Prostatacancer - Amboss

Question 1

Hvordan er insidensen av prostatacancer (PCa)?

Answer 1

The lifetime risk of prostate cancer for men living in the US is one in nine. Mortality: in 2020, second leading cause of cancer deaths in men in the US (after lung cancer).

Question 2

Hvilke risikofaktorer er identifisert når det gjelder PCa?

Answer 2

The average age of onset is 66 years. Autopsy studies have shown latent prostate cancer in 36% of Caucasians and 51% of African-Americans aged 70–79. 30% of African-American men aged between 30 and 39 had undiagnosed prostate cancer. Risk of being diagnosed with prostate cancer doubles if one first-degree relative is affected. In African-American men, the age of onset is earlier and the clinical course is more aggressive. BRCA2 mutations increase the risk for aggressive prostate cancer that already occurs at a young age.

Question 3

Hva er det typiske symptombildet ved PCa?

Answer 3

Prostate cancer is generally slow-growing and located in the periphery of the prostate remote from the urethra. Changes in micturition are uncommon. In individuals with coexisting benign prostatic hyperplasia, urinary frequency, urgency, nocturia, and hesitancy are commonly seen. E.g., in patients that require a transurethral resection due to BPH.

Question 4

Hvis symptomatisk, hva er symptomer ved PCa?

Answer 4

Caused by advanced prostate enlargement. Blood at the end of the urine stream (terminal hematuria) indicates damage to the vessels of the bladder or prostate by the tumor. If the urinary sphincter is infiltrated by the tumor. Caused by tumor infiltration of the bladder ostium.

Question 5

Hvordan kan avansert PCa presentere seg klinisk?

Answer 5

Sudden onset of severe neurological deficits (e.g., weakness of the legs) requires urgent spinal cord decompression surgery.

Question 6

Hva er DRE, og når bør man mistenke kreft pga. abnormal us.?

Answer 6

The 2018 American Urological Association (AUA) guidelines state that there is no evidence to support DRE as a primary screening modality but that it can be used to evaluate for adjunctive evidence of prostate cancer in individuals with elevated serum PSA levels. I.e., a smooth, symmetric, nontender bilobed gland with a palpable sulcus between the lobes. Approx. 75% of all prostate cancers occur in the peripheral zone (posterior lobe). Tumors that arise in the anterior lobes may be missed on DRE. In contrast to patients with a prostate infection, abnormal findings on DRE in patients with prostate cancer are not typically associated with pain.

Question 7

Fyll inn

Answer 7

Urinary bladder (male); Left: ventral view of the bladder, urethra, prostate, and penis (coronal section). Right: dorsal view of the bladder, seminal vesicles, terminal ureters, and prostate The coronal section of the seminal vesicle and vas deferens is depicted on the right.

Question 8

Hvordan bør man gå frem med diagnostikken ved mistanke om PCa?

Answer 8

E.g., in patients with moderately elevated PSA, or normal PSA levels in a patient with abnormal DRE findings.

Question 9

Hva er PSA?

Answer 9

PSA is a serine protease produced only in the prostate gland and, therefore, is an organ-specific marker. It is not cancer-specific however, as levels may also be elevated in benign conditions.

Question 10

Når er det indikasjon for å ta en PSA?

Answer 10

Question 11

Hvordan skal man tolke PSA-verdiene?

Answer 11

A PSA level ≤ 4 ng/mL does not exclude prostate cancer!

5-alpha reductase inhibitors (5-ARIs) can suppress PSA production, resulting in spuriously low PSA levels. This should be taken into consideration in patients on long-term 5-ARIs (e.g., for BPH).

I.e. free and bound PSA. While a threshold of > 4 ng/mL is commonly used, there is no standard cut-off for the detection of cancer. Some physicians prefer to use a threshold of 2.5 ng/mL, as 15% of patients with PSA < 4 ng/mL have prostate cancer found on biopsy. Free PSA is not complexed with alpha-1 antichymotrypsin.

Question 12

Hvilke andre årsaker kan gi en høy PSA-verdi?

Answer 12

Inflammation, manipulation of the prostate, and other malignant and benign prostate diseases may lead to a false-positive PSA result!

The rise in PSA is modest following DRE, however, if possible, obtain the blood sample for PSA testing before performing DRE, particularly if free PSA levels are to be tested.

Question 13

Hvilke funn på urinalyse tyder på PCa?

Answer 13

Question 14

Hvilken bildediagnostikk brukes ved PCa?

Answer 14

Many providers obtain mpMRI prior to biopsy but guidelines vary. The National Comprehensive Cancer Network, European Association of Urology, and National Institute for Health and Care Excellence (NICE) recommend mpMRI for all patients with suspected prostate cancer prior to biopsy; the AUA guideline states that mpMRI should be considered (Norge tar MR). MRI-guided biopsy reduces false-negative findings and decreases the overdiagnosis of insignificant disease. TRUS has low sensitivity and specificity in identifying prostate cancer and, therefore, is predominantly used to localize the prostate before obtaining biopsies. As tumor localization is poor on TRUS, TRUS-guided biopsies have a high (up to 46%) false-negative rate but remain a standard procedure in the initial workup of suspected prostate cancer.

Question 15

Hva viser bildet?

Answer 15

Multiparametric MRI of prostate cancer; MRI prostate gland (multiparametric; T2-weighted, 3 planes; diffusion-weighted imaging (DWI), axial plane; dynamic contrast-enhanced (DCE), axial plane) of a patient with prostate carcinoma: The prostate gland (green overlay) is enlarged and elevates the bladder floor (red overlay). A hypointense lesion (arrow) is seen in the right anterior transitional zone on the axial T2-weighted sequence. It is hyperintense on DWI and hypointense to the corresponding ADC map (bottom). It shows marked contrast enhancement on the DCE images.