Mistakes in the diagnosis and staging of prostate cancer. prostate cancer diagnosis prostate cancer diagnosis

B.P. Matveev,
B.V. Bukharkin,
V.B. Matveev

Chapter 4 Diagnosis of prostate cancer

A carefully collected history helps to establish some features of the disease. Symptoms of prostate cancer, especially dysuria, develop quickly. Sometimes the general condition gradually worsens, the patient complains of weakness, weight loss. The appearance of the patient changes only with a far advanced tumor process. Emaciation and severe pallor of the skin are rare. On examination, one should pay attention to the condition of the lymph nodes, liver, kidneys, bladder, determine the amount of residual urine. When there is a suspicion of prostate cancer, it is first of all customary to conduct three necessary studies:

I. Finger examination of the prostate.
II. Determination of the level of prostate-specific antigen (PSA).
III. Ultrasound examination (ultrasound) of the prostate, if indicated, simultaneously with a biopsy.

A digital examination of the rectum is the simplest, cheapest and safest method for diagnosing prostate cancer. However, the results of the study are largely determined by the size of the tumor and its localization. Palpation of the gland is carried out in the knee-elbow position of the patient, or when lying on the right side. As a result of palpation, the doctor can identify the following symptoms of a prostate tumor.

1. Asymmetric prostate.

2. Dense or woody consistency of the part of the prostate gland. Density can be determined in the form of individual nodes, or different sizes of infiltrates, up to their transition to the walls of the pelvis.

3. The immobility of the gland due to its fusion with the surrounding tissues.

4. Palpable seminal vesicles.

The data obtained by palpation is not always easy to interpret, since a false positive diagnosis of prostate cancer can be made under the following circumstances:

1. Benign prostatic hyperplasia.

2. Prostate stones.

3. Prostatitis.

4. Phleboliths of the rectal wall.

5. Polyps or cancer of the rectum.

6. Anomalies of seminal vesicles.

The results of palpation are certainly very difficult to differentiate from the listed diseases, but they are good reasons for further examination of the patient. On average, only one third of cases of palpable prostate nodules are later histologically verified prostate cancer.

Determination of the level of prostate-specific antigen (PSA). Since the prostate-specific antigen is of great importance not only for the diagnosis, but also for the treatment and prognosis of prostate cancer, we will dwell on this marker in more detail.

Screening programs traditionally use a threshold of 4 ng/mL for all age groups. The use of the proposed level reduces the number of false-positive determinations in prostatic hyperplasia.

Serum PSA levels may be elevated for the following reasons:
- prostate cancer,
- benign prostatic hyperplasia,
- the presence of inflammation or infection in the prostate,
- ischemia or infarction of the prostate,
- ejaculation on the eve of the study.

The diagnostic value of almost all tumor markers is limited due to false positive values observed in some non-malignant pathologies. There has been a long debate about whether prostate palpation has an effect on serum PSA levels. Some authors (Brawer et al., 1988) believe that there is practically no such effect, others have observed significant changes in the level of the marker after prostate massage, although not in all cases (Stamey et al., 1987). On the other hand, undoubtedly, invasive methods (transurethral biopsy or transurethral resection of the prostate) lead to a significant increase in serum PSA levels. Stamey et al (1987) in a detailed study showed that during prostate massage, the concentration of PSA in the blood serum after 5 minutes increased by 1.5-2 times, and was highest in patients with clinical signs of hypertrophy. In patients in whom massage was combined with cystoscopy, PSA increased by 4 times, and immediately after biopsy of the perineal lymph nodes and transurethral resection - by 50-60 times.

Of the non-malignant pathologies of the prostate, acute or chronic prostatitis can lead to a significant increase in PSA (Dalton et al., 1989). Benign hyperplasia can produce a high false-positive rate, with antigen expression depending on the size of the gland (Eicoreetal., 1987; Hudson et al., 1989). So Stamey et al (1987) showed that the PSA level in the group of patients with prostatic hyperplasia before surgery ranged from 0.3 to 37 ng/ml and exceeded the level of 2.5 ng/ml in 86% of those patients in whom the weight of the resected tissue was from 6 to 36 grams. It is estimated that the concentration of PSA in the serum of patients with prostatic hyperplasia is 0.31-0.2 ng/g of hypertrophied tissue. The frequency of false positive values in prostatic hyperplasia at a threshold level of 4 ng / ml, according to the literature, ranges from 20 to 55%. (Armitage et al., 1988; Lange et al., 1986; Hudson et al., 1989). Other authors argue that high PSA values in benign prostate neoplasms are not so rare.

However, PSA determination is certainly of greatest importance for the diagnosis of prostate cancer. It should be noted that of the three main studies: PSA determination, rectal and ultrasound examination of the prostate gland, the determination of prostate-specific antigen has the least number of false negative results and the highest specificity. Serial PSA screening doubles the proportion of T1-T2 prostate cancer diagnosed, while digital rectal examination detects only 30% of histologically confirmed cancers of the same stage. Up to 90% of prostate cancer detected by PSA is in the advanced stages of the disease. The sensitivity of the method is insufficient to detect latent, focal, highly differentiated prostate cancer. So, Oesterling J. (1993) found that 20-40% of all malignant neoplasms of the prostate gland are accompanied by a normal concentration of PSA in the blood serum. At the same time, this indicator in T3-T4 stages of the disease is positive in almost 100% of cases.

When comparing preoperative PSA levels with results obtained after prostatectomy, many authors note a high sensitivity and a clear correlation with the stage of the disease. So from a number of works (Stamey et al., 1987, 1989), it seems that the concentration of PSA in the serum of untreated patients is proportional to the volume of the tumor in the prostate tissue. Despite some variability in preoperative PSA levels in patients with clinical stages A and B, it has been shown that its levels below 15 ng/ml and above 40 ng/ml are fairly clear signs of the absence or presence of capsule penetration, invasion into the seminal vesicles, and metastases to the pelvis. lymph nodes, although at PSA levels of 15 ng / ml, invasion into the capsule of the gland is sometimes possible.

An increase in PSA levels to large values (about 20 ng / ml and above) is highly specific even with normal indicators of a rectal digital examination of the prostate. Therefore, with high PSA numbers, a biopsy of the prostate gland should be performed. necessarily. A PSA level greater than 50 ng/ml indicates extracapsular invasion in 80% of cases and involvement of regional lymph nodes in 66% of patients (Stanley et al., 1990). Research by Rana et al. (1992) showed that PSA results greater than 100 ng/ml indicated 100% metastasis (regional or distant).

The greatest difficulties arise when interpreting PSA values in the range from 4 ng/ml to 20 ng/ml. Studies have shown that the incidence of prostate cancer in patients with a total PSA concentration of 4 to 15 ng / ml and normal data on digital rectal examination of the prostate reaches from 27 to 37% according to various data.

The main thing for clinicians is the awareness of the possibility of PSA detection of subclinical forms of prostate cancer without signs of extracapsular invasion (stages T1 and T2), when radical prostatectomy is possible. According to Myrtle et al. (1986) serum PSA levels of more than 4 ng / ml were observed in 63% of patients with stage T1 prostate cancer and in 71% of stage T2. At the same time, with extracapsular lesions (stages T3 and T4), an increase in PSA was observed in 88% of cases. In this situation, in order to more accurately interpret elevated values of total PSA, it is highly desirable to study the concentration of free PSA and calculate the ratio "free PSA / total PSA".

In addition to the primary diagnosis of prostate cancer, PSA determination is widely used in the following cases:

1. After a radical prostatectomy, after a few weeks, PSA ceases to be determined. Regular follow-up studies (every 3 months) allow you to timely detect a relapse of the disease in the event of an increase in PSA. If the PSA values are normal and there are no clinical symptoms of the disease, then other studies are excluded.

2. In patients receiving radiation therapy, there is a significant decrease in the level of PSA in the blood serum, which indicates an effective treatment. At the same time, an increase in PSA indicates a low sensitivity of the tumor to the treatment, or a relapse of the disease. It should be noted that the decrease in PSA to normal values correlates with the level of antigen before treatment. Patients with pre-treatment PSA values less than 20 ng/ml had normal post-treatment PSA levels in 82% of cases. At the same time, in patients with higher PSA values before treatment, this percentage was only 30%. Most patients with stable PSA decline remained in remission for the next 3-5 years.

3. It is advisable to determine PSA in patients receiving antiandrogen therapy. An increase in PSA levels indicates the progression of the disease and the need to change the nature of treatment.

In antiandrogen treatment, the serum PSA level is an accurate indicator of the success or failure of therapy. After the start of therapy, the PSA level rapidly decreases in 50% of patients (from 85 to 2.1 ng / ml), while in the absence of a response, the PSA value does not change (Hudson et al., 1989). Disease progression was observed in 50% of cases when the PSA level did not fall below 10 ng/ml. This means that the PSA level does not play a predictive value before the start of therapy, while during the treatment PSA is a good indicator of the effectiveness of therapy and correlates well with both survival and the duration of remission. According to Stainey (1989), an increase in PSA levels 6 months after the start of therapy can serve as an assessment of sensitivity to therapy.

Ultrasound diagnosis of prostate cancer. Ultrasound examination has found a very wide application in the diagnosis of many diseases of the prostate gland, including cancer. Particular interest in the study manifested itself with the introduction of transrectal ultrasound tomography. Modern transrectal ultrasound sensors provide very high image quality and allow you to visualize in detail the structure of the prostate, surrounding organs and tissues, as well as take a targeted biopsy from the altered area of the gland. Normally, an unchanged prostate gland on ultrasound has a triangular shape. The base of the gland faces the rectum, and the apex faces the neck of the bladder. The largest size of the gland in the transverse direction is 40-45 mm, in the anterior-posterior directions it is 20-27 mm, in the longitudinal direction - 35-45 mm. On ultrasound tomograms, the central and peripheral zones of the prostate are distinguished, which usually occupy most of the prostate gland. In ultrasound examination, the peripheral zone has a homogeneous structure and is characterized by reflections of medium intensity. The central zone is located around the prostatic urethra, has a cellular structure, and is lower in echogenicity than the peripheral zone. Examination of the bladder neck reveals a hypoechoic glandless fibromascular stroma that forms the anterior portion of the prostate. According to V.N. Sholokhov (1997), with age, with the development of benign hyperplasia or inflammatory diseases, the central and peripheral zones of the gland may not differentiate. The prostatic urethra looks like a hypoechoic cord extending into the black central zone of the gland.

The prostate is surrounded by periprostatic fat and fascia, which form a hyperechoic boundary layer often described as a glandular capsule. The true capsule of the prostate, if it can be visualized, is defined as a very thin hypoechoic dashed line along the surface of the prostate.

The seminal vesicles are visualized as symmetrical hypoechoic strands located between the prostate and the bladder measuring 2 x 7 cm.

As noted above, cancer most often develops in the peripheral zone of the prostate. Given this feature, it is easier to carry out differential diagnosis with other diseases. Detected structural changes localized within the central zone are more likely to be attributed to the manifestation of a benign process, while the detection of structural changes localized in the peripheral zone more often corresponds to a malignant tumor.

The peripheral zone occupies 75% of the volume of the prostate, and cancer occurs in this part of the gland in 80% of cases. Most of the tumor is located at a depth of 3-4 mm from the boundary layer. The central zone occupies about 20% of the volume of the gland. Only 5% of malignant neoplasms develop in this part of the prostate. Around the prostatic urethra is a thin area of glandular tissue - the so-called transition zone. Normally, it practically does not differentiate from the central zone and occupies only 5% of the prostate volume. In the transitional zone, cancer develops in 20% of cases (Sholokhov V.N., 1997).

The most characteristic signs of prostate cancer, localized in the peripheral zone, is the presence of one or more nodes of irregular shape and reduced echogenicity (Fig. 4).

Rice. 4. Transrectal examination of the prostate gland (longitudinal plane at the border of the peripheral and transitional zones), tumor node (indicated by an arrow) not extending beyond the organ. There are no signs of capsule penetration.
Diagnosis: prostate cancer.

Often, the node is surrounded by a hyperechoic rim, which is explained by the fibrous reaction of the connective tissue of the prostate gland surrounding the tumor focus. As the tumor grows, bumpy contours of the gland appear with signs of penetration of the boundary layer (Fig. 5 and Fig. 6).

Rice. 5. Prostate cancer. Tumor node in the peripheral zone of the left lobe, infiltrates the posterolateral surface of the gland and periprostatic tissue.

Rice. 6. Transrectal examination of the prostate gland (transverse plane). Tumor node in the peripheral zone of the left lobe. There is a deformation of the outer contour of the gland, signs of penetration of its own capsule. (T3) Diagnosis: prostate cancer.

Of particular importance is the identification of infiltration along the anterior-lateral surface of the gland, which is inaccessible to digital examination.

The most difficult to diagnose are tumors that are localized in the central and transitional zones of the gland. Often, developing against the background of benign hyperplasia, cancer practically does not differ in echogenicity from the surrounding tissues, and therefore diagnostic errors often occur, and the diagnosis is established by histological examination of the removed material during surgery.

As the tumor infiltration of the gland stroma increases, its ultrasonic structure changes. The tissue of the gland becomes inhomogeneous, with erratic reflections of low intensity. Ultrasound tomography reveals infiltration of the prostate capsule, seminal vesicles of the bladder, rectal wall, lymph nodes, which, of course, allows you to clarify the stage of the disease.

Unlike cancer, prostatic hyperplasia usually develops in the transition zone towards the inside of the prostate. In this case, the transition zone begins to compress the central and peripheral zones, causing their gradual atrophy. A "surgical capsule" is formed from the central and peripheral zones and fibromuscular layers, along which the "husking" of hyperplastic nodes occurs during surgery. As benign hyperplasia grows, the gland acquires a spherical shape; with the predominant growth of the periurethral glands, the contour of the gland bulges into the lumen of the bladder and the middle lobe is formed, which grows, pushing forward and deforming the posterior wall of the bladder, squeezing the prostatic urethra and bladder neck to a large extent. Since benign prostatic hyperplasia is not characterized by infiltrative growth, the gland capsule is usually clearly visible along the periphery of the cut. Frequent findings in benign hyperplasia are small retention cysts and calcifications, the genesis of which is associated with compression of the gland ducts by hyperplastic tissue; they are located most often according to the so-called. surgical capsule. With ultrasound examination of the prostate, it is sometimes necessary to conduct a differential diagnosis with prostatitis. This is because prostate palpation for prostatitis sometimes gives results very similar to cancer. Ultrasound examination at the stage of edema and infiltration of the gland reveals: an increase in the gland (Fig. 7 and Fig. 8), a change in its shape (usually spherical) and structure. The echogenicity of the gland decreases, the echographic differentiation of the glandular and fibromuscular zones is lost.

Rice. 7. Transrectal examination of the prostate gland (transverse plane). Chronic prostatitis with areas of calcification in the gland.

Rice. eight. Chronic prostatitis; increased blood flow in the gland tissue (power Doppler mode).

With abscessing of prostatitis, against the background of hypoechoic edematous tissue of the gland, anechoic zones appear, corresponding to zones of necrotic changes. Gradually, the abscess wall is formed in the form of a cystic structure with a thick wall and liquid heterogeneous contents. In chronic prostatitis, the echostructure of the gland can be practically unchanged, or diffuse increased echogenicity of the structure is revealed as a result of cellular infiltration and sclerotic changes. Calcifications and small retention cysts are determined.

The described three main diagnostic methods require mandatory morphological confirmation of the disease in the future. For this purpose, a puncture biopsy is performed, which is most reliable when performed under ultrasound control. This is especially true for examining patients with small formations.

Prostate biopsy can be performed through the perineum, transrectal or transurethral access. Open biopsy is rarely used. Transurethral resection of the prostate not only allows you to clarify the diagnosis, but also ensures the restoration of urination.

Transvesical biopsy of the prostate gland is a forced manipulation in patients with suspected prostate cancer, in whom, due to acute urinary retention, exacerbation of chronic pyelonephritis and high azotemia, there is an urgent need for cystostomy.

In the diagnosis of prostate cancer, the frequency of false-negative results of histological analysis of tissue pieces with perineal and transrectal access does not exceed 20%.

Complications of needle biopsy are extremely rare and may be associated with damage to the bladder and urethra. Possible hematuria, hematospermia, perineal and retropubic hematoma. To prevent infectious complications, which make up about 2%, antibiotics are prescribed the day before and after the biopsy.

In some complex cases of differential diagnosis, cytological diagnosis of prostate cancer is successfully used. For cytological examination, an aspirate from the prostate gland is used.

Cystoscopy is an auxiliary diagnostic method. When conducting a cystoscope, deviation of the urethra by tumor nodes may be noted. Cystoscopy reveals an asymmetric deformity of the bladder neck. At the site of prostate tumor germination of the bladder wall, looseness of the mucous membrane, fibrin deposits, ulcers or tumor growths are determined, and it is difficult to decide whether the tumor grows from the prostate gland into the bladder or the bladder tumor into the gland.

Of the methods for diagnosing prostate cancer, X-ray computed tomography and magnetic resonance imaging deserve attention. The information received at the same time corresponds to that at ultrasonic research. The tomograms also show the structure of the prostate gland, tumor nodes, their size, the degree of germination of the capsule, infiltration of the bladder, seminal vesicles, surrounding tissue. These methods, however, were no more accurate than transrectal ultrasound in staging localized local growth of prostate cancer, and moreover, there is evidence that transrectal ultrasound is more reliable in staging the disease.

Excretory urography assesses renal function and upper urinary tract urodynamics. Ureteroectasia and ureterohydronephrosis are the result of compression of the pelvic ureters by a tumor. Such changes are often unilateral. With complete obstruction of the ureter, the kidney turns off, while the shadow of the radiopaque substance on the side of compression is absent.

Determining the stage of the disease. Behind the diagnosis of prostate cancer, the question of establishing the stage of the disease simultaneously arises, which ultimately determines the nature of future treatment. Let us briefly dwell on the possibilities of the applied research methods in establishing the stage of the disease.

Finger examination of the rectum. The accuracy of diagnosing prostate cancer with a digital examination of the rectum is 30-50%. Often there is an underestimation of the stage, since small tumors located in the anterior sections of the gland, as a rule, are not palpated; false-positive results are observed in patients with prostatic hyperplasia and prostatitis. This method, however, detects prostate cancer when PSA levels remain within the normal range and provides useful information about the stage of the disease, although not accurate. A palpable, immobile tumor infiltrate or invasion into the intestine is indicative of an advanced tumor process (T4).

Determination of prostate specific antigen. When assessed, there is a fairly clear correlation between PSA levels and the histological (and to a lesser extent clinical) stage of prostate cancer. In each individual patient, the correlation is not so strong due to the significant overlap of the limits of various age norms. Levels of 10-20 ng/ml are often indicative of a tumor growing beyond the prostate capsule, levels above 40 ng/ml are indicative of metastases.

Although serum PSA levels by themselves are not a reliable indicator of the stage of the disease, they can be used to avoid some research. It has been suggested that patients with newly diagnosed prostate cancer without bone symptoms and with PSA levels below 10 ng/mL do not require bone scintigraphy for staging. In such patients, the probability of bone metastases approaches zero, although many practitioners consider this method of research to be the main one, since it can be used to diagnose “hot spots”, such as osteoarthritis of the spine, which can later create confusion in the assessment of symptoms. According to Walsh et Partin (1994) in preoperative PSA< 4нг/мл и при сроке наблюдения 4 года у 92% больных не наблюдалось биохимического рецидива. При ПСА 4-10 нг/мл рецидива не было у 83% больных. При ПСА 10-20 нг/мл биохимического рецидива не было у 56%. И при ПСА >20ng/ml only 45% did not relapse.

It would seem that these figures convincingly show the importance of PSA for the prognosis of the disease, but nevertheless, other studies must be taken into account. According to Alice (1994) in 21% of patients with PSA< 4нг/мл был обнаружен рак, т.е., ПСА не является надежным критерием для установления стадии заболевания. На настоящий момент можно ориентироваться на следующие показатели ПСА. При ПСА свыше 40 нг/мл вероятность наличия метастазов в лимфатических узлах достигает 50%, поэтому выполнение тазовой лимфаденэктомии становиться необходимым. При ПСА < 10 нг/мл у нелеченных больных и показателе Глисона < 7 тазовая лимфаденэктомия может не выполняться.

Recently, more and more people began to talk about the use of PSA in conjunction with the Gleason index and digital examination of the prostate for the diagnosis of lymphogenous metastases. For example, if a patient is clinically staged T2a and has a Gleason score of 3, a PSA level of 6 ng/mL would not warrant bilateral pelvic node biopsy for staging, as the likelihood of pelvic lymph node metastasis approaches zero. Thus, PSA is a valuable method that is used to assess the stage in cases of newly diagnosed prostate cancer.

Ultrasound examination of the prostate. The possibilities of conventional transabdominal echography are limited: it is possible to determine the size of the gland, the state of the capsule, the symmetry of the gland, the volume of residual urine, however, the identification of subtle changes in the internal structure of the gland and the nature of pathological changes is possible only with the behavior of transrectal ultrasound.

With ultrasound, the main diagnostic parameter is a decrease in echogenicity, but the same is observed in other diseases. Therefore, the probability of error in establishing the diagnosis and, accordingly, the stage of the disease is high, especially with small tumors. Specificity in the diagnosis of prostate cancer averages 20-30%.

The search for metastases in prostate cancer is aimed at examining regional lymph nodes and bones, where metastases are first determined. Diagnosis of lymphogenous metastases in the small pelvis is difficult and there is a high probability of making an error (50-60%) even when using all modern diagnostic methods. Ultrasound, X-ray computed tomography, magnetic resonance imaging - can detect metastases when their size exceeds 2 cm in diameter, however, these diagnostic methods do not allow detecting small and microscopic metastases. It should also be noted that the detected enlarged lymph nodes are far from always affected by metastases and only their hyperplasia is found during histological examination.

The most reliable information is obtained after a pelvic lymphadenectomy, which is performed either during the prostatectomy operation or as an independent intervention.

According to Schubert E. and Wenert E. (1985), by pelvic lymphadenectomy, the authors revealed a high frequency of micrometastases in the pelvic lymph nodes, which are not detected by traditional research methods. At the same time, the histological structure of metastases in the lymph nodes did not always correspond to the structure of the primary tumor. This necessitates a lymphadenectomy with histological examination of the lymph nodes by the method of stepped sections.

In recent years, pelvic lymphadenectomy has been performed endoscopically.

bone scintigraphy, usually performed in the case of newly diagnosed prostate cancer to assess the initial state. However, this method has become less common in routine examination as PSA levels have been shown to be a more reliable diagnostic criterion for bone metastases; besides, the latter method is cheaper. Thus, in 50% of cases of prostate cancer with PSA levels below 20 ng / ml, bone scintigraphy is considered not indicated.

Characteristic changes are determined by radiography of the pelvic bones and lumbar spine, with their local lesions, which are often osteoblastic, less often osteolytic or mixed. Due to the alternation of osteoblastic and osteolytic sites, the pelvic bones have a mottled, marbled appearance.

Despite the use of all modern methods for diagnosing prostate cancer, a large percentage of errors in establishing the stage of the disease are still allowed. As can be seen from Table 15 (data from Zinke, 1994), out of 3170 patients, correct staging was only in 1497 patients (47%), stage pT3 was established after surgery in 1339 patients (42%), metastases to the lymph nodes in 334 patients (11 %), and a tumor along the incision line was detected in 770 (24%) patients. Mostly errors were made in the clinical stages T2b and c. Although there were errors in tumor sizes T1a and b. In a large percentage of cases, clinically there is an underestimation of the stage of the disease. A thorough and complete preoperative examination is necessary. However:

1) accurate staging of prostate cancer before surgery is limited;

2) in 20% of patients with preoperative stage T1a, a histological examination reveals a tumor larger than 1 cm 3 ;

3) in 26% of patients with preoperative staging of T1b, penetration of the capsule was revealed, in 10% - invasion of the seminal vesicles;

4) in 37% of patients with preoperative stage T1c, widespread cancer was found (capsule penetration), or a tumor along the resection margin, or invasion of the seminal vesicles, or the presence of metastases in regional lymph nodes).

Table 15 Clinical staging errors in 3170 patients undergoing radical prostatectomy for clinically localized PCa (stages T2c or less) (Zincke et al., 1994).

Clinical stage	Number of patients (%)	Pathologic stage
Clinical stage	Number of patients (%)	Limited to the prostate	pT3	PN+	Tumor along the resection line
T1a	49 (1.5%)	44 (88%)	4 (8%)	1 (2%)	2 (4%)
T1b	177 (5,6%)	120 (68%)	46 (16%)	11 (6%)	35 (20%)
T2a	897 (28%)	512 (57%)	330 (37%)	55 (6%)	140 (16%)
T2b,c	2047 (65%)	82 (40%)	959 (47%)	267 (13%)	593 (29%)
Total:	3170 (100%)	1497 (47%)	1339 (42%)	334 (11%)	770 (24%)

Let us dwell on the value of the degree of tumor differentiation and the Gleason index. What is their significance for deciding the question of choosing a method of treating a patient. It is clear that the expediency of prostatectomy is determined by:

1) the presence or absence of penetration of the prostate capsule by the tumor;
2) the presence of a tumor along the edge of the incision;
3) by tumor volume;
4) invasion of seminal vesicles;
5) metastases in the lymph nodes.

When reviewing these indicators in patients after prostatectomy, depending on the Gleason indicators, a direct pattern was revealed: the lower the Gleason score, the less likely the large spread of the tumor. Conversely, the greater the Gleason score, the greater the likelihood of tumor spread beyond the capsule, the greater the likelihood of tumor recurrence (Table 16).

Table 16 Correlation between Gleason scores and prostatectomy histological findings.

So, with a Gleason score of 8-10, penetration of the capsule occurs 4 times more often than with a score of 5, a tumor along the incision edge is 3 times, the volume of the tumor is 2 times larger, invasion of the seminal vesicles is 48 times, and metastases in the lymph nodes are 24 times.

Based on the data presented, the following conclusions can be drawn:

1. In patients with Gleason scores of 8-10 and metastases to the lymph nodes, surgery is not advisable. However, if the patient is still operated on with a Gleason score of 8-10, it is necessary to perform an urgent histological examination of all lymph nodes removed during pelvic lymphadenectomy before prostatectomy. If metastases are confirmed, prostatectomy is not performed.

2. If the Gleason score is less than 8, the lymph nodes can be examined routinely.

3. With a Gleason score of 7, the patient should be operated on.

4. When the Gleason score is less than 7, depending on age, the general condition of the patient can be observed.

In order to confirm what has been said, let us cite the data of Walsh (1993) as an example. Of 185 patients in stage T2 who underwent prostatectomy, after 5 years, 13% had tumor recurrence, and their Gleason score was less than 7, while in patients with a Gleason score of 7, tumor progression was noted in 59% of patients.

Diagnosis of prostate cancer in men at the earliest stages of its formation is the primary task of medical workers. The disease most often occurs in men aged 45–65 years and older, when there are already inflammatory processes and hyperplasia in the tissues of the organs. Therefore, it is inappropriate to evaluate only subjective complaints. Mandatory laboratory and instrumental examinations of a man who applied with suspected prostate cancer are required. With timely detection, a cancerous tumor has a very favorable prognosis.

Precancerous conditions and provoking factors

Most middle-aged men have certain deviations in the activity of their "second heart" - the prostate gland. They can live for years with an already formed cancer focus, not even knowing about their illness.

The causes of prostate cancer in men can be the following precancerous conditions:

Atypical hyperplasia of the organ - nodules are formed in the parenchyma of the prostate tissues, the cells in which change their structure, begin to multiply faster under the influence of negative factors from the outside or from the inside. In a situation that predisposes to this, a focus of cancer may well arise.
Hyperplasia with malignancy - increased in volume, for example, due to the chronic course of prostatitis, the prostate gland, under the influence of aggressive factors, suddenly begins to change in its individual sections, cells change structure, become malignant, transforming into cancer.

The following negative factors increase the risk of developing a malignant neoplasm of the prostate in men:

abuse of tobacco, alcohol products;
labor activity in hazardous industries, with constant intoxication with harmful substances;
advanced age of a man;
frequent exacerbation of infectious diseases of the small pelvis of men;
severe prolonged stressful situations;
a significant weakening of the immune structures in a man - a state of immunodeficiency;
negative hereditary predisposition.

Men who have one or more of the above predisposing factors need to pay close attention to their health and be sure to undergo an annual preventive medical examination, with a prostate cancer examination.

Warning Signs

Having reached a certain age and caring about maintaining their health at a high level, men often ask a specialist during a preventive visit how to identify prostate cancer even before obvious symptoms appear.

Warning signs such as various urination disorders help to suspect a malignant process in the prostate area. So, a man is increasingly disturbed by the urge to visit the toilet room, especially in the evening and at night. Whereas a full discharge of urine is not observed - it comes out in meager portions, sometimes even drops.

At the same time, dissatisfaction with urination remains - a feeling of incomplete emptying of the bladder, its overcrowding. The desire to urinate remains with the man, while there is either nothing to go out, or there are obstacles to it.

Less often, the process of going to the toilet is accompanied by discomfort in the pelvis, sacral region. Pain impulses in men are intermittent, intermittent, aching. More often they are perceived by them as manifestations of other pathologies, the same prostatitis, for example. It is impossible to diagnose the focus of cancer only on this basis.

Men seek medical help due to the appearance of blood clots in the urine, a change in its color to a darker shade, “bloody”, the color of “meat slops”. In a severe course of the disease, a man may experience acute urinary retention, without the presence of predisposing conditions. Or kidney failure is formed - the appearance of severe weakness, dry mouth in a man and a constant feeling of thirst, pain in the lumbar region, and a sharp exhaustion of the body. Immediate specialized medical care is required.

However, most often, prostate cancer at stages 1–2 of its appearance in a man does not manifest itself in any way. Cancer in the prostate becomes an extremely unpleasant surprise of a preventive annual examination in the clinic.

Cancer or prostate adenoma

Not wanting to waste his time visiting hospitals and laboratories, or, fearing to hear the formidable diagnosis of cancer, the man delays with a comprehensive examination. By this, he causes significant harm to his health, attributing the appearance of unpleasant sensations to the course of age-related prostatic hyperplasia.

Whereas early diagnosis is the key to success in carrying out therapeutic measures and restoring health in full. Do not confuse male organ cancer with adenoma. A characteristic difference between these two purely male diseases is the appearance of atypical, cancerous cells. But without a special analysis - a biopsy, differentiation is simply impossible.

Prostate adenoma in men is a benign pathology. But under certain conditions - the impact of traumatic factors, it can degenerate into a malignant process. However, there is no clear relationship between these two ailments - cancer and adenoma.

Another hallmark may be tumor growth. Most often, the focus of cancer in the prostate organ in a man grows outward, while with adenoma - not only outward, but also inward. Both lead to problems with the urethra in men. The enlarged prostate compresses the urinary canal. Laboratory and instrumental examinations are required to confirm or refute cancer in men.

The timing of the appearance of alarming symptoms is also important - prostate adenoma in a man can have a sluggish course for several decades, periodically disturbing him. Prostate cancer, after 2-4 years, in the absence of a full-fledged treatment, will affect the state of health - it deteriorates sharply. The disease in a man progresses and gives severe complications.

Early symptoms of prostate cancer

The course of cancer in the tissues of the prostate gland has its own specific order - if at the first stage of the formation of a focus of atypia, as a rule, there are no specific manifestations, then nothing bothers the man.

Much will depend on the form of cancer, the size of the tumor, the initial state of health of the man. It helps to detect cancer by such a laboratory analysis as blood for PSA - a male hormone that enters the bloodstream when the gland fails. In a healthy man, its parameters range from 0.5 to 1 ng / ml. An increase in the value of glycoprotein may indicate both an inflammatory process in the organ and the onset of a cancer focus. A specialist will evaluate all information from laboratory and instrumental examinations.

A careful history taking of a man reveals that he has been troubled by symptoms in the prostate for some time, such as:

problems with the onset of urination - there is an urge, but urine does not separate;
the jet flows out weak, intermittent, even in drops;
there is a feeling that the bladder has remained full;
the presence of urinary incontinence is possible - to one degree or another;
the urge to visit the toilet room prevails at night and in the evening, while during the day the need to empty the bladder in a man remains unchanged;
at the beginning of urine output in the canal itself or in the small pelvis, there is discomfort, even soreness, similar symptoms can be observed even after the end of urine output;
often exacerbation of pathologies of the genitourinary sphere of a man - urethritis, pyelonephritis, prostatitis.

Identification of the listed disorders of the prostate, the symptoms and signs of which were not previously observed in a man - all this requires mandatory clarification, diagnostic measures.

Laboratory and instrumental examinations for prostate cancer

Diagnosis of prostate cancer is based on the main verification method - taking biomaterial for cytological examination. A biopsy allows you to assess the presence of cancer cells in the parenchyma of the organ, their number, structure, high or low differentiation.

All this will contribute to the formulation of an adequate diagnosis of cancer. Other methods recommended by a specialist for implementation are auxiliary:

rectal examination - palpation of the prostate by a doctor through the rectum, a mandatory examination of men after 40 years, which allows you to establish the initial stage of the formation of the disease;
an increase in the concentration of prostate-specific antigen in the bloodstream - if it exceeds more than 10, a prostate biopsy is mandatory;
Ultrasound - visualization of the prostate, clarification of the presence in the prostate parenchyma of nodes, seals, and other abnormalities;
CT, MRI of the structures of the small pelvis of a man - an assessment of the prevalence of the tumor process, the involvement of other tissues and organs, lymph nodes in cancer;
PET-CT is effective for searching for small metastases, for example, those that have entered the prostate gland from another primary cancer site.

Only all the completeness of information, carefully studied by the urologist-oncologist, allows him to conduct an adequate differential diagnosis. This can cause some difficulties, especially if the man already has benign tumors in the prostate gland. However, a highly qualified specialist will not only make a full-fledged cancer diagnosis in a timely manner, but will also select the appropriate treatment. Improve prognosis for prostate cancer earlier seeking medical help.

What can be done on your own

In order to timely identify such a disease, formidable in its complications and consequences, as cancer in the structure of the prostate organ, a man is recommended to take the following preventive measures:

closely monitor your own health - listen to the signals coming from all organs, especially the pelvis and prostate;
timely treat all foci of inflammatory and infectious lesions, including adenoma or prostatic hyperplasia;
follow the recommendations of an andrologist - taking preventive anti-inflammatory drugs, passing laboratory tests;
avoid general or local hypothermia - the prostate is quite susceptible to low temperatures and can often become inflamed because of this;
to perceive sexual contacts not only as pleasure, but also as measures to prevent congestion in the pelvis, and, therefore, cancer.

If a man suddenly began to be disturbed by urination disorders, burning, discomfort, weakening of the jet, it is recommended to immediately repeat the doctor's consultation. Early detection of the focus of cancer is the key to a successful fight against it and recovery.

Early diagnosis of prostate cancer increases the chances of a favorable prognosis for cancer therapy. The development of a malignant tumor has symptoms similar to other pathological changes observed in prostate adenoma. Differentiation of cancer requires a number of diagnostic studies.

Early signs of prostate cancer

It is impossible to determine prostate cancer on your own, without a complete diagnostic examination. There are symptoms, upon detection of which you should immediately consult your doctor. After receiving the results of clinical tests and conducting an instrumental examination, an accurate diagnosis will be made.

Cancer symptoms:

Hematuria, blood in urine.
Pain during urination and intercourse.
Change in the smell of urine - the appearance of the so-called "pharmacy" or "fishy" aroma.
Frequent night trips to the toilet.
Pain in the lower back, radiating to the bladder, scrotum.

If any of the listed signs appear, a differential diagnosis of prostate cancer is carried out, including clinical and instrumental studies. Modern techniques make it possible to determine the initial manifestations of oncology, when there are no characteristic symptoms yet.

Even without the manifestation of the first signs of oncology, screening studies of the male population over 40 years old are carried out. Unlike a general medical examination, this examination is narrowly focused and aims to identify prostate cancer.

It is possible to determine prostate cancer by PSA tests, clinical and biochemical studies of urine and blood, biopsy followed by histology.

The main methods for detecting prostate cancer

Diagnostic methods for oncology include instrumental and clinical studies of tissue samples and internal organs. After the first signs of a tumor disease appear, the patient is registered with a urologist. The general condition of the body of a man is monitored, the presence and nature of tissue growth are determined.

The primary diagnosis of prostate cancer includes:

Express test - a study of the level of prostate-specific antigen is carried out. An increased amount of protein indicates an inflammatory process or the development of oncology.
Finger examination - helps to determine the presence of a tumor, but not its nature.
Biochemical and clinical analyzes of blood and urine. Changes in the level of erythrocytes and leukocytes indicate existing disorders in the work of the prostate gland. helps to differentiate chronic prostatitis from cancer.

If the initial examination revealed a suspicion of prostate cancer, additional instrumental diagnostic studies are prescribed:

Ultrasound or TRUS.
Biopsy.
Ureteroscopy and cystoscopy.
X-ray.
radioisotope scanning.
Tomography.

All men at risk (age after 40 years, the presence of close relatives with prostate cancer) are recommended to additionally pass a genetic analysis for a predisposition to oncology.

Rectal finger diagnostics

The cheapest and easiest test for prostate cancer is a rectal digital examination.

The advantage of the technique is the rapid determination of the presence of a tumor and tissue growth.
The main disadvantage is a large percentage of diagnostic errors and the possibility of exceptionally late detection of cancer.

It is impossible to determine the nature of the formation during rectal examination, as well as to differentiate primary tissue changes.

A rectal examination is performed by a qualified urologist. Through the anus, the doctor inserts the index finger 3-5 cm into the rectum. After that, he probes the prostate gland.

In digital rectal examination, the following changes are characteristic:

Palpable seals with a clear localization.
Knots of dense consistency are determined.
Growth of gland volumes is diagnosed.

The accuracy of the diagnostic examination is conditional. Several factors influence the data of a rectal digital examination:

Qualification of the physician conducting the examination.
Tumor growth, which does not always occur, especially at stages 1-2 of oncology.
Anatomical features of the patient. The sensitivity of the digital rectal examination is affected by the overweight of the patient. It is quite difficult to determine the growth of the gland in a man suffering from obesity.

It is impossible to accurately identify cancer by rectal examination. The results of the study allow us to suspect the presence of a tumor formation and create prerequisites for the appointment of a biopsy of prostate tissue.

Research using ultrasound

Ultrasound, in contrast to rectal digital diagnosis, allows you to differentiate changes in the structure of the gland. Transrectal and transabdominal examinations are performed:

Ultrasound - during the study, the gland is scanned through the abdominal cavity. The informativeness and effectiveness of ultrasound depends on the anatomical features of the patient. Transabdominal examination is prescribed only in the presence of direct contraindications to transrectal diagnostics.
TRUS - an ultrasound transducer is passed through the rectum directly to the prostate gland. TRUS is accurate and recommended during the screening of a patient with suspected prostate cancer. Contraindications: inflammation of the rectum, hemorrhoids in acute form.

The standard of ultrasound examination, which is distinguished by its accuracy, is TRUS. The transabdominal technique is used only with persistent psychological rejection by the patient, as well as in the presence of diseases that make transrectal examination impossible.

Prostate-Specific Antigen Analysis

The most informative laboratory diagnostic method for screening for prostate cancer is an analysis for a tumor marker or PSA. The essence of the technique is as follows:

In a normal state, a prostate-specific antigen is completely absent in the blood of a man.
When the structure of prostate tissue is disturbed, a certain amount of PSA enters the bloodstream.
The higher the antigen level, the stronger and more pronounced damage to the prostate.

Early diagnosis of prostate cancer is carried out with the obligatory appointment of an analysis for a prostate-specific antigen. A blood test for PSA is recommended to be carried out at least once a year after a man has passed the age of 40. After the suspicion of prostate cancer appears, tests are taken every 3 months.

There are several types of biochemical research for the presence of an antigen:

Determination of total and free PSA is considered the simplest and fastest way to differentiate oncology from inflammatory processes of the human genitourinary system. When making a diagnosis, it is taken into account: the upward trend in PSA levels and the difference between the total and free indicators.
Molecular test - called PROGENSA PCA3. It was developed and tested by English oncologists. Analysis of the prostate for cancer cells using a molecular test makes it possible to distinguish the development of oncology from other disorders with a high probability. It is popular due to the fact that it has reduced the number of patients referred for prostate biopsy by 35-40%.

The European randomized (subjects are divided into several groups) prostate cancer screening study confirmed the high efficacy of PROGENSA PCA3. In modern diagnostic methods, a molecular test is done simultaneously with a general analysis for PSA.

40 is the age at which men should be tested for prostate cancer annually.

Tissue collection for histology (biopsy)

After determining the increase in the size of the prostate gland during a digital examination or detecting an increase in the level of PSA, a histology (biopsy) is prescribed to clarify the diagnosis. The patient takes tissue samples from several parts of the prostate.

Histological examination determines the aggressiveness of the tumor and the stage of cancer. The cytological method is less informative and is practically not used in the examination of prostate formations.

Laboratory diagnosis of prostate cancer in men is carried out according to several standards and allows you to determine the nature and degree of education:

TNM is the standard international classification for determining the stage of cancer. Favorable prognosis of therapy when diagnosing 1-2 degrees. At the 3rd stage of oncology development, infiltration and metastasis to neighboring organs is observed. Stage 4 is inoperable. Therapy is reduced to prolonging life and reducing the symptoms of cancer.
The Gleason index - unlike TNM, differentiates the aggressiveness of the tumor process, and not the stage of its development. The assessment is made on the basis of the study of two tissue samples. An increase in scores indicates an increase in the aggressiveness of malignant cells.
PIN - prostatic intraepithelial neoplasia. precancerous condition. Tissue growth is benign, but can mutate into a malignant tumor.
Immunohistochemical study - a tissue section is checked for sensitivity to stimulation with hormones and other medications. Immunohistochemical markers ER and PR, Ki-67 er2neu, VEGF and p53 are used. The analysis is necessary to determine the tactics of treatment.
After the IHC study, the resistance of the tumor to, is revealed. The use of immunohistochemical markers helps to make an accurate prognosis of treatment and to see the feasibility of carrying out.

Prostate biopsy is one of the most informative types of research. The widespread use of the technique is somewhat limited due to the high traumatic nature of the procedure.

Urinalysis for prostate cancer

Indicators of urine tests for prostate cancer serve as an additional factor necessary for making a diagnosis. Research is aimed at deviating from the norm of the following elements:

Leukocytes - it is optimal when, during the study, white blood cells in urine are not detected at all. If a man has elevated leukocytes, this indicates serious disorders in the functioning of the internal organs of the genitourinary system and often indicates cancer.
The level of hemoglobin - there are many reasons for increasing the volume, from playing sports to severe poisoning. A high level of hemoglobin is manifested by staining the urine in a dark and brown-red color.
The tumor marker UBS, a protein fragment, undoubtedly indicates the presence of prostate cancer. In differential diagnosis, indicators are taken into account that are 150 times higher than the norm.

Separately, acidity, urine density, the presence of bilirubin, an infectious marker, are examined. Clinical analyzes are included in the list of studies required for screening diagnostics.

Urethroscopy and cystoscopy

The essence of the method is reduced to a visual examination of the prostate gland using a cystoscope. The device under local anesthesia is injected through the urethral canal.

During ureteroscopy, the mucous membrane of the gland and bladder is examined for growths, cystic and tumor formations. Through the cystoscope determine the volume of the prostate.

If the presence of pathological changes is determined, the necessary studies include tissue sampling for histology. Contraindication to cystoscopy - any inflammatory process of the urethral canal and genitourinary system, during the period of exacerbation.

X-ray use

The diagnosis of prostate cancer is made on the basis of clinical and biochemical studies in combination with the results of an instrumental examination.

To differentiate the causes of the appearance of alarming symptoms (reduced potency, hematuria, urination disorders), radiography, radioisotope scanning and tomography are prescribed. The choice of a specific method depends on the capabilities of the medical center, the required speed of obtaining tests.

X-rays are taken with contrast. The marker is administered intravenously. Prostatography is characterized by low information content and is practically not prescribed due to the dangers of exposure. The pictures show an increase in the gland and the appearance of focal formations.

radioisotope scanning

Radioisotope or radionuclide diagnostics is used to determine bone metastasis. The technique is quite informative in the study of soft tissues.

The essence of the method lies in the features of the prostate-specific membrane antigen synthesized on cancer cells. Under chemical conditions, ligands (radionuclides) were created that specifically combine with PSMA.

After the introduction of radioisotopes into the tissues of the prostate gland, the marker accumulates in malignant cells. Scanning allows you to detect the localization of the tumor and metastases.

Radioisotope examination is carried out in the diagnosis of bone lesions. The technique is not used for anemia, renal failure.

prostate cancer on tomography

Tomography is a reference diagnostic method. Depending on the method of examination, the images can show the initial signs of the development of cancer, changes in the structure of damaged tissues that cannot be differentiated by other methods.

Today, CT, MRI and PET are the standard for diagnosing cancer:

Magnetic resonance imaging is an absolutely safe method. As a result of scanning the human body, a three-dimensional image of the prostate gland and the entire genitourinary system is obtained. MRI diagnostics is especially effective in the early stages of cancer.
The decoding of the analysis gives an idea of the pathological changes in the tissues of the gland and the presence of infiltration in the soft tissues. The recommendations for the early detection of prostate cancer, compiled by European experts, indicate the need for an MRI.
Computed tomography is not prescribed for the primary diagnosis of cancer. CT is effective for monitoring the growth and localization of the tumor in the preoperative period. To increase the information content, scanning is carried out with the addition of contrast.
Positron emission tomography (PET - CT) - scanning is carried out after the introduction of special pharmaceutical preparations: choline, fluorodeoxyglucose, metoin and ammonium. PET examination makes it possible to see structural changes, to determine the presence of disturbances in the functioning of internal organs. Similar results are not available for any other method of instrumental examination.
Morphological diagnostics of microwave radiothermometry differentiates inflammation of the prostate gland from oncological formation with high accuracy.

Tomography is included in the category of mandatory diagnostic studies for prostate cancer. Widespread use is limited by the relatively high cost of analysis.

Differential Diagnosis

After receiving the results of tests confirming or excluding prostate cancer, the urologist conducts a differential diagnosis of cancer. Accurate conclusions require clinical tests of urine and blood, PSA results, images obtained by scanning during a tomography or x-ray.

Making an accurate diagnosis requires the professionalism of a urologist-oncologist. Under his leadership, types of research are assigned. He also gives recommendations on diagnostics and deciphers the results.

As practice shows, in order to detect oncology at an early stage, it is better to contact a specialized medical center that has a good reputation. Only in this case, you can be sure that the medical staff will take into account modern aspects of diagnosis and will be able to detect early signs of cancer. Saving on your health and life is dangerous!

If you are attentive to your health, then you can detect a tumor already at the second stage, but, unfortunately, in most cases, men come to the doctor at the third or fourth stage, when it is extremely difficult to achieve a full recovery.

What should be of concern:

both at night and during the day;
in the pelvic area and / or;
problems with potency, decrease in sperm volume;
urinary incontinence;
intermittent or weak stream of urine (fluid can flow out literally drop by drop);
frequent urge to go to the toilet, or a feeling that the organ is not completely emptied even after the fact of urination;

In the third stage, the symptoms increase, and are also supplemented by the presence and sperm, a noticeable swelling of the male genital organs, in some cases, pain in the spine, hypochondrium, pelvic bones and other neighboring areas.

Early diagnosis of prostate cancer in men

Under the age of 50, the problem is quite rare: only 2-3 representatives of the male half of humanity out of 1000 are faced with a diagnosis of oncology.

Among men over 60, the statistics are completely different: one in a hundred is sick. When approaching the age of eighty, the risk increases tenfold more: cancer affects every eighth man.

There is only one conclusion: those at risk should carefully monitor their own health, as well as periodically take tests.

Early diagnosis includes:

rapid test for the detection of prostate-specific antigen in the blood. The study is abbreviated as: PSA;
and urine;
external palpation examination, which is carried out.

By visiting the doctor once a year after the age of forty, you. If during the initial diagnosis, the doctor has certain suspicions, extended studies will be prescribed.

Surveillance tactics

Active surveillance is an officially recognized treatment for prostate cancer in men with a low or intermediate risk that the disease will progress.

Screening indications:

age from 40 to 50, if at least one of the man's relatives is diagnosed with prostate cancer;
age from 50 to 70 years - for all other categories.

After the age of seventy, as well as in men suffering from severe chronic diseases, screening is not carried out, since it can significantly worsen the patient's condition.

prostate ultrasound

An ultrasound examination of the prostate can be performed in several ways: transrectal (through the rectum), transurethral (the probe is inserted into the urethra), and also (through the perineum or abdominal wall).

The doctor evaluates the shape and volume of the gland, its structure, as well as other important indicators.

The external method of examination is significantly inferior to the transrectal one. The efficiency of the latter reaches approximately 80%. The transurethral technique is quite complicated, it requires the use of anesthesia and the high qualification of the doctor conducting the examination.

Urethroscopy and cystoscopy

During ureteroscopy, the ureter is examined using a special instrument - a ureteroscope. It is injected directly into the body. The method is used, as a rule, to study the urethra, as well as the renal pelvis.

Cystoscopy is an examination of the bladder using a special instrument, a cystoscope, inserted into the bladder through the urination canal.

Both methods in the diagnosis of prostate cancer are used only indirectly, for example, if a man has complaints, and no signs of cancer are detected during an in-depth study.

Blood prostate specific antigen (PSA) test

This antigen is a protein that is produced exclusively in the prostate gland. The release into the blood in large quantities is an alarming signal.

Usually, the analysis is taken once a year, if there is a suspicion of cancer, then once every three months.

Relatively recently, a molecular PSA test has appeared, which is the most modern way to verify prostate cancer. Thanks to this test, the frequency of biopsies performed on patients was reduced immediately by a third.

How else can cancer be diagnosed?

The main diagnostic methods have been listed above.

Sometimes, in addition to them, CT or MRI is prescribed, but they are carried out if oncology has already been diagnosed, and there is a need to determine the size of the tumor, its structure, and so on.

Separately, it is worth mentioning the analysis of urine, which has a fairly high information content. Three components are usually determined: the presence of leukocytes, the analysis of the oncomarker UBS, and the level of hemoglobin.

Histology

- an outpatient procedure for splitting off pieces of biomaterial from an organ, the oncology of which needs to be confirmed or refuted.

A prostate biopsy is performed through the rectum.

With the help of an ultrasound probe, the doctor controls the process of the “operation”, and a special device called a gun takes tissue from different parts of the prostate gland.

As a rule, at least 10-12 sampling points are required. The method is quite effective, but it can be erroneous if the tumor is too small, located in a hard-to-reach place, or the examination was carried out using the old method (not a gun, but a sampling needle).

The histological method, in combination with PSA analysis, is the most effective way to detect prostate cancer.

Morphological verification of cancer

Morphological diagnostics refers to the determination of the histogenesis of tumor tissues.

When determining prostate cancer, the main method of verification is the ongoing histological examination - biopsy.

Tissue sampling allows you to determine the degree of damage to cells, tissues, the degree of growth of the neoplasm, and so on.

Related videos

About methods for diagnosing prostate cancer in men in the video:

Despite the difficulties in detecting prostate cancer, every year doctors manage to make some progress. Thanks to early and timely diagnosis, men gain a chance for a long and fulfilling life.

S. Kh. Al-Shukri, S. Yu. Borovets, M. A. Rybalov

Department of Urology, St. Petersburg State Medical University named after acad. I. P. Pavlova

This review evaluates the advantages and disadvantages of the main methods for diagnosing and staging prostate cancer, provides information about modern high-tech staging methods and nomograms. The causes of errors in the diagnosis and staging of prostate cancer are considered.

Keywords: prostate cancer; diagnostics; staging.

Introduction

Increasing the effectiveness of the treatment of prostate cancer (PC) is one of the most urgent problems of modern urology. In the world, prostate cancer occupies the 3rd-4th place in the structure of the incidence of malignant neoplasms. In Russia, the incidence of prostate cancer in 2004 was 6.9%, and in 2009 it was already 10.7%. At the same time, over the past three decades, the number of men who died from this disease has increased.

I. METHODS OF DIAGNOSING PCa

Methods for diagnosing prostate cancer - include an assessment of the results of a digital rectal examination (DRE), determining the level of PSA in the blood plasma. The final diagnosis of prostate cancer can only be established based on the results of a biopsy of the prostate gland, which is advisable to perform under TRUS control. In clinical staging, to clarify the boundaries of the local spread of prostate neoplasms and to detect local and distant metastases, in addition, various methods are used to obtain an image: computed tomography (CT), magnetic resonance imaging (MRI), skeletal bone scintigraphy, etc. However, the results of these methods can be interpreted erroneously in favor of both underdiagnosis and overdiagnosis. The works of many researchers are devoted to the optimization of screening and early diagnosis of prostate cancer.

1.1. AT. Prior to the introduction of PSA into widespread clinical practice, PRI was the only method for diagnosing prostate cancer. The majority of PCa malignancies are located in the peripheral zone of the prostate and can be detected by PRI if their volume exceeds 0.2 cm 3. The positive predictive value of PRI varies from 4% to 11% in men with PSA levels from 0 to 2.9 ng / ml, and from 33% to 83% - from 3 to 9.9 ng / ml and above. Due to the fact that both of these methods have diagnostic value independent of each other, it is recommended to use their combination.

1.2. PSA and its derivatives. Despite the fact that the level of PSA in the blood plasma increases in various diseases of the prostate - prostate cancer, benign prostatic hyperplasia (BPH) and prostatitis, PSA remains almost the only marker used for the early diagnosis of prostate cancer. However, there are no universally accepted international standards for PSA thresholds that could be used to diagnose PCa. The results of a recent study on prostate cancer prevention conducted in the United States confirmed that many men can have prostate cancer despite a low blood PSA level (see Table 1).

When using higher conditional PSA level limits (>4 ng / ml) to decide whether to perform a prostate biopsy, the risk of missing clinically significant PCa also increases; at the same time, with a decrease in this indicator (

Table 1. Risk of PCa with low plasma PSA levels

PSA derivatives - PSA slew rate and PSA doubling time - have been proposed by various researchers, however, upon in-depth study, it turned out that they are of no greater value than PSA, and are currently not included in clinical guidelines for the diagnosis of prostate cancer.

In contrast, free PSA % calculation turned out to be a more significant indicator, used mainly to detect PCa in patients with PSA values from 4 to 10 ng/ml and a negative PRI result. Prostate cancer is detected in more than half of men with % free PSA 10, the incidence of prostate cancer does not exceed 8%.

1.3. PCA3. A relatively new and intensively studied marker is PCA3 (prostate-specific non-coding mRNA), which is determined in the urine sediment after prostate massage. This marker has a higher sensitivity and specificity than PSA, does not depend on the volume of the prostate and the presence of prostatitis in the patient. A relatively small number of published works on the analysis of the diagnostic value of this marker does not allow us to recommend it for widespread use in clinical practice. In this regard, at present, this marker can be considered as an experimental method for diagnosing prostate cancer.

1.4. TRUS. The classic picture of a hypoechoic formation located in the peripheral zone of the prostate is not always found, therefore, TRUSINE is referred to as a method that can reliably determine the presence of prostate cancer. TRUS control is widely used in prostate biopsy.

1.5. Biopsy of the prostate. Prostate biopsy is a reliable method for verifying the diagnosis of prostate cancer. Many authors have proposed various methods for performing this study, differing in the number and location of biopsy punctures. With a prostate volume of 30–40 cm3, it is necessary to conduct a biopsy from at least 8 points. With an increase in the number of points over 12, the accuracy of the analysis does not change significantly. A 10-site biopsy was recommended based on the results of the British Study for the Diagnosis and Treatment of PCa.

II. STAGING METHODS FOR PCa

2.1. AT. It is customary to single out clinical staging based on DRI data, determining the level of PSA, X-ray, radioisotope and other clinical research methods, as well as pathoanatomical staging, which becomes possible after a morphological analysis of the removed prostate gland, seminal vesicles and lymph nodes. Pathological staging more accurately allows you to assess the spread of the disease and judge its prognosis. The most important pathoanatomical prognostic factors after radical prostatectomy are the degree of differentiation of the neoplasm, positive surgical margin, extracapsular extension of the tumor, its invasion into the seminal vesicles, and metastasis to the pelvic lymph nodes. Information about errors in post-mortem staging is not included in this literature review.

DRI allows you to determine not only the presence of prostate cancer, but also the degree of its local spread. A palpable tumor in the prostate is a sign characteristic of poorly differentiated prostate cancer (grade of malignancy according to Gleason - 8–10 points). The sensitivity and reproducibility of DRE are very low, leading to both underestimation and overestimation of the prevalence of PCa. The sensitivity of the method in determining the clinical stage of prostate cancer does not exceed 30%. The stage of prostate cancer is correctly diagnosed using this study in less than 50% of cases.

2.2. PSA. A higher PSA level in the blood plasma indirectly indicates a greater degree of PCa spread, but does not allow one to reliably predict either its clinical or pathomorphological stage.

2.3. TRUS can detect only 60% of prostate tumors, the rest are not recognized due to echogenicity similar to that of surrounding healthy tissues. At the same time, more than 60% of PCa at the pT3 stage remain undiagnosed. TRUS in combination with color Doppler allows visualization of blood vessels passing through the capsule, which is typical for extracapsular extension of the neoplasm. However, this technique has low reproducibility, and therefore it is classified as an auxiliary one.

2.4. Biopsy of the prostate. According to the results of prostate biopsy, it is possible to assess the degree of local spread of prostate cancer, as well as the degree of malignancy of the neoplasm in points on the Gleason scale. The percentage of affected tissue is the most reliable predictor of the risk of tumor invasion into the seminal vesicles and extracapsular spread of the neoplasm.

2.5. CT and MRI are not sufficiently reliable to judge the extent of prostate cancer to recommend them as mandatory methods of examination. MRI with an endorectal coil allows you to more accurately determine the stage of prostate cancer and the germination of the tumor in the seminal vesicles. However, against the background of hemorrhoidal and inflammatory changes in the pancreas or after its biopsy, interpretation of the data can be difficult. The combination of contrast MRI and MRI in T2-enhanced mode and the use of MRI spectroscopy allows better verification of tumor tissue and diagnosis of extracapsular extension of the tumor.

Disadvantages of imaging techniques for PCa:

False negative results due to post-biopsy blood.
Artifacts from gas in the rectum, peristalsis.
False positive spots.
False-negative EMRI findings in prostate cancer with rectal invasion.
Detection of prostate cancer in the central zone.
Undetectable foci of cancer.
High dependence on the experience of the radiologist. Solutions:
MRI before biopsy or 4 weeks after it.
Preparation of the patient (microclyster).
dynamic contrast.
MRI with surface coil.
MR spectroscopy.
Subspecialization.

2.6. High-tech methods for PCa staging. New promising imaging modalities include PET, which is used to diagnose about 70% of pT2 and pT3a-4 prostate cancer. In this case, the focus of cancer and micrometastases

The most promising imaging modality is combined positron emission/computed tomography. This method makes it possible to obtain information about the anatomical structure and metabolic processes in one examination. Metabolic processes (according to PET results) here can be correlated with a certain anatomical localization (according to CT data). Combined positron emission/computed tomography has a higher resolution accuracy - up to 2 mm, however, like PET, it involves the use of radiopharmaceuticals specific for tumor tissue.

Modern ultrasonic high-tech methods for diagnosing and staging prostate cancer include elastography and histoscanning.

Elastography is a non-invasive technique used in the diagnosis of tumors, in which the degree of stiffness (elasticity) of soft tissues is assessed. The technique is based on the classical technique of palpation of volumetric formations. Tumor tissue has a stiffness factor up to 28 times higher than that of healthy tissue. At the moment of mechanical compression, the tumor deforms less than the surrounding tissues. With elastography, palpation is carried out by means of an ultrasonic wave and mechanical compression. The software of the ultrasound machine processes the received reflected signal and displays the image on the screen in color mapping format, which allows differentiating tissues depending on elasticity. As a result, denser tissue structures are displayed in shades of blue, and easily compressible elastic areas are marked with a red color scale. The results of elastography can help in deciding on a biopsy and the choice of a “target” site in case of ambiguous PSA data; the use of this method is possible even after repeated prostate biopsies. The disadvantages of elastography include: high dependence on the experience of the doctor performing the study, the difficulty of mastering this diagnostic method, as well as the low repeatability of the results.

Histoscanning is another new high-tech method for ultrasound diagnosis and staging of prostate cancer. Differentiation between the tumor and healthy tissue is carried out, the localization of the tumor is determined at its small size, which cannot be detected using standard TRUS. The sensitivity of the method is 90%, the specificity is 72%. As a result of the study, information is obtained about the localization of areas suspected of being tumorous, which makes it possible to perform a targeted biopsy.

2.7. Nomograms. A large number of groups of researchers have proposed a variety of algorithms and nomograms to determine the local spread of prostate cancer, the likelihood of lymphogenous metastasis, as well as patients belonging to a prognostically unfavorable group. The method is based on a comprehensive assessment of the results of PRI, the level of PSA in the blood plasma and the degree of differentiation of the neoplasm. One example would be the CAPRA index, which makes it possible to assess the probability of relapse-free survival in patients with prostate cancer based on a combination of clinical and morphological criteria. The use of a combination of PSA level, Gleason biopsy score and clinical stage T (Partin nomogram) gives better results in predicting pathological stage than either of the parameters alone.

2.8. N, M-staging. Pelvic lymphadenectomy is the gold standard for determining lymph node metastasis, N (open or laparoscopic).

M-staging. In 85% of patients who died from prostate cancer, metastatic lesions of the skeleton are noted. The presence and prevalence of bone metastases allows you to determine the prognosis in each case. An elevated level of bone-specific alkaline phosphatase in 70% may indicate the presence of bone metastases, but the most sensitive method of investigation is bone scintigraphy. In addition to bones, cancer cells can affect distant lymph nodes, lungs, liver, brain, and skin. Depending on the localization of distant metastases, a clinical examination, chest x-ray, ultrasound, CT, MRI can be used to detect them in soft tissue localization. At plasma PSA levels >100 ng/mL, almost all patients have distant PCa metastases.

III. Causes of errors in the diagnosis and staging of prostate cancer

Among the reasons leading to errors in the diagnosis and staging of prostate cancer, one can single out subjective and objective ones.

Subjective:

Insufficient qualification of specialists.
Misinterpretation of survey data.

Objective:

Lack of highly specific diagnostic methods.
Insufficient use of modern diagnostic methods.
Failure to use the standard recommendations proposed by the European Association of Urology.

In conclusion, it should be noted that in recent years, attempts have been made to improve the methods of early diagnosis and staging of prostate cancer.

However, there is a need to create new, more accurate methods to detect clinically significant PCa. Promising methods to optimize diagnostic and staging processes include PET/CT, diffusion MRI, MR spectroscopy, dynamic MRI with contrast enhancement. Further development of PCa-specific radiopharmaceuticals is needed. In addition, unification is important when interpreting the data obtained - using the recommendations of the European Association of Urology.

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