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Sections Prostate Cancer
- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Localized Prostate Cancer
- Management of Advanced and Metastatic Disease
- Metastatic Hormone-Sensitive Prostate Cancer
- Castrate Resistant Prostate Cancer
- Radiation Therapy in Metastatic Disease
- Surgery in Metastatic Disease
- Adverse effects of androgen suppression
- Palliative Therapy
- Consultations
- Long-Term Monitoring
- Prevention
- Show All
- Guidelines
- Medication
- Medication Summary
- Antineoplastics, GnRH Agonist
- Antineoplastics, Antiandrogen
- Antineoplastics, GnRH Antagonist
- Antineoplastics, Antimicrotubular
- Antineoplastics, Anthracenedione
- Antineoplastics, Hormones
- Chemotherapy Modulating Agents
- Antineoplastics, PARP Inhibitors
- Bisphosphonate Derivatives
- Antifungals, Systemic
- Monoclonal Antibodies, Endocrine
- Corticosteroids
- Radiopharmaceuticals
- Show All
- Questions & Answers
- Media Gallery
- Tables
- References
Diagnostic Considerations
In most cases, the differential diagnoses of advanced prostate cancer do not present any difficulty. However, certain caveats must be considered.
Radiologic findings of bony metastases can mimic Paget disease of the bone. Although bony metastases are blastic in nature, lytic lesions can occur, resulting in pathologic fractures. In men treated with luteinizing hormone-releasing hormone (LHRH), osteoporotic fractures must be distinguished from pathologic fractures.
Neurologic manifestations should be underscored. Sudden onset of weakness of the legs in an elderly man with a history of prostate cancer should raise the suspicion of spinal cord compression, necessitating emergency treatment (spinal cord decompression). Although brain metastases with associated neurologic manifestations are rare, they do occur with enough frequency to deserve recognition.
Lymphomas can manifest as pelvic masses and bone lesions. Although coexistence of lymphomas with prostate cancer has been reported, it is extremely rare.
Transitional cell carcinoma (TCC) and sarcoma of the prostate are more common in men who have undergone prior pelvic radiation therapy for prostate cancer than in men who have not. (The reported incidence of prostatic TCC ranges from 21.8% to 36.7%, depending mainly on the manner of examination. [55, 56, 47, 48, 49, 50, 51, 53] Over 90% of cases are associated with bladder cancer. [57] ) Likewise, squamous cell carcinoma of the prostate may be observed in men treated with hormone therapy. All of these can present as a large pelvic mass with or without metastases.
Differential Diagnoses
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Acute Bacterial Prostatitis and Prostatic Abscess
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Bacterial Prostatitis
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Fosså SD, Wiklund F, Klepp O, Angelsen A, Solberg A, Damber JE, et al. Ten- and 15-yr Prostate Cancer-specific Mortality in Patients with Nonmetastatic Locally Advanced or Aggressive Intermediate Prostate Cancer, Randomized to Lifelong Endocrine Treatment Alone or Combined with Radiotherapy: Final Results of The Scandinavian Prostate Cancer Group-7. Eur Urol. 2016 Oct. 70 (4):684-691. [QxMD MEDLINE Link]. [Full Text].
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Prostate cancer. This diagram depicts the relevant anatomy of the male pelvis and genitourinary tract.
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Prostate cancer. Histologic scoring system showing the 2 most common patterns seen on the biopsy specimen, termed the Gleason score.
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Prostate cancer. The standard approach for grading prostate cancer depends on a Gleason score, which is based on pathologic evaluation of a prostatectomy specimen and is commonly estimated from prostate biopsy tissue. Prostate cancer patterns are assigned a number from 1-5; the score is created by adding the most common pattern and the highest-grade patterns. Courtesy of Wikimedia Commons.
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Prostate cancer. Adenocarcinoma around a small nerve (center). Courtesy of Thomas M. Wheeler, MD.
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Prostate cancer. Small focus of adenocarcinoma on needle biopsy on right side of slide (normal glands on left side). Courtesy of Thomas M. Wheeler, MD.
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Prostate cancer. Immunohistochemical stains showing normal basal cells (brown) in a benign gland with no basal cells in malignant glands (on right side with no brown staining). Malignant glands show increased expression of racemase (red cytoplasmic stain). Courtesy of Thomas M. Wheeler, MD.
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Prostate cancer. Micrograph of high-grade prostatic intraepithelial neoplasia
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Prostate cancer. Diagram illustrates the progression of prostate cancer and associated treatment options.
Tables
| Gleason Grade | Grade Groups |
|---|---|
| 3+3 | 1 |
| 3+4 | 2 |
| 4+3 | 3 |
| 4+4, 3+5, 5+3 | 4 |
| 4+5, 5+4, 5+5 | 5 |
Organization |
Screening Tools |
Ages to Screen |
Repeat Testing Interval |
Indication for Prostate Biopsy |
NCCN (2018) |
PSA and DRE |
45-75 >75 (only in very healthy men) |
PSA* < 1 ng/mL, 2-4 years PSA* 1-3 ng/mL, 1-2 years |
PSA > 3 ng/mL or Suspicious DRE |
AUA (2018) |
PSA |
-Not indicated in men < 40 -Not recommended in men 40-54** -After shared decision making for men 55-69 -Not recommended for men >70 or men with life expectancy < 10-15 yrs |
2 or more years |
Consider if PSA >3, but with additional consideration of factors affecting PSA*** |
EAU (2016) |
PSA |
Risk adapted model after shared decision making for men with a life-expectancy >10-15 years -Men >50 -Men >45 with a family history -African American men >45 -Men with PSA >1 ng/mL at age 40 -Men with PSA >2 ng/mL at age 60 |
Risk adapted: -Every 2 years for men with PSA >1 ng/mL at age 40 or PSA >2 ng/mL at age 60 - Every 8 years for those not at risk |
-PSA should be addressed continuously - Consider the addition of novel risk assays |
ACS (2019) |
PSA +/-DRE |
Risk adapted model after shared decision making -Men >50, life expectancy > 10 years -Men >45 at high risk -Men >40 at very high risk¥ |
PSA* < 2.5 ng/mL, 2 yrs PSA* >2.5 ng/mL, 1 yr |
Not discussed |
*assumes normal DRE **Screening should be individualized for men aged 40-54 and those at higher risk, such as African-American men, men with a family history of metastatic or lethal adenocarcinoma (including prostate, breast, ovarian, and pancreatic cancers), multiple affected first-degree relatives of affected generations, and family members with cancer detected at younger ages. ***A second confirmatory PSA should be obtained prior to biopsy ǂ African-American men or men with a first-degree relative with prostate cancer diagnosed at < 65 years of age ¥ More than one first-degree relative with prostate cancer at an early age |
||||
ISUP Grade |
Gleason Score |
Definition |
1 |
2-6 |
Only individual discrete well-formed glands |
2 |
3+4=7 |
Predominantly well-formed glands with lesser component of poorly formed/fused/cribriform glands |
3 |
4+3=7 |
Predominantly poorly formed/fused/cribriform glands with lesser component of well-formed glands |
4 |
4+4=8 |
Only poorly formed/fused/cribriform glands |
3+5=8 |
Predominantly well-formed glands and lesser component lacking glands (or with necrosis) |
|
5+3=8 |
Predominantly lacking glands (or with necrosis) and lesser component of well-formed glands |
|
5 |
59–10 |
Lacking gland formation (or with necrosis) with or without poorly formed/fused |
Chad R Tracy, MD Assistant Professor, Department of Urology, University of Iowa, Roy J and Lucille A Carver College of Medicine
Chad R Tracy, MD is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society
Disclosure: Nothing to disclose.
Nathan A Brooks, MD Resident Physician, Department of Urology, University of Iowa Hospitals and Clinics
Nathan A Brooks, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.
Mohammed Said, MD Fellow in Minimally Invasive Surgery and Endourology, Department of Urology, University of Iowa, Roy J and Lucille A Carver College of Medicine
Disclosure: Nothing to disclose.
Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association
Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.
Tracey L Krupski, MD, MPH Assistant Professor, Department of Urology, University of Virginia School of Medicine
Tracey L Krupski, MD, MPH is a member of the following medical societies: American Medical Association, American Urological Association, American Society of Clinical Oncology, Society of Women in Urology
Disclosure: Nothing to disclose.
Bagi RP Jana, MD, MBA, MHA, FACP Professor of Cancer Medicine, MD Anderson Cancer Center; Professor of Medicine, University of Texas Medical Branch at Galveston
Bagi RP Jana, MD, MBA, MHA, FACP is a member of the following medical societies: American Cancer Society, American Medical Association, American Society of Clinical Oncology, SWOG
Disclosure: Nothing to disclose.
Gerald W Chodak, MD † Editor, www.ProstateVideos.com; Medscape Urology, Experts and Viewpoints--Controversies in Urology; Director of Medical Content, Answers Media, LLC; Author, Winning the Battle Against Prostate Cancer
Gerald W Chodak, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.
Isamettin Andrew Aral, MD, MSc Attending Physician, Nassau Radiologic Group (Long Island Radiation Therapy); Clinical Assistant Professor of Radiation Oncology, State University of New York Downstate College of Medicine
Isamettin Andrew Aral, MD, MSc, is a member of the following medical societies: American College of Radiology, American Medical Association, and American Society for Therapeutic Radiology and Oncology
Disclosure: Nothing to disclose.
Hassan Aziz, MD Clinical Professor, Department of Radiation Oncology, Downstate Medical Center and Long Island College Hospital, State University of New York at Downstate
Hassan Aziz, MD is a member of the following medical societies: American College of Radiology and American Society for Therapeutic Radiology and Oncology
Disclosure: Nothing to disclose.
Michael Giasullo, MD Clinical Assistant Professor, Department of Urology, State University of New York Downstate Medical Center; Chief, Department of Surgery, Division of Urology, Lutheran Medical Center; Consulting Staff, Bay Ridge Urology Associates; Assistant Attending Physician, Department of Surgery, Urology Section, Methodist Hospital
Michael Giasullo, MD is a member of the following medical societies: American Medical Association and American Urological Association
Disclosure: Nothing to disclose.
Leonard Gabriel Gomella, MD, FACS The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University
Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, Society for Basic Urologic Research, Society of University Urologists, and Society of Urologic Oncology
Disclosure: GSK Consulting fee Consulting; Astra Zeneca Honoraria Speaking and teaching; Watson Pharmaceuticals Consulting fee Consulting
Fazal Hussain, MD, MBBS Director, Clinical Research, King Faisal Cancer Centre
Fazal Hussain, MD, MBBS is a member of the following medical societies: American College of Radiology
Disclosure: Nothing to disclose.
Nicholas Karanikolas, MD Associate Professor, Department of Urology, SUNY Downstate College of Medicine; Director, Urologic Oncology, Staten Island University Hospital; Attending Physician, Department of Urology, Brooklyn Veterans Administration Hospital
Nicholas Karanikolas, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Dan Theodorescu, MD, PhD Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center
Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology
Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership; KromaTiD, Inc Stock Options Board membership
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Sections Prostate Cancer
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