Prostate cancer is usually an adenocarcinoma. The symptoms are not usually available until tumor growth hematuria and / or obstruction causes pain. The diagnosis is suspected by a digital rectal examination or determination of prostate specific antigen (PSA) and biopsy-confirmed. Screening is controversial and should involve joint decision-making. The prognosis for most patients with prostate cancer, especially in localized or regional disease (usually before symptoms develop), very good. More men die with prostate cancer than of one. Treatment includes prostatectomy, radiation therapy, palliative measures (for. Example, hormone therapy, radiation therapy, chemotherapy), or, in many older and younger carefully selected patients by active surveillance.

In the US, adenocarcinoma of the prostate is the most common non-dermatological malignancies in men> 50 years. Annually (in the US) are about 238,590 new cases and about 29,720 deaths from cancer (estimated in 2013) recorded. The incidence increases with each decade of life; Autopsy studies show prostate cancer in 15-60% of men aged 60-90 years and an increasing incidence with age. The lifetime risk of developing prostate cancer is 1: 6. The mean age at diagnosis is 72 years. > 75% of prostate cancers are diagnosed> 65 years for men. The risk is highest for men with dark skin.

Prostate cancer is usually an adenocarcinoma. The symptoms are not usually available until tumor growth hematuria and / or obstruction causes pain. The diagnosis is suspected by a digital rectal examination or determination of prostate specific antigen (PSA) and biopsy-confirmed. Screening is controversial and should involve joint decision-making. The prognosis for most patients with prostate cancer, especially in localized or regional disease (usually before symptoms develop), very good. More men die with prostate cancer than of one. Treatment includes prostatectomy, radiation therapy, palliative measures (for. Example, hormone therapy, radiation therapy, chemotherapy), or, in many older and younger carefully selected patients by active surveillance. In the US, adenocarcinoma of the prostate is the most common non-dermatological malignancies in men> 50 years. Annually (in the US) are about 238,590 new cases and about 29,720 deaths from cancer (estimated in 2013) recorded. The incidence increases with each decade of life; Autopsy studies show prostate cancer in 15-60% of men aged 60-90 years and an increasing incidence with age. The lifetime risk of developing prostate cancer is 1: 6. The mean age at diagnosis is 72 years. > 75% of prostate cancers are diagnosed> 65 years for men. The risk is highest for men with dark skin. A sarcoma of the prostate is rare and occurs primarily in children. Undifferentiated prostate cancer, squamous cell carcinoma and ductal urothelial carcinoma also occur irregularly. As a prostatic intraepithelial neoplasia refers to possible premalignant histological changes In the course of adenocarcinoma hormonal influences play a role. but this does not apply to other prostate cancer types with probability bordering on certainty. Symptoms and complaints Prostate cancer progresses slowly and usually rarely causes symptoms before the disease has progressed. In advanced tumor disease hematuria and symptoms of voiding dysfunction can (z. B. strenuous or hesitant urination, weak or intermittent urine stream, sensation of incomplete bladder emptying, dribbling) occur. Bone pain, pathologic fractures or spinal cord compression can occur (often pelvis, ribs, vertebrae) by osteoblastic bone metastases. Diagnostic screening by digital rectal examination and prostate specific antigen judgment of abnormalities by transrectal needle biopsy classification by histology staging means of CT and scintigraphy Sometimes rock hard induration or nodes in the digital rectal examination (DRE, “digital rectal examination”) palpable, often the but palpation normal; Induration, and nodularity indicate a carcinoma, but must be differentiated from granulomatous prostatitis, prostate stones and other prostate diseases. The extension of induration to the seminal vesicles and lateral fixation of the gland indicate a locally advanced prostate cancer. discovered by DRE prostate cancers are usually locally advanced and> 50% stretch for about the capsule out. The diagnosis of prostate cancer requires histological confirmation. Most commonly, these controlled by using transrectal ultrasound (TRUS) biopsy needle that can be performed in a practice under local anesthesia is done. Hypo echogenic areas are cancer suspect. Occasionally prostate cancer is found as an incidental finding in tissue (BPH) was surgically removed due to benign prostatic hyperplasia. Screening methods The most carcinomas with screening by serum PSA levels found (and sometimes DRE), to be carried out. Screening is usually done annually in men> 50 years but sometimes in men at high risk (eg. As those with prostate cancer in the family history and dark-skinned) earlier. Screening is not generally recommended for men with a life expectancy <10 to 15 years. Abnormal findings are further investigated with biopsy. It is not yet clear whether be reduced by screening morbidity or mortality, or whether the findings obtained from the screen to the reduced quality of life, resulting from the treatment of asymptomatic cancers overshadow. Screening is recommended by some professional organizations and discouraged by others. Most patients with newly diagnosed prostate cancer have a normal DRE and PSA measurements of serum values ??are not as a screening test. Although PSA levels in 25-92% of patients with prostate cancer are increased (depending on tumor volume), these are moderately increased (depending on prostate size and degree of obstruction) even at 30-50% of patients with BPH. Elevated PSA levels can also be found in some smokers and for several weeks after a prostatitis. A PSA ? 4 ng / ml is considered as an indication for biopsy in men> 50 years (in younger patients should PSA levels> 2.5 ng / ml lead to biopsy because a BPH most common cause of a PSA increase this age group is rare). Although very high levels are significant (they have extracapsular extension of tumor or metastatic disease) and the probability of cancer with rising PSA levels rise, there is no threshold below which there is no risk. In asymptomatic patients, the positive predictive value (for the presence of cancer) of PSA> 10 ng / ml in 67% and PSA 4-10 ng / ml at 25%. More recent data suggest that the prevalence of cancer in men ? 55 years with PSA <4 ng / ml was 15% and the incidence in men with a PSA level of 0.6 to 1.0 ng / ml at 10%. However carcinomas tend in patients with lower levels tend to be small (often <1 ml) and better differentiated, although poorly differentiated carcinomas (Gleason score 7-10) at all PSA levels may be present. Probably 15% of carcinomas with a PSA <4 ng / ml at Diagnosstellung are poorly differentiated. Although it seems that at a cutoff of 4 ng / ml, some potentially serious cancers are not detected, the cost and morbidity, resulting from the increased number of biopsies that are necessary to identify such unclear. The decision whether a biopsy is performed might be influenced by other PSA-dependent factors, even if no prostate cancer is in the family history. For example, the difference in PSA (PSA velocity) should be <0.75 ng / ml / year (low in younger patients). A biopsy is displayed at a PSA velocity> 0.75 ng / ml / year. Assays that determine the ratio of free to total PSA and the PSA complex are tumor-specific than the usual PSA measurements and the biopsy rate could lower without carcinoma in patients. Prostate cancer is associated with less free PSA. To date, no standardized limit has been set, but in general, PSA levels require <10-20% a biopsy. (N. D. Talk .: The determination of PSA is now an indispensable part of the screening because just early stages of prostate cancer can often only see about this blood level. The interpretation of the PSA findings belongs in the hands of an experienced urologist.) other isoforms of PSA and new markers for prostate cancer are investigated. None of these other uses of the PSA values ??eliminates any concerns about the potentially too much triggered biopsies. Many new tests (z. B. urinary prostate cancer antigen 3 [PCA-3]) are under evaluation as a tool for screening decisions. Doctors should discuss the risks and benefits of PSA testing with patients. Some patients prefer to remove a carcinoma in all circumstances, no matter how low the potential for progression and possible metastases and therefore may prefer annual PSA tests. Other assess the quality of life is very high and can accept a degree of uncertainty. You may prefer less often (or not) PSA tests durchzuführen.Grad- and staging Histological graduation is based on the similarity between tumor and normal glandular architecture structure and helps the aggressiveness of the tumor to determine. The scale takes into account the histological heterogeneity of the tumor. The Gleason score is often used. The most common pattern and the next most frequent patterns are each associated with a level of 1-5, and the two stages are then summed to produce a total value. Most experts consider a score of ? 6 for good, moderate and 7 8-10 difficult to differentiate The lower the score, the less aggressive and invasive the tumor is and the better the prognosis. In localized tumors of Gleason score helps assess the likelihood of capsular perforation and an infiltration of seminal vesicles and lymph nodes. Gleason score, clinical stage and PSA level together (using tables or nomograms) say the pathological stage and prognosis better than previously each criterion alone (n. D. Talk .: In 30-40% of patients, however, it comes Under a staging of the tumor stage.) to the extent of the tumor to determine which prostate cancer is divided into stages (AJCC / TMN * staging of prostate cancer and TNM definitions for prostate cancer). Transrectal ultrasonography (TRUS) may provide information for staging, in particular, whether a capsule breakage or infiltration of the seminal vesicles are present. Patients with tumors in clinical stage T2a-T1c, low Gleason score (? 7) and PSA <10 ng / mL received any additional staging tests usually before treatment. Radionuclide bone scans are until the PSA level> 20 ng / ml or if the Gleason score is not high (ie, ? 8 or [4 + 3]) rarely helpful to find bone metastases (they are often due the trauma of arthritic changes abnormally) A CT (or MRI) of the abdomen and pelvis is often performed to assess pelvic and retroperitoneal lymph nodes when the Gleason score is 8-10 and the PSA value> 10 ng / ml or when the PSA level> 20 ng / ml with each other Gleason score. Suspicious lymph nodes can be further evaluated by a needle biopsy. An MRI with endorectal coil can also be helpful to define the local extent of the tumor in patients with locally advanced prostate cancer (stage T3). The role of In-111-radioimmunoscintigraphy for staging is becoming increasingly important, but it is certainly not for early, localized disease required. Increased acid phosphatase in serum – especially in enzymatic tests – correlates well with the presence of metastases, v. a. in lymph nodes. However, this enzyme can be increased even with BPH (and is slightly increased by vigorous prostate massage) in multiple myeloma, for Gaucher disease and hemolytic anemia. It is rarely used today to plan treatment or to accompany the patient to the treatment, mainly because its value when used as radioimmunoassay (as it is usually the case) is carried out, has not been established. Reverse transcriptase-PCR assays for circulating prostate cancer cells are being investigated for their suitability for staging and prognostic assessment. AJCC / TMN * staging of prostate cancer stage tumor Regional lymph node metastasis Distant metastasis prostate specific antigen level Gleason score 1 T1a-T1c N0 M0 <10 ng / ml ? 6 T2a N0 M0 <10 ng / ml ? 6 T1-T2a N0 M0 Unknown IIA T1a-T1c N0 M0 <20 ng / ml 7 T1a-T1c N0 M0 ?10 ng / ml but <20 ng / ml ? 6 T2a N0 M0 ? 10 ng / ml, but <20 ng / ml ? 6 T2a N0 M0 <20 ng / ml 7 T2b N0 M0 <20 ng / ml ? 7 T2b N0 M0 Unknown IIB T2c N0 M0 Each Each T1-T2 N0 M0 ? 20 ng / ml Each T1-T2 N0 M0 Each PSA ? 8 III-T3a T3b N0 M0 Each PSA Each Gleason IV T4 N0 M0 Any PSA Any Gleason each T N1 M0 Any PSA Any Gleason any T any N M1 Any PSA Any Gleason For definitions of the AJCC / TNM TMN definitions for prostate cancer. AJCC = American Joint Commission on Cancer; PSA = prostate specific antigen; TNM = Tumor, Node, metastases. Taken from Edge SB, Byrd DR, Compton CC, et al: AJCC Cancer Staging Manual, 7th edition. New York, Springer, 2010. TNM inapparent by palpation or imaging T1a random discovered definitions for prostate cancer characteristic definition primary tumor T1 Clinically in ? 5% of the resected tissue T1b Randomly at> 5% of the resected tissue discovered T1c diagnosed by needle biopsy, which is performed due to an increased PSA level T2 is palpable or can be seen clearly by imaging method limited to the prostate T2a Subject ? 50% of one lobe T2b Composition> 50% of a lobe and protects the other lobe T 2c Subject both Lap pen T3 extends through the prostatic capsule T3a Covers one or both sides through the prostate capsule T3b infiltrated the seminal vesicles T4 is fixed or invades adjacent structures outside the seminal vesicles Regional lymph node metastases NX Not rated N0 No N1 presence distant metastasis M0 No M1 presence AJCC = American Joint Commission on Cancer; PSA = prostate specific antigen; TNM = Tumor, Node, metastases. Data from Edge SB, Byrd DR, Compton CC, et al: AJCC Cancer Staging Manual, 7th edition. New York, Springer, 2010. The risk of spread of cancer is considered to be low if the stage ? T2a The Gleason score ? 6 The PSA ? 10 ng / ml is a T2b tumor, Gleason score 7 or PSA> 10 ng / ml are considered medium risk by most experts. T 2c tumors, Gleason score ? 8 or PSA> 20 ng / ml (or 2 medium risk factors) are generally considered to be high risk. The risk of cancer spread, by tumor stage, Gleason score and PSA level to be estimated: Low Risk: stage ? T2a, Gleason score ? 6, and PSA level ? 10 ng / ml Medium Risk: Stage T2b, Gleason score = 7 or PSA-value ? 10 and ? 20 ng / ml High risk level ? T2c, Gleason score ? 8 or PSA ? 20 ng / ml Both the acid phosphatase and the PSA levels decrease after treatment and get off at relapse again. The most sensitive marker of disease progression or monitoring of treatment response, however, the PSA and has almost completely replaced for this purpose acid phosphatase. Prognosis The prognosis of most patients with prostate cancer is very good, especially if it is located. The life expectancy for older men with prostate cancer only slightly from the same age men without prostate cancer may be different, depending on their age and comorbidities. In many patients, a long-term local control or even cure is possible. The probability of cure is also directed at a clinically localized tumor to tumor grade and tumor stage. Without early treatment, patients have a poor prognosis with a high-grade, poorly differentiated carcinoma. The undifferentiated prostate cancer, squamous cell carcinoma and ductal transitional cell carcinoma speak poorly to conventional therapies. Metastasis can not be cured, the average life expectancy with metastatic disease is 1-3 years, although some patients survive for many years. Therapy For localized carcinoma of the prostate, surgery or radiation In cancer outside the prostate, palliation with hormonal therapy, radiation therapy or chemotherapy For some men, the cancer at low risk have active surveillance without treatment The therapy is based on PSA level, tumor grade and stage, age of the patient, concomitant diseases and life expectancy. The goal of therapy may be Active monitoring local (for healing) Systemic (aimed at removing or limiting the extent of the tumor) Regardless of age, most patients prefer a definitive therapy if the cancer is potentially curable. However, the therapy is palliative rather than definitive when the cancer has spread outside the prostate as a cure then is unlikely. Watchful waiting can be used for men who hardly benefit from definitive treatment (due to advanced age or comorbidity, for example.); these patients are treated with palliative measures if symptoms progress. Active surveillance in many asymptomatic patients> 70 years with low or possibly even medium-risk, localized prostate cancer one, or when the life-limiting comorbidities exist, a watchful waiting is appropriate. In these patients, the risk of dying from other causes, greater than the risk to die from prostate cancer. This treatment approach requires repeated DRE, PSA measurements and symptom observation. In healthy young men with carcinoma of low risk active monitoring requires periodic repeat biopsies. The optimal distance between biopsies has not been studied, but most experts agree that it should be ? 1 year, possibly less frequently when biopsies were negative again. If the cancer progresses, a therapy is needed. About 30% of patients with active surveillance eventually require therapy. In older men, can be reached by actively monitoring the same overall survival rate as with prostatectomy; However, patients who undergo surgery, a significantly lower risk of distant metastasis and disease-specific therapies Mortalität.Lokale The local therapy has to cure prostate cancer to target and definitive therapy can therefore be called. Radical prostatectomy, radiotherapy and cryotherapy eineige forms of options are. Careful counseling about the risks and benefits of these treatments and reflections on patient-specific characteristics (age, health, tumor characteristics) are crucial in decision making. A radical prostatectomy (removal of the prostate with seminal vesicles and regional lymph nodes) is based on available data, the best choice for patients <70 years with a limited to the prostate tumor. Depending on the life expectancy, comorbidities and the ability to withstand surgery and anesthesia, a prostatectomy is appropriate for some older men. The prostatectomy is performed through an incision in the lower abdomen. More recently, a robot-assisted laparoscopic approach has been developed that minimizes blood loss and hospitalization, but has not made any changes in morbidity or mortality. Complications include urinary incontinence (about 5-10%), Blasenhalskontrakturen or urethral strictures ((about 7-20%), erectile dysfunction -the at about 30-100% values ??are very much on the age and the current erectile function and the protection of the neurovascular bundle dependent) and fecal incontinence (1-2%). A radical prostatectomy with preservation of the neurovascular bundle reduces the likelihood of erectile dysfunction, but may, depending on tumor stage and location, are not always carried out. Cryotherapy (destruction of prostate cancer cells by freezing with cryoprobes followed by thawing) is less mature; Long-term results are not yet available. Unwanted side effects are bladder neck obstruction, urinary incontinence, erectile dysfunction and rectal pain or injury. Cryotherapy is not generally the treatment of choice in the US, but can be used if the radiation therapy is not successful. External radiation therapy generally applied 70 Gy in 7 weeks, but this technique has been replaced by the three-dimensional conformal radiotherapy and intensity modulated radiotherapy, in which doses up to 80 Gy administered safely to the prostate. The data suggest that the rate of local disease control, in particular in high risk patients is higher. A certain decline in erectile function occurs at least 40%. Other undesirable side effects include radiation proctitis, -zystitis, diarrhea, fatigue and possibly urethral strictures, particularly in patients who have had a transurethral resection of the prostate in the past. In patients with low PSA levels and a localized prostate cancer, the results of radiotherapy and prostatectomy are comparable. Newer forms of radiation therapy, such as proton therapy are more expensive, and the benefits for men with prostate cancer are not clearly defined. External radiation therapy also plays a role in cancer remains after radical prostatectomy, or if the PSA level starts to rise after surgery and no metastases are found. DieBrachytherapie involves the implantation of radioactive seeds into the prostate through the Peineum. These sources emit a burst of radiation over a period of time (usually 3-6 months) and will be inert. examine research protocols, whether quality implants are superior to monotherapy or implants plus external radiotherapy in patients with moderate risk. By brachytherapy also erectile function decreased, but this may later occur and patients can better respond to phosphodiesterase type 5 inhibitors than patients with resection or perioperative injury to neurovascular structures. Increased urinary frequency, urinary urgency and urinary retention are often rare, but usually resolve with time. Other adverse effects include increased bowel movements, tenesmus, bleeding or ulceration and prostatorektale fistula. If the cancer is localized to the prostate, there is a high risk, various therapies have to be combined (eg. B. in high-risk prostate cancer treatment with external-beam radiation, the addition of hormone therapy) .Systemische therapies when cancer has spread beyond the prostate gland, is a cure unlikely; Systemic therapy that is aimed at removing or limiting the extent of the tumor is usually eingsetzt. Patients with locally advanced or metastatic tumor can benefit from androgen by castration, either surgically by bilateral orchidectomy or conservative means of LHRH agonists such as leuprorelin, goserelin, triptorelin, histrelin and buserelin, is carried out with or without additional radiotherapy. LHRH antagonists (eg. As degarelix) can also lower testosterone levels, usually faster than LHRH agonists. LHRH-Agonisten und LHRH-Antagonisten reduzieren meist Serum Testosteron fast genauso viel wie die bilaterale Orchiektomie. Alle Androgenentzugstherapien verursachen einen Verlust von Libido und Erektionsfähigkeit und können Hitzewallungen zur Folge haben. LHRH-Agonisten können die PSA-Spiegel vorübergehend erhöhen. Manche Patienten profitieren von der zusätzlichen Gabe eines Antiandrogens zur vollständigen Androgenblockade (z. B. Flutamid, Bical

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