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For further information, see CMDT Part 39-17: Prostate Cancer

Key Features

Essentials of Diagnosis

  • Prostatic induration on digital rectal examination (DRE) or elevated level of serum prostate-specific antigen (PSA)

  • Most often asymptomatic

  • Rarely, systemic symptoms (weight loss, bone pain)

General Considerations

  • Most common cancer detected in American men

  • Second leading cause of cancer-related death in men

  • In the United States, in 2018, an estimated 164,690 new cases of prostate cancer were diagnosed, and 29,430 deaths resulted

  • At autopsy, > 40% of men aged > 50 years have adenocarcinoma of the prostate, most often occult

  • Incidence increases with age: autopsy incidence is ∼30% of men aged 60–69 years versus 67% of men aged 80–89 years

  • Risk factors

    • African American race

    • Family history of prostate cancer

    • History of high dietary fat intake

  • A 50-year-old American man has lifetime risks of 40% for latent cancer, of 16% for clinically apparent cancer, and of 2.9% for death from prostate cancer

  • Majority of prostate cancers are adenocarcinomas

Clinical Findings

Symptoms and Signs

  • Discrete nodules or areas of induration within the prostate on DRE

  • Obstructive voiding symptoms

  • Lymph node metastases

  • Lower extremity lymphedema

  • Back pain or pathologic fractures

  • Rarely, signs of urinary retention (palpable bladder) or neurologic symptoms as a result of epidural metastases and spinal cord compression

Diagnosis

Laboratory Tests

  • The serum PSA level is typically low and correlates with the total volume of prostate tissue and tends to increase with age

  • Measurement of serum PSA is useful in

    • Detecting and staging prostate cancer

    • Monitoring response to treatment

    • Identifying recurrence before it becomes clinically evident

  • As a screening test, PSA is elevated (> 4.0 ng/mL [4.0 mcg/L]) in 10–15% of men

  • Approximately 18–30% of men with PSA 4.1–10 ng/mL (4.1–10 mcg/L) and 50–70% of men with PSA > 10 ng/mL (10 mcg/L) will be diagnosed with prostate cancer

  • Patients with PSA < 10 ng/mL usually have localized and therefore potentially curable cancers

  • Interestingly, approximately 20% of patients who undergo radical prostatectomy for localized prostate cancers have normal levels of PSA

Imaging Studies

  • Transrectal ultrasound (TRUS): most prostate cancers are hypoechoic

  • MRI of the prostate

  • CT imaging can be useful in detecting regional lymphatic and intra-abdominal metastases

  • Conventional radionuclide (99-technetium) bone scan is recommended for patients with a PSA level > 20 ng/mL

  • PET (eg, 18F-sodium fluoride [18F-NaF] PET) and hybrid [18F-NaF] PET/CT imaging appear to be more sensitive than conventional bone scans

  • PET imaging using fluciclovine (Axumin) has been approved for suspected cancer recurrence based on elevated PSA after prior treatment

  • Small molecules targeting PSMA (prostate-specific membrane antigen) also show significant promise as next generation imaging agents (eg, 18F-DCFBC (N-[N-[(S)-1,3-dicarboxypropyl]carbamoyl]-4-18F -fluorobenzyl-L-cysteine), a low-molecular-weight radiotracer that targets PSMA)

Diagnostic Procedures

  • TRUS-guided biopsy from the apex, mid portion, ...

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