What is Prostate Cancer? What are the Symptoms?
Prostate is an organ below the bladder and in front of the rectum. Prostate is not a title for a specific disease and does not occur later on, but it is the name of a male reproductive system organ which exists when men are born healthy.
Behind it, the seminal vesicles, the glands that produce the most of semen are located. It is in the size of a walnut in young men, but it can grow larger in elder men. Urethra, the tube-like organ which carries urine and semen out of the body is located in the center of the prostate.
Prostate cancer does not have a specific symptom but men over 50 years usually refer physicians with symptoms due to enlargement of prostate. These include:
- Difficulty in urination
- Waiting to urinate
- Weak urine stream
- Intermittent urination
However, symptoms other than urination as:
- Blood in urine or semen
- Trouble in getting an erection
- Pain in hips, chest or spine or other areas where cancer may spread
- Weakness or numbness in the legs or feet, even loss of bladder or bowel control
may be indicative of advanced prostate cancer.
How do we manage men with symptoms of prostatic enlargement?
When evaluating our patients with complaints of urination we perform a digital rectal examination (DRE) routinely and draw blood sample for Prostate Specific Antigen (PSA) testing. DRE is the only way for a urologist by inserting his finger through anus, to palpate and feel the size, consistency and any abnormal findings of prostate. PSA blood test is mainly used to screen men for prostate cancer and can be performed in every lab. There is no need for fasting.
PSA, Digital Rectal Examination and Prostate Cancer Detection
In order to doubt for prostate cancer either a nodule or a rigid-hard area should be palpated on DRE or the patient’s PSA level should be over 2,5 ng/ml (not 4 ng/ml formerly).
Detection rate of prostate cancer is 25% when PSA rise is the only finding; this rises 50% with concurrent abnormal finding on DRE. PSA level is in normal range in 18 % of prostate cancers where the only finding is abnormal DRE. Thus, an experienced urologist is a key factor for detecting prostate cancer.
When an abnormal DRE finding or arise in PSA level or both exist, biopsy of prostate is the sole way of confirming diagnosis. Namely, prostate cancer diagnosis is made by prostate biopsy.
Diagnosis of Prostate Cancer; What is Fusion Biopsy?
When detected in early stages treatment success for prostate cancer is high over 90%. The goal of urologist is to diagnose prostate cancer in early stages, thus before cancer spreads outside prostate.
At present there are 2 ways of detecting prostate cancer in an early stage:
The simple blood test for PSA: This must be interpreted by urologist wit accordance to patient’s age and must not exceed 2 ng/ml before the age of 50.
TA DRE performed by an experienced urologist; when this examination through anus (the only way to palpate prostate) yields a suspicious are (a hard, firm area) it usually indicates a cancerous tissue until otherwise proved. This finding by an experienced urologist carries a high risk for prostate cancer diagnosis.
When DRE and PSA test are indicative of prostate cancer it is mandatory to proceed for diagnostic techniques to prove the existence or absence of cancer.
Prostate Cancer is Diagnosed By Biopsy of Prostate
- Tissue samples obtained by inserting special biopsy needles into the prostate through rectum, are evaluated by pathologic examination and presence of cancer is confirmed or excluded
- This procedure has been performed by ultrasound guidance and obtaining 12-16 prostate tissue samples in a random manner. However, this had been a ‘blind’ approach since the tissue samples were not always representative of the malignant or suspicious areas due to the lack of defining these areas by ultrasound. Therefore, this approach always has the disadvantage of missing cancer, even if it exists, when the biopsy needle does not match the target; the cancerous tissue in the prostate.
What is New Lately? What Has Been Changed?
Incorporation of suspicious areas obtained by Multiparametric MR with Advances in MR imaging technologies and interpretation criteria have been introduced ‘Multiparametric Prostate MR Imaging’ in urology practice
Patients with suspicion of prostate cancer are evaluated by Multiparametric Prostate MR in order to define doubtful areas of high risk for malignancy. As these areas are interpreted and marked, this data is transferred on a CD.
Biopsy of prostate is planned under anesthesia and data obtained by MRI is matched with transrectal ultrasound image of the gland to create a 3- dimensional view of prostate delineating the precise areas to be biopsied.
Thus, biopsy is performed exactly in the areas where MRI denotes high risk for malignancy. This procedure is named as ‘Fusion Biopsy’ denoting transrectal ultrasound images during biopsy. In this manner urologist is able to biopsy the exact suspicious area without missing the cancerous tissue.
MR-Ultrasound Fusion Biopsy ensures obtaining biopsy samples from the accurate tissue determined by MR imaging which is combined and targeted through intelligent biopsy robot and advanced computer software.
Advantages of Fusion Biopsy
- The rate of diagnosing cancer by fusion biopsy is 4 times over the ‘blind’ standard biopsy procedure; the rate of missing highly aggressive tumor on the 1st biopsy is 40 % in the old-fashioned standard biopsy technique.
Standard ‘blind’ biopsy has a rate of diagnosing prostate cancer on the 1st biopsy procedure is 30 to 40 % thus leading 2nd ,3rd biopsies whenever clinical suspicion for prostate cancer persists. On the other hand, fusion biopsy has the advantage of a higher rate of diagnosing cancer on 1st biopsy over the standard technique. Cancers diagnosed by fusion biopsy are often life-threatening aggressive tumors with higher grades (Gleason score 7 or over).
- Patients get rid of repeat biopsy procedures as fusion biopsy possesses a high rate of correct diagnosis on the 1st procedure.
- Samples from areas which are blind to ultrasound can be obtained by MR guidance.
Fusion Biopsy: Outcomes
- By Fusion Biopsy, the ‘worm in the apple’ is precisely defined on Multiparametric MR and images are incorporated through advanced software technologies to create a 3-dimensional view of prostate ‘the apple’ on transrectal ultrasound targeting the correct area, ’the worm’ to be biopsied easily
- 1 kez yapılan biyopsi ile kanser odağını bulmak ihtimali standart yönteme göre füzyon biyopside çok daha yüksektir, yani tekrarlayan biyopsilere gereksinimi azaltmaktadır.
- The rate of cancer diagnosis is higher than the standard biopsy on the 1st procedure eliminating the need for repeat biopsies
- Cancers diagnosed by fusion biopsy are often more aggressive high grade (Gleason score at least 7) tumors which should be treated at once
- We (Urology Istanbul Team) can perform fusion biopsy through perineal access, not by inserting trans-rectal probe through anus, which reduces possibility of infection after the procedure. We employ Artemis fusion biopsy device, approved by FDA, utilizing the advanced software technologies
Causes Increasing PSA Other Than Cancer
- Urinary tract infections, procedures employed through urethra (i.e. Endoscopy, bladder stone fragmentation, catheter insertion), biopsy of prostate and a high-volume prostate may increase PSA values
- Certain drugs may reduce actual plasma levels of PSA; medications for enlargement of prostate, control of hair-loss may reduce PSA levels over a period of use.
Facts to Know When A Cancer Diagnosed After Biopsy
Prostate cancer is defined as Prostatic Adenocarcinoma when diagnosed on biopsy specimen.
As seen in the pathology report down below, the number of cancerous tissues in the total number of samples, the length of the malignant tissue in mm and the percentage of the cancerous samples are predictive of biological behavior, the aggressiveness of cancer.
The most important parameter is the ‘Gleason Sum=Gleason Score’ which is the sum of 2 numbers interpreted by pathologic assessment. The basis for treatment modalities highly depends on this score. As the sum approaches 10, cancer is defined as high grade; the higher the score, the more aggressive the cancer becomes. Usually, grades 7 and over are life-threatening cancers.
For instance, expressions as 3+3=6, 4+3=7, 4+5=9 may be encountered; the first digit also has its own significance; thus, a cancer of 4+3 is more aggressive than a 3+4 cancer although total Gleason grade is 7 in each.
Management of Prostate Cancer
Management of prostate cancer is strictly related to the stage of the disease. When diagnosed, prostate cancer may be in one of 3 stages and treatment is scheduled in accordance with the stage.
- Cancer bounden in the prostate, without extension into surrounding tissues and spread to distant organs; Localized Prostate Cancer: With utilization of PSA and higher public awareness we are encountered with this early stage more often then previously. The ideal therapy for these localized prostate cancer patients is surgery, namely Radical Prostatectomy.
- Extension into surrounding tissues without distant organ metastases; Locally Advanced Disease: In this subgroup of patients with prostate cancer, surgery (Radical Prostatectomy) is offered to relatively younger patients, under 70 years old. However, surgery alone does not suffice, adjuvant Radiotherapy and sometimes Hormonotherapy should be instituted.
- Patients with metastases, spread to distant organs; Metastatic Disease: Prostate cancers usually have metastases to bones and lymphatic tissues adjacent to great vessels in abdomen and pelvis. Primary management of metastatic disease is Hormonotherapy. Either medications or bilateral orchiectomy (surgical removal of both testicular tissue) may be employed for this purpose. Both reveal the same effect.
Defining The Stage of Prostate Cancer
We used to evaluate patients with whole body bone scans, MRI to find out extension of prostate cancer; nowadays Positron Emission Tomography (Ga-68 PSMA PET) is sufficient in delineating the stage of prostate cancer. This is a specific PET imaging modality for prostate cancer and yields invaluable information on the extent of disease.
Radical Prostatectomy: Before and After
This surgery is the best and standard surgical therapy for early diagnosed prostate cancer worldwide. It is a special surgery requiring an experienced surgical team. Prostate gland is removed totally together with seminal vesicles and lymphatic tissue adjacent to the major vessels in the pelvis when necessary. The portion of the urethra in the prostate is also removed during surgery and at the end it is anastomosed (reattached) to the bladder.
In an early diagnosed prostate cancer patient, the aim of this surgery:
- To remove all the malignant tissue as a whole (No tumor at surgical margins)
- To be continent after the operation (Maintain urine storage without leakage)
- To maintain potency (The capability of sustaining penile erections)
In the figure down below, you can see the scales ensuring the balance; i.e. while getting rid of malignancy, preservation of urine continency and maintenance of penile erections should be ensured. We can offer all these as an experienced surgical team.
Patients who are candidates for radical prostatectomy are admitted to the hospital either the day before surgery or early at the day of surgery and are assessment by anesthesiologist and cardiologist if needed.
Following preoperative evaluations surgery is performed under general anesthesia. Surgery is performed through a 6 to 8 cm midline incision below umbilicus without compromising muscles which reduces postoperative pain, thus reducing the need for analgesics.
If postoperative intensive care is not required, the patient is brought back to his room and is fed on the same night. Patients are encouraged to be mobilized the day after surgery and discharged on day 3 with an indwelling urethral catheter. The catheter is removed on day 10 after surgery and patients return to normal life.
Urine Leakage After Surgery
The most fearful and annoying distress for patients undergoing radical prostatectomy is urine leakage after surgery. However, at this point we have experienced through years, urinary incontinence is out of question!
Penile Erection After Surgery
Under normal circumstances, patients could not maintain penile erection as vessels and nerves to the erectile tissue of penis are partially or totally removed after this operation. However, penile erection can be maintained if nerves and vessels are protected during surgery. The fine point is to remove the whole diseased prostate without residual tumor at the surgical margins and protecting the nerves and vessels to the penile cavernous tissue attached to the prostate as a bundle. This fine surgical technique is only achieved with high experience in this surgical procedure.
According to USA data, penile erection is maintained in 80% of patients when nerve sparing surgery is utilized by competent and experienced surgeons performing radical prostatectomy. Out of hundreds of radical prostatectomies performed by our team, our data indicates a 68 % of erectile capability with ‘Penile Rehabilitation’ after nerve-sparing radical prostatectomy.
What Is Penile Rehabilitation?
After Nerve Sparing Radical Prostatectomy we enroll our patients in a penile rehabilitation program. As an example, patients who suffer from injuries to extremities lose muscle strength in the affected region are managed through rehabilitation and exercise programs in order to gain their usual muscle tonus, the same principal is deployed for penile rehabilitation.
In Which Patients Penile Nerves Can Not Be Spared?
As stated above, we do not attempt to preserve penile nerves in local advanced prostate cancer; i.e. patients who do not have distant spread of the disease but exhibit probability of local advancement to the adjacent structures. In this group of patients there is a possibility of cancer cells to advance into the tissues where the penile nerves are attached to prostate; therefore, the high risk of leaving cancer behind restrains from preserving the bundles. In these patients, prostate should be widely excised and removed with a safe margin together with removal of regional lymph nodes.
Which Patients Need Removal of Lymph Nodes?
Radical Prostatectomy, removal of entire prostate gland will not be sufficient for patients diagnosed as Locally Advanced Disease or in those having the chance of cancer spread outside the prostate. In addition to radical prostatectomy surgery, extended removal of lymph nodes which are prone to spread of prostatic cancer cells is mandatory in these patients. The acceptable number of lymph nodes removed after lymph node removal is at least 16.
Down below is a pathology report of a local advanced prostate cancer with removal of 37 lymph nodes during lymph node dissection. Removal of lymph nodes yields actual stage of the disease (whether there is involvement other than prostate or not) and provides the possibility of planning the best suitable treatment option securing a longer survival expectancy with better quality of life.
Other Treatment Modalities for Prostate Cancer
We offer Radiotherapy and Hormonotherapy for those patients unsuitable for ‘Radical Prostatectomy’