Assessment and staging of prostate cancer

Even before the biopsy is taken, the clinician may want to perform the MRI of the pelvis – to assess whether the tumour breaches the capsule (the biopsy needle tracks producing the false positive interpretation) and whether pelvic nodes or bones are affected. A bone scan may also be requested as the nodes and bones are the sites of most likely metastatic spread.

The key element of staging is to decide whether the disease is organ confined (within capsule), locally spread through the capsule or metastatic (the TNM staging system is useful).

The clinical “staging” is as follows :-

  • T. Primary Tumour
  • T0 – No tumour palpable
  • T1 – Tumour in one lobe of the prostate
  • T2 – Tumour involving both prostate lobes
  • T3 – Tumour infiltrating out of the prostate to involve seminal vesicles
  • T4 – Extensive tumour, infiltrating local structures
  • N – Nodal status
  • N0 – No nodes
  • N1 – one sided nodes
  • N2 – Bilateral nodes
  • N3 – Fixed regional nodes
  • N4 – Juxta regional nodes
  • M – Metastases
  • M0 – No metastases
  • M1 – Metastases

PSA and Staging

The clinician will also take great note of the PSA result, as PSA levels reflect the extent of spread of prostate cancer.  Thus, a PSA level of > 100 is generally thought to indicate that the prostate cancer has spread to involve organs such as lymph nodes or bones, and that the tumour is no longer confined to the prostate alone.

PSA levels of >15 also influence management decisions and many surgeons will not operate on a patient with PSA levels >15 as this indicates to them that there may be a strong possibility that surgery may not be successful.

Therapy

I. Localised disease. For patients with localised disease, the chance of cure is very high – for some low Gleason score patients with only a minority of positive biopsies, a “watchful waiting” policy may be pursued for some time.

Thus, for example, the patient with a single focus of Gleason Grade 3 turnover after multiple prostate gland biopsies, has a low chance of early progression of cancer and, particular where there are other potentially serious medical conditions (e.g. heat disease) “watchful waiting” with monitoring of PSA is merited. For others, active treatment is indicated.

Where the patient has obstructive symptoms and a large gland (>55cc), then surgical options have appeals. However, for most other patients there is a genuine choice between radical/curative surgical options and radio therapeutic options – the cure chance (80-90%) being equivalent (Stage of stage, grade for grade). Ablative therapies by cryotherapy or high intensity frequency ultrasound do not have the two decade validity of follow up date to prove equivalence and only the surgical and radio therapeutic options will be discussed in full here.

The radiotherapy options usually carry less side effects than the surgical options.