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Chapter 32: Prostate Cancer

Avni Shah; Wenhui Zhu; William L. Dahut

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INTRODUCTION

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Epidemiology

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Epidemiology
Incidence: 233,000 (Estimated new cases for 2014 in the United States) 152 per 100,000 males per year Stage at Presentation
Deaths: Estimated 29,480 in 2014 Stage I: 50%
Median age: 66 years Stage II: 20%
Stage III: 17%
Stage IV: 13%

Siegel R et al. CA Cancer J Clin 2014;64:9–29

Surveillance, Epidemiology and End Results (SEER) Program, available from http://seer.cancer.gov (accessed in 2013)

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Pathology

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Pathology
Adenocarcinoma (acinar): >95% Gleason Score at Presentation
Ductal adenocarcinoma✫: <1% (Radical prostatectomy specimens)
Mucinous✫: <1% 2–4:  6%
Small cell✫: <1% 5–6:  54%
Transitional cell✫: <1% 7: 30%
Small cell✫: <1% 8–9: 10%

✫Poor prognosis

Kantoff PW et al. Prostate Cancer: Principles & Practice. Philadelphia: Lippincott

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Work-up

Bone scan if:

 T1 and PSA >20

 T2 and PSA >10

 Gleason > or >8

 T3/T4 disease

 Symptomatic

Pelvic CT/MRI if:

 T3/T4

 T1/2 and normogram indicates probability of LN invasion >10%

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Staging

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Staging

Primary Tumor (T)
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Clinically inapparent tumor neither palpable nor visible by imaging
T1a Tumor incidental histologic finding in 5% or less of tissue resected
T1b Tumor incidental histologic finding in more than 5% of tissue resected
T1c Tumor identified by needle biopsy (eg, because of elevated PSA)
T2 Tumor confined within prostate✫
pT2 Organ confined
T2a Tumor involves one-half of 1 lobe or less
pT2a Unilateral, one-half of 1 side or less
T2b Tumor involves more than one-half of 1 lobe but not both lobes
pT2b Unilateral, involving more than one-half of side but not both sides
T2c Tumor involves both lobes
pT2c Bilateral disease
T3 Tumor extends through the prostate capsule†
pT3 Extraprostatic extension
T3a Extracapsular extension (unilateral or bilateral)
pT3a Extraprostatic extension or microscopic invasion of bladder neck‡
T3b Tumor invades seminal vesicle(s)
pT3b Seminal vesicle invasion
T4 Tumor is fixed or invades adjacent structures other than seminal vesicles: such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall
pT4 Invasion of rectum, levator muscles, and/or pelvic wall

Note: There is no pathologic T1 classification

✫Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, is classified as T1c

†Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is classified not as T3 but as T2

‡Positive surgical margin should be indicated by an R1 descriptor (residual microscopic disease)
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Staging

Staging Groups
Group T N M PSA Gleason
I T1a–c N0 M0 PSA <10 Gleason ≤6
T2a N0 M0 PSA <10 Gleason ≤6
T1–2a N0 M0 PSA X Gleason X
IIA T1a–c N0 M0 PSA <20 Gleason ...

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