Post on 02-Apr-2018
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KANKER PROSTAT
By
H.T.FARIZAL FADIL4 OKT 2010
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Prostat Illustration
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What is prostate cancer?
Prostate cancer is a malignant
(cancerous) tumor (growth) that consists
of cells from the prostate gland. Generally,
the tumor usually grows slowly and
remains confined to the gland for manyyears. During this time, the tumor
produces little or no symptoms or outward
signs (abnormalities on physicalexamination). However, all prostate
cancers do not behave similarly.
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As the cancer advances, however, it can
spread beyond the prostate into the
surrounding tissues (local spread).
Moreover, the cancer also can
metastasize (spread even farther)
throughout other areas of the body, suchas the bones, lungs, and liver.
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Why is prostate cancer important?
Prostate cancer is the most commonmalignancy in American men and the
second leading cause of deaths from
cancer, afterlung cancer. According to the
American Cancer Society's most recent
estimates, 192,280 new cases of prostate
cancer would be diagnosed in 2009 and
27,360 would die
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The estimated lifetime risk of being
diagnosed with the disease
is 17.6% for Caucasians
20.6% for African Americans.
The lifetime risk of death from prostatecancer similarly is 2.8% and 4.7%
respectively.
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What are prostate cancer causes?
The cause of prostate cancer is unknown,
but the cancer is not thought to be related
to benign prostatic hyperplasia (BPH).
The risk (predisposing) factors for prostate
cancerinclude advancing age,
genetics (heredity),
hormonal influences, and such
environmental factors as toxins,
chemicals, and industrial products.
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Testosterone, the male hormone produced
by the testicles, directly stimulates the
growth of both normal prostate tissue andprostate cancer cells.
this hormone is that decreasing the level
of testosterone should be (and usually is)effective in inhibiting the growth of prostate
cancer.
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Although still unproven, environmental
factors, such as
cigarette smoking and
diets that are high in saturated fat, seem to
increase the risk of prostate cancer. There
is also a suggestion that
obesityleads to an increased risk of
having more aggressive, larger prostate
cancer,
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Of note, there is no proven relationship
between the frequency of sexual activity
and the chances of developing prostate
cancer.
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What are prostate cancer symptoms
and signs?
In the early stages, prostate cancer often
causes no symptoms for many years. As a
matter of fact, these cancers frequently
are first detected by an abnormality on a
blood test (the PSA, discussed below) or
as a hard nodule (lump) in the prostate
gland.
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Rarely, in more advanced cases, the
cancer may enlarge and press on theurethra. As a result, the flow
of urine diminishes and
urination becomes moredifficult. Patientsmay also experience
burning with urination
blood in the urine
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The cancer then can spread even farther (metastasize)to other areas of the body. Symptoms of metastaticdisease include
fatigue, malaise, and weight loss.
rectal examination can sometimes detect local spreadinto the surrounding tissues. That is, the physician canfeel a hard, fixed (not moveable) tumor extending from
and beyond the gland. Prostate cancer usually metastasizes first to the lower
spine or the pelvic bones (the bones connecting thelower spine to the hips), thereby causing back or pelvicpain.
The cancer can then spread to the liver and lungs.
Metastases
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to the liver can cause
pain in the abdomen and
jaundice (yellow color of the skin) in rare
instances.
Metastases to the lungs can cause chestpain and coughing.
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What are the screening tests for
prostate cancer?
These screening tests are a digital rectal
examination and a blood test called theprostate specific antigen (PSA). The PSA
level is usually higher than 4ng/mL in
people with prostate cancer than in people
without the cancer.
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Results of the PSA test under 4 nanograms per
milliliter of blood are generally considered
normal. Very high values, such as 30 or 40 andover, are usually caused by prostate cancer.
What are false-positive elevations in the PSA
test?
False-positive elevations in the PSA are
increases in the PSA that are caused by
conditions other than prostate cancer. For
example, benign prostatic hyperplasia (BPH)and infection or inflammation of the prostate
(prostatitis)
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Accordingly, the age-specific
normal ranges are 0 to 2.5 for in their 40s,
0 to 3.5 in their 50s,
0 to 4.5 in their 60s, and
0 to 6.5 for men 70 years of age and over.
Therefore, as an example, a PSA of 4would be considered borderline for men in
their 30s and 40s but could be normal for
men in their 50s, 60s, and 70s.
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Prostate cancer gene 3 (PCA3) is a new
gene-based test carried out on a urine
sample.
PCA3 is highly specific for the diagnosis
of prostate cancer.
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How is prostate cancer diagnosed and
graded?
Prostate cancer is diagnosed from the
results of a biopsy of the prostate gland. If
the digital rectal exam of the prostate or
the PSA blood test is abnormal, a prostatecancer is suspected. A biopsy of the
prostate is usually then recommended.
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Gleason score
of 6 is supposed to indicate low-grade(less aggressive) disease while that of 8-
10 demonstrates high grade (more
aggressive) cancer; 7 is regarded as
somewhere in between these two.
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How is the staging of prostate cancer
done?
The staging of a cancer refers to
determining the extent of the disease
(where in the body have the prostate
cancer cells spread). Once a prostatecancer is diagnosed on a biopsy,
additional tests are done to assess
whether the cancer has spread beyond thegland.
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Radionuclide bone scans can determine if
there is a spread of the tumor to the
bones.
Chest X-ray can be used to detect
whether or not cancer has spread to the
lungs. Additionally,
CT scans (coaxial tomography) and
MRIs (magnetic resonance imaging)
Cystoscopy is usually performed in
selected situations.
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The stages of prostate cancer are categorized as follows:
Stage I (or A): The cancer cannot be felt on a digital rectal exam,
and there is no evidence that it has spread outside the prostate.These are often found incidentally after surgery for an enlargedprostate.
Stage II (or B): The tumor is larger than a stage I and can be felt ona digital rectal exam. There is no evidence that the cancer hasspread outside the prostate. These are usually found on a biopsy
when a man has an elevated PSA level.
Stage III (or C): The cancer has invaded other tissues neighboringthe prostate.
Stage IV (or D): The cancer has spread to lymph nodes or to otherorgans
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Evaluation of the (primary) tumor ("T")
TX: The primary tumor cannot be evaluated.
T0: There is no evidence of tumor.
T1: Tumor is present but not detectable clinically or with imaging.
T1a: Tumor was incidentally found in less than 5% of prostate tissueresected (for other reasons).
T1b: Tumor was incidentally found in greater than 5% of prostate tissueresected.
T1c: Tumor was found in a needle biopsy performed due to an elevatedserum PSA.
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T2: The tumor can be felt (palpated) onexamination but has not spread outside theprostate.
T2a: The tumor is in half or less than half of oneof the prostate gland's two lobes.
T2b: The tumor is in more than half of one lobe,but not both.
T2c: The tumor is in both lobes
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T3: The tumor has spread through the prostatic capsule(if it is only partway through, it is still T2).
T3a: The tumor has spread through the capsule on oneor both sides.
T3b: The tumor has invaded one or both seminalvesicles.
T4: The tumor has invaded other nearby structures.
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Evaluation of the regional lymph nodes ("N")
NX: The regional lymph nodes cannot be
evaluated.
N0: There has been no spread to the regionallymph nodes.
N1: There has been spread to the regionallymph nodes.
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Evaluation of distant metastasis ("M")
MX: Distant metastasis cannot be evaluated.
M0: There is no distant metastasis.
M1: There is distant metastasis.
M1a: The cancer has spread to lymph nodes beyond the regional ones.
M1b: The cancer has spread to bone.
M1c: The cancer has spread to other sites (regardless of boneinvolvement)
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What are the treatment options for
prostate cancer?
surgery,
radiation therapy,
hormonal therapy,
cryotherapy, combinations of some of
these treatments
chemotherapy, therefore, are considered
palliative
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What about prostate cancer surgery?
The surgical treatment for prostate cancer
is commonly referred to as a radical
prostatectomy,
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The potential complications of a radical
prostatectomy include
the risks of anesthesia, local bleeding,
impotence (loss of sexual function) in 30%-70%
of patients, and incontinence (loss of control of urination) in 3%-
10% of patients.
Radical prostatectomy can be performed by
open surgery, laparoscopic surgery, or by
robotic surgery (robotic assisted radical
prostatectomy)
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Ifpost-treatment impotence does
occur, it can be treated by sildenafil (Viagra) tablets,
injections of such medications as
alprostadil (Caverject) into the penis, various devices to pump up or stiffen the
penis, or
penile prosthesis (an artificial penis).
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Incontinence after treatment often
improves with time, special exercises, and
medications to improve the control of
urination. Occasionally, however,
incontinence requires implanting an
artificial sphincter around the urethra. Theartificial sphincter is made up of muscle or
other material and is designed to control
the flow of urine through the urethra.
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What about radiation therapy for
prostate cancer?
Incontinence and impotence can occur as
complications of radiation therapy, as with
surgery,
(brachytherapy) directly into the prostate.
Both can cause severe fatigue, diarrhea,
and discomfort on urination. These effects
are almost always temporary
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What about hormonal treatment for
prostate cancer?
The male (androgenic) hormone is called
testosterone. It stimulates the growth of
cancerous prostatic cells and, therefore, is
the primary fuel for the growth of prostatecancer. The idea of all of the hormonal
treatments (medical and surgical), in short,
is to decrease the stimulation bytestosterone of the cancerous prostatic
cells
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Testosterone normally is produced by the
testes in response to stimulation from a
hormonal signal called LH-RH. The LH-RHstands for (luteinizing hormone-releasing
hormone) and is also called gonadotropin-
releasing hormone. This hormone comesfrom a control station in the brain and
travels in the bloodstream to the testes.
Once there, the LH-RH stimulates thetestes to produce and release
testosterone.
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The surgical hormonal treatment is
removal of the testes in an operation
called an orchiectomy or a castration.
The LH-RH agonists, leuprolide (Lupron)
orgoserelin (Zoladex), are given as
monthly injections in the doctor's office.The anti-androgenic drugs, flutamide
(Eulexin) orbicalutamide (Casodex),
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What is cryotherapy for prostate
cancer?
Cryotherapy is one of the newer
treatments that is being evaluated for use
in the early stage of prostate cancer. This
treatment kills the cancer cells by freezingthem. The freezing is accomplished by
inserting a freezing liquid (for example,
liquid nitrogen or argon) through needlesdirectly into the prostate gland
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What is HIFU for prostate cancer?
HIFU( high intensity focused ultrasound,)
was first developed as a treatment of
benign prostatic hyperplasia (BPH) and
now is also being used as a procedure for
the killing of prostate cancer cells.
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What is chemotherapy for prostate
cancer?
Chemotherapeutic agents, or
chemotherapy, are anticancer drugs. They
are used (for hormone resistant prostate
cancer) as a palliative treatment (palliationto relieve symptoms) in patients with
advanced cancer for whom a cure is
unattainable.
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Several chemotherapeutic agents have
been used effectively to palliate metastatic
prostate cancer. One such agent isestramustine (Emcyt).
Another agent called mitoxantrone
(Novantrone) has been shown to beeffective in combination with prednisone
for palliating androgen-independent
prostate cancer Newer chemotherapy medicines like
docetaxel (Taxotere)
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side effects of chemotherapy include
weakness,
nausea,
hair loss, and
suppression of the bone marrow. The
suppression of marrow, in turn, can
decrease the red blood cells (causing
anemia), the white blood cells (leading to
infections), and the platelets (resulting inbleeding).
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What are the differences between
hormonal treatment and
chemotherapy? Hormonal therapy is the mainstay of
treatment for symptomatic, advanced-
staged prostate cancer
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Orchiectomy is the surgical removal of the
testicles. Luteinizing hormone-releasing
hormone (LHRH) agonists, such asleuprolide (Lupron, Viadur, Eligard),
goserelin (Zoladex), or buserelin
(Suprefact), stop the production oftestosterone from the testes and induce a
state of "medical castration" (castration
without surgery). Many men prefer this
over surgical castration.
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Antiandrogens, such as flutamide
(Eulexin) orbicalutamide (Casodex), block
the action of testosterone on the prostatecancer cells and other parts of the body.
Each of the above two classes of
medicines produce symptomatic relief inabout 80% of patients. Improvement is
often dramatic.
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Side effects of these medications vary.
Orchiectomy and LHRH agonists may
cause impotence, hot flashes, and loss ofsexual desire. Antiandrogens may cause
nausea, vomiting, diarrhea, and breast
enlargement or tenderness. Any of thesetherapies can weaken bones and lead to
osteoporosis and bone fracture.
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Other agents that are helpful include the
following: progestins such as megestrol
acetate given daily orally and other drugsthat inhibit androgen production such as
aminoglutethimide (Cytadren) or
ketoconazole (Nizoral, Extina, Xolegel,Kuric). These agents are effective but are
sometimes difficult to tolerate.
Corticosteroids are often given
simultaneously.
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What about herbal or other alternative
medicine treatments for prostate
cancer?
Alternative medicine, also called
integrative or complementary medicine,
includes such non-traditional treatmentsas herbs, dietary supplements, and
acupuncture. A major problem with most
herbal treatments is that their compositionis not standardized.
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Can prostate cancer be prevented?
No specific measures are known to prevent the
development of prostate cancer. At present,therefore, we can hope only to prevent
progression of the cancer by making early
diagnoses and then attempting to cure the
disease. Early diagnoses can be made byscreening men for prostate cancer with PSA and
digital rectal examination The purpose of the
screening is to detect early, tiny, or even
microscopic cancers that are confined to the
prostate gland
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Recently, studies have shown that certain
medications (finasteride [Propecia] and
dutasteride [Avodart]) decrease thechances of getting prostate cancer when
taken over the long term.
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What will be the future treatments for
prostate cancer?
the genetic basis of this disease. Genes,which are chemical compounds located on
the chromosomes, determine the
characteristics of individuals. Accordingly,investigators at research centers have
focused on identifying and isolating the
gene or genes responsible for prostatecancer.
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the FDA approved a prostate cancer
vaccine called sipuleucel-T (Provenge)
that has been made for people who are atan advanced stage of prostate cancer.
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There is also a great interest in inventing
better methods to image prostate cancer
to detect its location and spread in thebody. Newer techniques like MRS
(magnetic resonance spectroscopy), PET
(positron emission tomography) andcertain molecular imaging techniques hold
promise in this regard.
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Prostate Cancer At A Glance
Prostate cancer is the second leading cause of deathsfrom cancer among U.S. men.
While the causes of prostate cancer are still unknown,some risk factors for the disease, such as advancing ageand a family history of prostate cancer, have beenidentified.
Prostate cancer is often initially suspected because of an
abnormal PSA blood test or a hard nodule (lump) felt onthe prostate gland during a routine digital (done with afinger) rectal examination.
Refinements in the PSA test, including the PSA ratio,age-specific PSA, and PSA velocity or slope haveimproved the accuracy of the test.
If one of the screening tests is abnormal, the diagnosisof prostate cancer should be suspected and a biopsy ofthe prostate gland is usually done.
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The diagnosis of prostate cancer is made whencancerous prostatic cells are identified in the biopsytissue under a microscope.
In some men, prostate cancer is life threatening, while inmany others, it can exist for many years without causinghealth problems.
The choice of treatment for prostate cancer depends onthe size, aggressiveness, and extent or spread of thetumor, as well as on the age, general health, andpreference of the patient.
The many options for treating prostate cancer includesurgery, radiation therapy, hormonal treatment,cryotherapy, chemotherapy, combinations of some ofthese treatments, and watchful waiting/active
surveillance. Research is under way to identify the genes that cause
prostate cancer.
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Pattern 1 - The cancerous prostate closely resemblesnormal prostate tissue. The glands are small, well-formed, and closely packed.
Pattern 2 - The tissue still has well-formed glands, butthey are larger and have more tissue between them.
Pattern 3 - The tissue still has recognizable glands, butthe cells are darker. At high magnification, some of these
cells have left the glands and are beginning to invade thesurrounding tissue.
Pattern 4 - The tissue has few recognizable glands.Many cells are invading the surrounding tissue
Pattern 5 - The tissue does not have recognizable
glands. There are often just sheets of cells throughoutthe surrounding tissue.
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Interpreting the results
The lower the score, the better. A combined
Gleason score of 10 is very bad (although thereare still many treatments that doctors can offermen with high Gleason scores). Here's how thescores break down:
Scores from 2 to 4 are very low on the canceraggression scale.
Scores from 5 to 6 are mildly aggressive.
A score of 7 indicates that the cancer is
moderately aggressive. Scores from 8 to 10 indicate that the cancer is
highly aggressive.