Epidemiology and morphology
Prostate cancer develops from the epithelium of the alveolar acinar elements and is coded in the ICD as C61. It is one of the most common oncological diseases in men worldwide: over 400,000 cases are detected annually, and this figure is constantly growing. In a number of countries, the disease ranks second or third after lung cancer and stomach cancer. The increase in detection is not related to an increase in the number of cases, but to the improvement in diagnostic quality, primarily through PSA level screening. Most patients present to an onco-urologist as an incidental finding against the background of elevated PSA.
Histologically, in 90% of cases, this is acinar adenocarcinoma of the prostate. More aggressive and rare variants, such as neuroendocrine carcinoma, are less common, and their treatment tactics differ fundamentally from standard ones.
Risk factors
- Advanced age: more than 75% of cases are diagnosed in men older than 65 years, with men under 65 accounting for only about 7% of cases.
- Hereditary predisposition, including BRCA gene mutation, is uncommon, but allows for targeted treatment.
- Dietary factors: excessive consumption of animal fats impairs the absorption of vitamin A and beta-carotene, which are protective factors against malignant neoplasms, thereby increasing the risk of the disease by about 2-fold.
- Occupational hazards, in particular working with cadmium or in the rubber industry.
- Smoking is not a risk factor for prostate cancer, unlike bladder cancer, but remains a harmful habit with other health risks.
Diagnostics and staging
MRI is the gold standard for diagnosing prostate lesions and allows for clear visualization of the tumor against the background of healthy tissue. Findings are described using the PI-RADS scale from 1 to 5 points; scores of 3 and above require further attention, especially in young patients. In case of contraindications to MRI (metal implants, pacemakers, contrast intolerance), a combination of TRUS (transrectal ultrasound) and CT is used.
Staging is performed using the classic TNM system, as well as the Gleason score. During a prostate biopsy, the two most characteristic biopsy core areas are evaluated on a five-point scale, where 1 point corresponds to the highest degree of differentiation (benign variant) and 5 points to the lowest degree of differentiation. The sum of the two scores constitutes the Gleason index ranging from 2 to 10 points. The higher the score, the worse the prognosis and the higher the likelihood of metastasis. In clinical practice, scores of 6-9 points are more common.
Prostate biopsy is the gold standard for morphological verification of the diagnosis. It is performed under ultrasound guidance via a transrectal approach, routinely retrieving 16 tissue cores from different areas of the gland.
- Normal PSA is below 4 ng/mL at any age.
- Any elevation in PSA, especially in young patients, requires further evaluation.
- About 95% of cancer cases are detected precisely as an incidental finding based on PSA levels.
Special histological findings
Prostatic intraepithelial neoplasia (PIN) is a benign alteration of prostate tissue that is not an oncological pathology and does not require specific treatment, but is subject to strict dynamic monitoring by a urologist.
An ASAP (atypical small acinar proliferation) report means that the morphologist cannot definitively determine whether the process is malignant. In such cases, repeating the biopsy 3-4 months after the resolution of inflammatory changes caused by the initial procedure is indicated. Sometimes, several repeat biopsies are required to establish a definitive diagnosis.
Metastasis and clinical presentation
Prostate cancer is characterized by a pronounced tropism for bone tissue: when a tumor is detected, bone scintigraphy is mandatory to search for bone metastases, which are frequently symptomatic (painful) and require radiation or other therapy. Lymph node and bone metastases rarely occur simultaneously—usually, involvement affects either one or the other target organ, and co-involvement is only possible in widespread disseminated disease.
In early stages, the disease is asymptomatic in the vast majority of cases. With long-standing benign prostatic hyperplasia (prostate adenoma), patients may complain of urinary hesitancy, frequent urination, and a feeling of incomplete bladder emptying. The appearance of blood in the urine, regardless of the severity of the benign process, is a red flag symptom and requires mandatory further evaluation. In advanced disease, general oncological symptoms associated with the systemic effect of the tumor on the body appear.
Treatment approaches
The choice of tactics depends on the extent of the process (localized or metastatic), the patient's age, and the prostate volume.
- Radical prostatectomy is the gold standard for patients under 70 years of age with localized disease; a frequent complication of the surgery is urinary incontinence, which is poorly correctable and can persist for a long time.
- Radiation therapy is preferred in older patients (approximately 70-80 years) and is accompanied by the risk of inflammatory complications (proctitis, cystitis).
- Brachytherapy is interstitial radiation therapy involving the insertion of radioactive seeds directly into the gland tissue; the method has age limitations and requires a gland volume of less than 40 cm3.
- Hormone therapy (GnRH agonists, antiandrogens) is effective until the development of castration-resistant prostate cancer.
- In castration-resistant cancer, chemotherapy (docetaxel, cabazitaxel), bone-modifying agents (zoledronic acid) for bone involvement, and radionuclide therapy (lutetium, strontium) are used.
Key points
- Prostate cancer (C61) is one of the most common oncopathologies in men, represented in 90% of cases by acinar adenocarcinoma.
- Main risk factors: advanced age, heredity, excess dietary animal fats, occupational hazards; smoking is not a risk factor.
- Normal PSA is below 4 ng/mL at any age; MRI with PI-RADS evaluation is the gold standard for diagnosis.
- Biopsy evaluated with the Gleason score (2-10 points) determines prognosis and monitoring or treatment strategy.
- The disease frequently metastasizes to bones, and less commonly to lymph nodes and bones simultaneously.
- Blood in the urine at any degree of prostate hyperplasia is always a pathological sign.
- Radical prostatectomy is indicated for patients under 70 years of age, while radiation therapy and brachytherapy are indicated for elderly patients.
- In castration-resistant cancer, chemotherapy, bone-modifying agents, and radionuclide therapy are used.