutf kltlón fTHM)

A -¡ofL'iLh.

" N M tcanrm die aHrtiedi

T, N U (nonpalpable)

A,: Fo«l

Fool d dHwe

A,: Diffuae

S (CCtfílWl 10 píOSTiTít


fl,. Single nmiuV in 1 lob?, le»

T. (C nka'ly irhUJiM'cnl Lumar jHijíableof vliOle by 'raging)

Ihktt (,5-tni

í lumen ax ideníMl nucotogic finding In yn Of 1«! pf (rttk* r«wed

T..1 rumor irKidLfUjl liiilolugk liridiny i" 5%o< moieofl

T.. Tumoj rienlified by needle bojisy (<?jg, because of devaled PiA)

B. ÍJiíluie invotnemenlQl whole

T.: fTumoi corfirwd vnilhin Ihe proiljce')

íjnwter rhsn l,i cm

T . Tumor Inwohtes half of a lobe or lew

T. Tuno« ¿wolves more 1han half j lobe, but no( both lobes

T : Turne* ImíQlve? berth lo^ji?

C featHd toptripwJilJIk; jréjj

T.N.M,,. TJiJ\

(Wti seminal iieíicle Invofwrntmr,

\: ( Tumor esiendi through The prostatic í jpíulpl

leu than 70 g

Tl! Unilancrjl eniijtjfjyjldi esternón

T : Tumor invades lhe seminal vesklefcj

C. : Serenfial wesiilf? Invotíemenr,

T,: Tumof is. f¡k«í of Invacl(?i sdhifífii inmigres «hit (han ti*? jeminjfl ues*!«

(piPiitei tlun 70 9

f,_: TunWf iiwJcJH ¿ity í>í Wjtü.-i rwxk, ííIhjuI splMtKH. Of roilum

T : r^intor invíd« tviw mudei and/o ü í¡»«J B (he pet^c ITJII

f> irnutd^tdHc die ihü)


D,; Pítvit lyflTipHJyKJWO' uífltrjl

ÍJ ■ .WtWUÍ ij i* ¿ fif^í lyíi^jh íKJOí. } ("i Of KSi IrLgifiHCiT dlflwrrílc*!

cfcsliuc non

H : Mplsslflsí1. in singsp lyro-ptn norie mcmefhan 1 cm but ntH monclhan í cm in create« dnnmitin;

0,: Bof&dttlWt lymph node,

of mirtíjle lymph node meUsUi«, norerno<e IhjuStm in guiltiest dimenuois

i^qan, cvwf[ írtttií metastases

TJ ■ M^q^i.i^ in lympl^ rod? nKMUiin S cm )n hii'mch-iC [liiin^nsion

Idj Nonnpqmnal tympb node(i)

M,.': BofieiiJ

M^rOthor SilOfi)

■ Amwkan Urckge Association.

■ Amwkan Urckge Association.

^mHitan Joint CcmnWee fanra-lntf«naliior>al llnton Against Cancer.

Tumor found in one or both tabes by necdk? Liopvy, but net palpable of visible by Imping, k clasiilied jt 1 . 1n;a<;-.vi Into (he prostalfc ape*-or ln(o(bu1 not beyondHhe proslatic c-ify-ulr ri not cEats<fedas T but asT..

During 1996 to 2003, 5-year overall survival rates were estimated at 99% for whites and 95% for African Americans.1 For this same period, the survival rates for localized or regional disease (100%) and distant disease (31%) in white males were about the same as the survival rates for localized or regional disease (100%) and distant disease (26%) in African American males.1 A 4.1% decline in age-adjusted mortality has been documented for the period 1994 to 2004. 10-year cancer-specific survival is estimated as 95% for stage A1, 80% for stages A2 to B2, 60% for stage C,

40% for stage D1, and 10% for stage D2. It is estimated that more than 85% of patients with stage A1 can be cured, whereas fewer than 1% of patients with stage D2 will be cured.


Desired Outcome

The desired outcome in early stage prostate cancer is to minimize morbidity and mortality due to prostate cancer. The most appropriate therapy of early stage prostate cancer is a matter of debate. Early stage disease may be treated with surgery, radiation, or watchful waiting. While surgery and radiation are curative, they are associated with significant morbidity and mortality. Since the overall goal is to minimize morbidity and mortality associated with the disease, watchful waiting is appropriate in selected individuals. Advanced prostate cancer (stage D) is not currently curable, and treatment should focus on providing symptom relief and maintaining quality of life.34

General Approach to Treatment

The initial treatment for prostate cancer depends primarily on the disease stage,

Gleason score, presence of symptoms, and life expectancy of the patient. Prostate cancer is usually initially diagnosed by PSA and DRE and confirmed by a biopsy, where the Gleason score is assigned. Asymptomatic patients with a low risk of recurrence, those with a Ti or T2a, with a Gleason score of 2 through 6, and a PSA of less than 10 ng/mL (10 mcg/L) may be managed by expectant management, radiation, or radical prostatectomy (Table 92-5). As patients with asymptomatic early stage disease generally have an excellent 10-year survival, immediate morbidities of treatment must be balanced with the lower likelihood of dying from prostate cancer. In general, more aggressive treatments of early stage prostate cancer are reserved for younger men, although patient preference is a major consideration in all treatment decisions. In a patient with a normal life expectancy of less than 10 years, expectant management or radiation therapy may be offered. In those with a normal life expectancy of equal to or greater than 10 years, either expectant management, radiation (external beam or brachytherapy), or radical prostatectomy with a pelvic lymph node dissection may be offered. Radical prostatectomy and radiation therapy generally are considered therapeutically equivalent for localized prostate cancer, although neither has been proven to be better than observation alone. 4,35 Complications from radical prostatectomy include blood loss, stricture formation, incontinence, lymphocele, fistula formation, anesthetic risk, and impotence. Nerve-sparing radical prostatectomy can be performed in many patients; 50% to 80% regain sexual potency within the first year.

Acute complications from radiation therapy include cystitis, proctitis, hematuria, ur-

inary retention, penoscrotal edema, and impotence (30% incidence). Chronic com plications include proctitis, diarrhea, cystitis, enteritis, impotence, urethral stricture, and incontinence.2 Since radiation and prostatectomy have significant and immediate mortality when compared with expectant management alone, many patients may elect to postpone therapy until symptoms develop.

Table 92-5 Management of Prostate Cancer With Low and Intermediate Recurrence Risk

E>pftlfJ Survival (ygar-tt Initial Therapy

Tf-T ,ind üImílcti 2-6 ¿nd PÍA l«i [hvín to ny/iiii (lo nxtyi) jmJ ifw than 5»1umof In specimen ln«Hm*dla»

liian 10 GaWtd Hurt O lt> 10

Ltst than 10

Gieate* Uian or «iual 1o 10

CxpeK.tiiiï1 management ex udulton Nn.>ij|iy

1.45« (am rrunigtiïitfiKH lidicol [WSLdWttomy wilht" withoul pelvuc lymph nocJedksfitlonor ration iherafy txpeiUM marugumcrU or udfcjl (*fBljfletlijmy wiliot witliout pdvit lymptL nodi di«« ciflíi a rjjLjiioniheui(5y wiiJiornihout çj .îrtiïiv^ncicptiv.iium

Radkal poitafeciomy wrth or withoul pclvK lymph nette fjisieeiiûiny "iJiatioti Uic<af7vküIior withtniM jrnJiO.)«! Oeprlv^ition ihropy

Individuals with T2b and T2c disease or a Gleason score of 7 or a PSA ranging from

10 to 20 ng/mL (10-20 mcg/L) are considered at intermediate risk for prostate cancer recurrence. Individuals with less than a 10-year expected survival may be offered expectant management, radiation therapy, or radical prostatectomy with or without a pelvic lymph node dissection, and those with a greater than or equal to 10-year life expectancy may be offered either radical prostatectomy with or without a pelvic lymph node dissection or radiation therapy (see Table 92-5).

The treatment of patients at high risk of recurrence (stages T3, a Gleason score ranging from 8 to 10, or a PSA value greater than 20 ng/mL [20 mcg/L]) should be treated with androgen ablation for 2 to 3 years combined with radiation therapy (Table 92-6). Selected individuals with a low tumor volume may receive a radical prostatectomy with or without a pelvic lymph node dissection.

Table 92-6 Management of Prostate Cancer With High and Very High Recurrence Risk

Recurrence Risk

Initial Therapy


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