Prostate cancer

The prostate is a small male gland located at the intersection of the urinary and sperm lines, in front of the rectum.
It is thus a passage zone for the bladder channels that allow the passage of urine and the seminal channels that transport semen during ejaculation. An important channel is the prostatic urethra.
Most of the prostate is made up of glands and is surrounded by a fibro-elastic capsule.
The prostate is composed of 3 zones:
• A central zone that surrounds the ejaculatory ducts.
• An intermediate zone crossed by the prostate urethra. Initially it represents only 5% of the prostate then increases from 40 years of age, responsible for benign prostatic hypertrophy.
• A peripheral area that is the most important area that can be felt with A rectal exam. This is the preferred area for malignant tumours.
There are 3 types of cells in the prostate:
Glandular cells (ejaculate secretors), fibrous cells (constitutional) and muscle cells (control urine and ejaculation jets) in the shape of a small inverted chestnut (base at the top and top at the bottom). It weighs 20 grams.
It consists of 3 lobes: 1 central and 2 lateral, right and left.
It is highly vascularized and depends on so-called androgenic male hormones to function properly.
EPIDEMIOLOGY:
Prostate cancer is the most common cancer in men over 50 years of age. It is the 2nd largest human cancer mortality rate in the world. It is the first of the urogenital cancers.
The highest incidence is in the USA and Canada with African Americans predominating. The lowest incidence is in China, Japan and India. The incidence is intermediate in Europe, with a higher incidence in Sweden than in Spain.
Its incidence increases with age; rare before age 50, it reaches 50% after age 50 and 75% after age 80. Its average age of diagnosis is 70 years.
SYMPTOMS:
• Urinary disorders are often the reason for consultation: frequent urination during the day and especially at night, often patients even describe bladder weakness. Also, problems with urine evacuation are reasons for consultation (weakness of the stream, delayed drops, feeling of incomplete urination).
• Erectile dysfunction or ejaculation are also symptoms.

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THE DIAGNOSIS:
L’interrogatoire et l’examen clinique sont essentiels. L’interrogatoire permet au médecin de noter l’âge ainsi que les antécédents familiaux et personnels.
The clinical examination looks for neurological disorders, a bladder globe, lumbar pain reflecting the impact of urinary disorders on the kidneys, an inguinal hernia developed by the thrust effort, and inflammatory bone pain associated with bone metastases.
The rectal examination is an essential test. It allows you to feel the prostate to notice an increase in size or volume, determine its consistency and the regularity of its contours.
Biological examinations:
Standard tests (blood count, sedimentation rate, ionogram, ureatemia and creatinine) are always required.
The specific dosage is the prostate specific antigen or PSA (pathological so high) with measurement of the ratio of free PSA to total PSA (pathological if it is less than 15-20%).
A cytobacteriological examination of the urine is systematically performed.
Mictional flow measurement:
It objectively measures the maximum and average flow rates during urination. The normal maximum flow rate is between 25 and 35ml/sec.
Transrectal vesico-prostatic ultrasound:
It consists of passing an ultrasound probe by rectal way under local anaesthesia after taking antibiotics 48 hours before and a rectal enema the day before in the evening. The ultrasonic waves are transmitted back to the screen thanks to a gel placed on the probe.
This imaging is used to evaluate the volume of the prostate gland, its echostructure. It also allows to see the higher urinary tract and to evaluate the post-micturition residue. During this ultrasound, biopsies are performed.
Echoguided prostate biopsies confirm the diagnosis and assess its prognosis using the Gleason score (degree of tumour differentiation, i. e. the tendency of the tumour to resemble normal prostate tissue. It is a microscopic evaluation rated from 2 to 10, 10 being the maximum degree of aggressiveness).
At the end of this assessment, prostate cancer can be classified according to the D'amico classification based on 3 prognostic factors:
• The clinical stage with the rectal examination
• Gleason's score
• The PSA rate
There are thus 3 categories: low risk, intermediate risk and high risk.
The international cancer classification is based on the TNM classification:
T = tumour
N = nodes
M = metastases
The extension assessment:
It is reserved only for patients considered most at risk according to D'Amico's classification.
• Prostatic MRI in search of capsular crossing and invasion of seminal vesicles or pelvic lymph nodes.
• The thoraco-abdomino-pelvic CT scanner, which looks for pelvic and lumbo-aortic lymph nodes, visceral metastases, invasion of the bladder and its appendages.
• Bone scanning for Bone metastases.
There are 4 different stages of prostate cancer:

• Localized prostate cancer that is limited to the prostate (no extension beyond the prostate capsule);
• Locally advanced prostate cancer that extends beyond the prostate capsule or to adjacent organs; no lymph nodes are affected; there is no remote metastasis;
• Prostate cancer with pelvic lymph node involvement;
• Metastatic prostate cancer, i. e. metastasis at a distance.

This is an active treatment in which patients with prostate cancer and a life expectancy > 10 years are closely monitored and regularly rebiopsied.
This treatment is for patients with low-risk localized prostate cancer with certain criteria:

• Number of positive biopsies < 3
• Less than 50% tumor on each invaded biopsy.
  RADICAL PROSTACTETOMY:
  This is the reference treatment. Preliminary appointments with the surgeon and the anaesthetist are organised for a clear and precise explanation of the modalities of the operation and anaesthesia.
  This is an operation carried out by retropubic surgery or laparoscopy or assisted robot.
  The surgeon removes the prostate and seminal vesicles. Sometimes, surgery performs lymph node cleaning of the ilio-shutter nodes (it removes the neighbouring nodes that cause cancer lymph to spread and be analyzed under a microscope) and is performed under general anesthesia.
  Prostatectomy is secondarily indicated for localized cancers with a change in the Gleason score or a significant increase in PSA. It is indicated immediately for localized cancers with intermediate risk.
  Pain treatments are prescribed by the anaesthetist in the recovery room. A urinary catheter is placed through the urethra. It ensures a good healing. It is removed at the exit.
  The potential complications are mainly urinary and genital:
  • Urinary incontinence is transient for 6 to 12 weeks.
  • Sexual disorders are important (erectile dysfunction and ejaculation). These complications can be treated with corrective medication such as VIAGRA.
  Hospitalization lasts on average 5 to 7 days. A biological and clinical control are carried out. A control consultation is scheduled for one month with PSA dosage.

EXTERNAL RADIOTHERAPY:

• In the case of low-risk localized prostate cancer, it is proposed as an alternative to total prostatectomy at a second stage after active surveillance.
• In case of localized prostate cancer of intermediate risk, it is also an alternative to surgery.
• In the case of localized or locally advanced high-risk cancer, it is associated with hormone therapy by LHRH agonist.
  The modalities:
  It uses high energy rays at a dose of between 65 and 80 grays directed at the prostate with or without irradiation of the lymph node areas depending on the tumor.
  A dose of 1 Gy corresponds to an energy of 1 joule absorbed in a mass of 1 kg.
  Radiation therapy consists of the emission of rays that destroy the DNA of cancer cells. The rays often affect the cells around the tumor, which explains the side effects. To allow the cells to renew themselves, it is important to split the sessions. This is why it is generally organized 4 to 5 sessions per week.
  After each session at the hospital, a follow-up consultation is organized with the radiotherapist.
  At the end of the sessions, a follow-up at one month then every 3 months with clinical examination and PSA dosage is performed and then every 6 months for 2 years. The effectiveness of radiotherapy is assessed by a progressive decrease in PSA which 18 months to 2 years after the end of treatment should be <1ng/ml or even 0.5ng/ml.
  Side effects:
  • In 40 to 50% of cases, erectile dysfunction is reported.
  • There are very regular Urinary disorders: This is called radiocystitis.
  • There are also digestive disorders (radiococcal rectitis) resulting in bleeding (rectorragies), abdominal cramps and sudden sensations of wanting to have a bowel movement.
  HORMONE THERAPY:
  Prostate cancer is a hormone-sensitive cancer. The cells are stimulated by an androgenic hormone called testosterone.
  Hormone therapy consists in blocking the stimulating action of testosterone. This prevents the development of cancer and metastases.
  The indications:
  Hormone therapy is either associated with radiotherapy or used as an exclusive treatment depending on the type of cancer and the patient.
  It is indicated for:
  • High-risk Localized prostate cancers
  • Locally advanced prostate cancers (pelvic irradiation).
  • Metastatic cancers
  The treatment doses are chosen on a case-by-case basis. High-risk localized or locally advanced cancers. LHRH agonists are used to block the action of testosterone by suppressing pituitary LH secretion (a hormone that stimulates testosterone secretion in the testicles) for 3 years.
  Metastatic cancers:
  Castration is necessary. It can be surgical (testicles are removed) or medicinal by LHRH agonists. They are administered by subcutaneous or intramuscular injection. Depending on the doses and modalities, either every month or every 3 months.
  There are many side effects:
  • Hot flashes
  • Decrease in testicle size
  • Initial push of LH responsible for A significant and more or less sustained increase in testosterone in the blood.
  For the latter reason, steroidal or non-steroidal antiandrogens are systematically used. These are tablets to be taken every day. The side effects of these drugs are numerous: mood disorders, loss of libido, erection, loss of muscle mass, osteoporosis, breast augmentation (gynecomastia), hot flashes controlled by treatment.

About Prostate cancer

Chemotherapy is only used in cases of castrate-resistant cancer. A drug that can be combined with oral corticosteroids is injected every 3 weeks as a one-hour infusion. It is carried out in a one-day hospital stay.
Biological and clinical control examinations are systematically carried out. It is associated with hormone therapy by taking oral medication.
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