The prostate has grown into the rectum

Symptoms of prostate cancer by stages

The proportion of PROSTATE CANCER in the total oncological incidence is growing every year. If a few years ago it ranked 6th in terms of prevalence, then in recent years it has come close to the top three most common cancerous tumors in men in terms of localization.

We will tell you how not to overlook such a formidable disease and with what symptoms you should seek medical help.

Symptoms of the disease

The first two stages of Prostate cancer are such a small pathological focus that most often it does not disrupt the normal functioning of the male reproductive system. Such cancers are usually found by chance during surgery or screening.

The tumor grows at a slow pace and the disease progresses unnoticed by the man. In this regard, the first signs of prostate cancer, which clearly attract attention, develop on average 20 years after the onset of the disease.

Stage 1 - a tumor in the submucosal layer, microscopic in size. There are no typical symptoms of grade 1 prostate cancer. From nonspecific symptoms are possible:

• weight loss;
• headache;
• appetite reduction;
• fatigue;
• recurrent thrombophlebitis;
• bleeding.

Most often, prostate cancer at this stage is completely asymptomatic.

In a biochemical blood test, there is a decrease in the level of all proteins, in particular, albumin - hypoalbuminemia.

Stage 2 - the tumor grows through the entire thickness of the organ and the capsule. Depending on whether the tumor interferes with the outflow of urine through the ureter, the symptoms of grade 2 prostate cancer may or may not appear.

If the tumor compresses the ureter, then there are:

• feeling of incomplete emptying;
• frequent urination;
• nocturia - frequent urination at night;
• weakening of the urine stream;
• false urge to urinate;
• imperative urge - the inability to hold urine when you want to urinate.

Sometimes there is Urinary incontinence, which is a consequence of either urinary retention, or a tumor lesion of the sphincter. The germination of the tumor in the sphincter is a symptom of prostate cancer already stage 4.

Stage 3 - the tumor grows outside the capsule. Symptoms of prostate cancer either only occur if there were no manifestations up to grade 3, or progress. Mostly, the tumor is detected at this stage, because the discomfort it causes forces you to see a doctor.

All those signs that were in the previous stages come into full force. Minor pain in the pelvis or back becomes bothersome, it becomes more and more difficult to urinate, weakness increases, and efficiency decreases. Back pain at this stage is due to compression of the overgrown gland of sensitive nerve endings of the small pelvis.

4 stage - invasion of the tumor into neighboring organs, metastases to regional lymph nodes or to distant ones, to bones, to internal organs. The first symptom of the appearance of metastases is moderate pain in the pelvis, lower back.

Signs of prostate cancer spreading into the rectum are symptoms such as:

• constipation;
• tenesmus - painful urge to defecate without bowel movements;
• bleeding from the rectum;
• mucus and anus secretion;
• intestinal obstruction.

If the cancer has grown into the bladder or ureter, there is an admixture of blood in the urine and semen. urinary incontinence develops when the sphincter of the bladder is damaged.

When metastasizing, the symptoms of grade 4 prostate cancer depend on the location of metastases, the prognosis in their presence worsens significantly.

Most often, the bones of the skeleton are affected, so the main symptom is pain in a place corresponding to the location of the metastatic focus. Germinating, it destroys the bone up to a pathological fracture.

Metastases to the vertebrae can lead to compression of the spinal cord and flaccid limb paralysis.

In addition to the inguinal, para-aortic and supraclavicular lymph nodes are affected.

Rarely, metastasis to organs is observed: lungs, liver, brain and spinal cord. Here, the symptoms of damage to this system will come first:

• cough, shortness of breath with lung injury;
• heaviness or pain in the right hypochondrium, jaundice, indigestion with liver damage;
• Central and peripheral paralysis, loss of sensitivity in CNS lesions.

Cancer can develop from prostate adenoma, the symptoms will remain the same, but the obstructive moment will be more pronounced - impaired urination, development of bilateral hydronephrosis. Chronic prostatitis as a focus of inflammation sometimes degenerates into a malignant tumor.

Diagnosis

Treatment of prostate cancer (prostate) by symptoms and stages

The scheme is drawn up individually, taking into account the stage of the disease and the patient's condition.

Radical prostatectomy is performed at stages 1 and 2. Does not affect potency in half or more patients. In young people, external radiotherapy is used.

Treatment stage 3 - radiation therapy. The pelvic lymph nodes and residual tumors are surgically removed. Radiotherapy plus hormonal therapy may be used. At stages 3 and 4, palliative transurethral resection is performed. Read more about prostate cancer surgery here.

Prevention

Specific prophylaxis has not been developed. Men over the age of forty need to undergo an annual examination by a urologist to detect a tumor in the first stages.

This test includes a digital examination of the prostate and a PSA test. To reduce the risk of prostate cancer, you need to:

• limiting the amount of animal fats in the food consumed, dieting;
• exclusion of toxic effects on the body of alcohol, nicotine;
• regular sex life;
• high physical activity and light sports (with the approval of a doctor!);
• rational mode of work and rest.

Attentive and careful attitude to your own health will allow you to notice the signs and symptoms of incipient prostate cancer in time. Diagnosed in the first stages and treated with cancer is a guarantee that many more years of a full life lie ahead.

Learn about early symptoms of lung cancer in case you suspect metastasis.

What is the prognosis for lung cancer at different stages? In this material, you can find out what to hope for.

Prostate tumors (prostate cancer, adenoma, etc.)

Disease diagnosis

For the DIAGNOSIS OF PROSTATE CANCER, a digital examination of the rectum, a blood test for the presence of a prostate-specific antigen (PSA), radionuclide scanning and radiography of the bone skeleton, ultrasound examination of the prostate through the rectum (TRUS), X-ray computed tomography (CT) are used , magnetic resonance imaging (MRI).

Statistics

The incidence of prostate cancer (PCa) is steadily increasing, especially in older men.

In a number of countries, in the structure of oncological diseases, this tumor comes in 2-3 place after lung and stomach cancer, and in the USA - in first place. Mortality from prostate cancer among oncological diseases ranks second after lung cancer. In the late 80s, there was a sharp increase in the incidence of prostate cancer, which gradually decreased to normal levels, which is explained by the detection (screening) of a large number of asymptomatic forms of cancer in connection with the introduction of a tumor marker - prostate-specific antigen (PSA) into everyday practice. /p>

Up to 40% of men aged 60-70 have microscopic (latent) prostate cancer. Only in 10% of cases, the latent form becomes clinically manifested and leads to the death of only 3-5% of the male population. Due to the peculiarities of the clinical course, the tumor may not affect the patient's well-being for many years.

Factors affecting the development of prostate cancer

Age is the most important epidemiological factor. 70% of men over 80 have various forms of prostate cancer, including latent ones (which do not manifest clinical symptoms).

Food. A number of studies have found that the risk of developing the disease increases with the consumption of large amounts of animal fats. Obese men are more likely to be diagnosed with prostate cancer.

Vitamin D. Ultraviolet radiation may also affect the risk of developing prostate cancer. The further south, the lower the incidence. This is explained by the sufficient content of vitamin D3, a cell growth inhibitor.

Genetic factors. Approximately 9% of prostate cancer cases are due to genetic causes, although it is not known which gene is responsible for this. The risk of getting prostate cancer is 2-3 times higher in men whose next of kin got sick with prostate cancer at a relatively young age. The more relatives were sick, the higher the likelihood of developing the disease. If blood relatives are sick, the risk increases by 8 times.

Metastasis

Prostate cancer spreads by local invasive growth, through the flow of lymph (lymphogenic) and blood (hematogenous). Local invasion often precedes the appearance of metastases. The tumor most often invades the prostate capsule, involving the base of the bladder and seminal vesicles in the process.It is possible for prostate cancer to spread to the urethra and urethra. Germination in the rectum is quite rare due to the presence of an anatomical barrier between the prostate and the intestine in the form of a dense connective tissue septum of Denovillier's fascia.

Lymphogenic metastases most often affect the intrapelvic lymph nodes. The next most frequent metastases are the internal and external iliac lymph nodes.

Hematogenous metastases often affect the bone skeleton, mainly the spine, femurs and pelvic bones. Bone metastases are found in 80% of patients who die from prostate cancer. It is not uncommon for advanced cancer metastases to the lungs, liver, brain.

Clinical picture of prostate cancer

In the initial stages, prostate cancer is not clinically manifested, it is usually detected during an in-depth examination of patients with elevated levels of prostate-specific antigen (PSA).

The development of symptoms is associated with an increase in the size of the organ and the appearance of regional and distant metastases. An increase in the volume of the prostate gland leads to the development of symptoms of infravesical obstruction (difficulty urinating, a sluggish stream, the appearance of residual urine), irritative symptoms (frequent urination, imperative urge to urinate), impaired urodynamics of the upper urinary tract (impaired outflow of urine from the kidneys), which, in turn, turn, leads to the development of chronic renal failure.

Locally advanced prostate cancer can compress and grow into the rectum. In such cases, they complain of constipation, false urge to defecate, bleeding, mucus discharge from the rectum. The patient is forced to consult a doctor for pain that appears with bone metastases. Some patients complain of lymphostasis and swelling of the lower extremities caused by tumor transformation of the lymph nodes. As the tumor process progresses, the patient's condition worsens, cachexia, anemia, and bleeding from the bladder develop.

DIAGNOSIS OF PROSTATE CANCER

Digital examination of the rectum

Digital examination of the rectum is the easiest, cheapest and safest method for diagnosing prostate cancer. The characteristic signs of this disease are an increase in size, a change in consistency, the presence of dense nodes, asymmetries, impaired mobility. Palpable motionless tumor infiltrate or germination in the intestine speaks of a far advanced tumor process. Differential diagnosis is carried out with benign hyperplasia (BPH), prostate stones, prostatitis, tumors of the rectum. Only one-third of cases of palpable nodules in the prostate gland are subsequently diagnosed with cancer. The accuracy of diagnosing prostate cancer with a rectal digital examination is 30-50%.

Prostate Specific Antigen (PSA)

PSA is a protein isolated in 1979 from human prostate tissue. And already in 1980, a serological test was created to determine PSA in blood serum. The half-life of PSA is 2.2-3.2 days. Therefore, it may take several weeks for PSA to normalize after prostate manipulation or radical surgery.

Biopsy and transurethral resection necessarily lead to an increase in serum PSA, on average, by 5.9-7.9 ng / ml. After 15-17 days, the level returns to normal. With cystoscopy, transrectal ultrasound and digital examination of the prostate gland, PSA practically does not increase.

In acute and chronic prostatitis, when the cells of the prostate epithelium are destroyed and physiological barriers are violated, which normally do not allow PSA to penetrate beyond the ducts of the prostate gland, its increase is also noted.

PSA detection allows you to detect early and local forms of prostate cancer. But the sensitivity of the method is insufficient to detect latent, microscopic prostate cancer: in 20-40% of cases, there is a normal concentration of PSA in the blood serum. And in the third and fourth stages of cancer, PSA is positive in almost 100% of cases. With a normal size and consistency of the gland, established by digital examination, an increase in the PSA level above 20 ng / ml indicates in favor of a malignant process and requires a biopsy.

The greatest difficulties arise when interpreting PSA values in the range from 4 ng/ml to 10 ng/ml. To address the issue of the need for prostate biopsy in these patients, such indicators as PSA density, PSA growth rate, age norms, and the ratio of various serum PSA fractions were proposed.

PSA density

PSA density is the ratio of PSA concentration to the volume of the prostate gland, determined using TRUS - ultrasound examination of the prostate through the rectum.Considering the higher concentrations of PSA in cancer patients compared with adenoma with the same volume of the gland, this indicator can be used to determine the probability of the presence of adenocarcinoma in a normal gland on a digital examination at PSA values of 4-10 ng / ml, and, accordingly, to decide on indications for a biopsy. Some authors believe that with normal digital examination data and a PSA density of 0.15). With a PSA in the range of 2-10 ng/mL, using this ratio helps to avoid unnecessary biopsy. Clinically significant prostate cancer can be detected by using this ratio even at a lower PSA range.

The described methods of diagnosis in the future require mandatory morphological confirmation of the disease. For this purpose, a puncture biopsy is performed, which is most reliable when performed under ultrasound control.

Staging

Traditionally, the stage of prostate cancer is determined by digital rectal examination. Despite subjectivity, prostate palpation data are taken into account in most classifications. Low cost and ease of implementation are undeniable advantages of the method.

PSA

PSA is of great importance in assessing the prevalence of prostate cancer, correlating with the stage of the disease. In patients with stage 1-2 with PSA>10 ng/ml, capsule germination is noted in 46%, invasion into the seminal vesicles - in 13%, and metastases to the pelvic lymph nodes - in 11% of patients. A PSA level of more than 50 ng/ml indicates spread beyond the gland capsule in 80% of cases and damage to regional lymph nodes in 66% of patients. A PSA concentration of more than 100 ng/ml is associated with the presence of regional or distant metastases in 100% of cases.

However, in each individual patient, it is impossible to accurately determine the prevalence of the tumor process only by the PSA value. The combination of PSA data with the results of digital rectal examination and the degree of tumor differentiation according to biopsy data (Gleason sum) significantly increases the importance of PSA in staging the disease.

Radionucleide skeletal scan

Until recently, this method was mandatory in determining the stage of prostate cancer. Skeletal scintigraphy is highly sensitive in the diagnosis of bone metastases, significantly superior to radiography, clinical examination, and alkaline phosphatase. Due to the high sensitivity, false-positive results are often noted in patients with bone fractures and arthropathies. Recently, radionuclide scanning to establish the stage of the process has been abandoned, since at PSA levels below 10 ng / ml, the probability of the presence of bone metastases is almost zero. However, in newly diagnosed patients with prostate cancer with PSA>10, the presence of bone pain or high alkaline phosphatase, a radionuclide study of the bone skeleton is mandatory.

Bone radiography is required to confirm the presence of metastases in case of ambiguous interpretation of radionuclide scanning. The method determines the characteristic changes in the bones of the pelvis and lumbar spine.

Lung X-ray detects metastases in 6% of patients with prostate cancer at the time of diagnosis and should be performed in all cases.

TRUS

Modern transrectal ultrasound sensors provide very high image quality and allow you to visualize in detail the structure of the prostate, its surrounding organs and tissues, as well as take a targeted biopsy from the altered area of the gland.

Ultrasound tomography reveals infiltration of the prostate capsule, seminal vesicles, bladder, rectal wall, lymph nodes, which, of course, allows you to clarify the stage of the disease. Unfortunately, about half of prostate cancer nodules larger than 1 cm are not visible on TRUS. The sensitivity of the method in the assessment of the stage is 66%, the specificity is 46%.

X-ray computed tomography (RCT)

RCT poorly visualizes the architectonics of the prostate gland, does not allow to reliably distinguish the second stage from the third, has low accuracy in assessing the state of the lymph nodes and, in general, has no advantages over TRUS.

Magnetic resonance imaging (MRI)

The information obtained from MRI corresponds to that obtained from TRUS. 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. Given the high cost, MRI has no advantage over TRUS. The sensitivity of the method in assessing the stage of prostate cancer is 77%, the specificity is 57%.

Excretory urography assesses renal function and upper urinary tract urodynamics.Cistoscopy is a subsidiary diagnostic method. Cystoscopy can detect the asymmetric deformation of the bladder neck. It is difficult to solve whether the tumor germs from the prostate gland in the bladder or vice versa.

Plumber Limfadenectomy

Despite the use of all modern methods for diagnosing prostate cancer, the underestimation of the stage is noted in a large percentage of cases. The most reliable information on the state of iliac lymph nodes gives the removal of lymphatic nodes (lymphadenectomy), performed either during radical prostatectomy, or as an independent (laparoscopic) intervention in patients who planned radical surgical or radiation treatment. With the advent of PSA, the diagnostic value of the pelvic lymphadenectomy is somewhat decreased, because The level of serum PSA, the amount of glues and stage make it possible to quite accurately predict the presence of metastases in lymph nodes. In this regard, the implementation of lymphadenectomy in prostate cancer patients with the first and second stages, the PSA 7 and PSA>10 reduces the risk of local recurrence and improves non-random survival.

Adewant (prophylactic) hormonal therapy

The current advantages of the early maximum androgen blockade after radical prostatectomy in patients with metastases in lymph nodes are proven.

Antandrogen monotherapy (CASTEX 150 mg / day) as adjuvant treatment after prostatectomy and radiation therapy significantly reduces the risk of the progression of the disease under the observation period of up to 3 years.

Radiation therapy

Radiation therapy is shown to patients with local forms of prostate cancer of the first and second clinical stages wishing to avoid surgical treatment or having a high operational anesthesiological risk, as well as patients with the third clinical stage. In recent years, conformal exposure has been widely used, allowing in three projections to choose the most rational conditions of radiation impact with minimal influence on the surrounding tissues, and a large total focal dose of up to 81 grams can be reduced. With traditional radiation therapy, the total focal dose of 60-70 gr.

In patients with high risk of lesions of lymphatic nodes (PSA>10 ng / ml, the amount of points on the Gleason scale>7) It is desirable to perform the basic lymphadenectomy, the results of radiation therapy during metastases are unsatisfactory. The question of the feasibility of using radiation therapy in patients with metastases in lymphatic nodes (N +) remains controversial. A number of work showed a reliable increase in non-dedicious survival, improving local control, but an increase in overall survival (compared to the use of delayed hormonal treatment) No.

Direct local radial reactions of varying degrees of severity on the side of the lower urinary tract and the rectosigmoid division of the colon are observed in a large part of patients. Most of them are bought over the next 4 months. Impotence develops more than half (55-63%) patients in long-term deadlines after the end of radiation therapy. Other possible coming and remote complications of radiation treatment include diarrhea (1.4-7.7%), rectal bleeding (2.6-14.9%), blood in the urine (2.6-10.8%), strictures (narrowing) of urethra (4, 1-11%), urinary incontinence (0.4-1.4%).

Recent years of years indicate the advantage of combined hormone-radiation treatment in patients with local prostate cancer with unfavorable forecast, as well as patients with third clinical stage.

Observation of the patients who suffered radiation therapy is not different from that after surgical treatment: the regular definition of the PSA and the execution of the finger rectal study. When recurring tumor after radiation treatment, the implementation of radical prostatectomy is associated with a large number of complications (stricture of bubble and urethral anastomosis, urinary incontinence) and therefore it is rare.

Brahitherapy

An alternative method of radiation impact at the first and second stage is brachytherapy or interstitial radiation therapy. Brachytherapy Introduction to the prostate gland under the control of ultrasound granules of radioactive I 125. The dose of irradiation of the prostate tissue when using monotherapy I 125 reaches 140-160gr, during combination with external radiation therapy 120g. Unlike remote radiation therapy, the surrounding tissues in brachitherapy practically do not suffer. The procedure for introducing the capsules takes about an hour and is carried out on outpatient conditions, which distinguishes it from other types of radiation treatment.

The results of brachytherapy of the initial stages of prostate cancer are not inferior to remote radiation therapy. Possible complications: acute urine delay, urethritis, stricture of urethra, urinary incontinence, rectum ulcers with possible bleeding, formation of urethrorectal fistula. However, the frequency of these complications is small.In patients with the third clinical stage, brachytherapy should be combined with external radiation.

Delayed treatment

Only observation without cancer treatment is justified in patients with serious concomitant diseases, such as severe forms of diabetes mellitus, coronary artery disease, renal, hepatic, pulmonary insufficiency, etc. Prostate cancer practically does not affect their life expectancy. Patients with highly differentiated adenocarcinoma - benign along the course - are subject to observation without treatment. In stage 2, well- or moderately differentiated tumors, age, life expectancy, comorbidities, and the patient's opinion should be taken into account when considering possible follow-up. The basis of monitoring is the regular determination of PSA and the performance of a digital rectal examination. If signs of progression appear, you can return to consider other treatment options or start hormone therapy.

Local prostate cancer poses a real threat to life and can ultimately lead to the death of the patient. Determining the level of PSA in the blood serum allows diagnosing the disease 5-7 years earlier, which gives a chance for a cure. Radical prostatectomy is one of the most effective treatments for local prostate cancer, which gives a low complication rate and high 10- and 15-year survival rates.

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Prostate cancer

"Handbook of Oncology" Edited by MD B. E. Peterson

Prostate cancer is quite common and accounts for about 5% of all cancers in men. The disease is usually observed after 50 years. The bulk of patients with prostate cancer falls at the age of 60-70 years.

Recently, a connection has been established between this disease and a violation of the correlation of androgens and estrogens in the patient's body. A number of experimental and clinical observations confirm the dependence of prostate cancer on the androgenic function of the testicles. For example, it was possible to obtain experimental prostate cancer in rats by administering androgens to them. It is well known to reverse the development of prostate cancer in humans with estrogen treatment.

Pathological anatomy. Prostate cancer develops from the epithelium of the prostate. The prostate gland is sharply enlarged, with a bumpy surface. On sections, bulging gray-yellow areas are visible among the whitish strands. In other cases, the gland is slightly enlarged, dense, pierced by grayish-yellow strands on the cut. According to the histological structure, adenocarcinoma, solid cancer, sometimes scirr are distinguished. Squamous cell carcinoma is very rare.

Prostate cancer can grow into the capsule of the gland and adjacent organs (seminal vesicles, bladder, pelvic tissue).

Clinic. Prostate cancer can be asymptomatic for a long time, so patients in the initial stage of the disease do not present any complaints. In these cases, prostate cancer can be detected during a routine examination, or accidentally by finger palpation through the rectum for some other disease.

In the vast majority of observations, the symptoms of the disease appear with advanced cancer. Before the appearance of metastases, the main complaints of patients are no different from those of prostate adenoma and are reduced to various disorders of the act of urination. Patients complain of increased urge to urinate, and nighttime urination becomes more frequent than daytime. Almost half of the patients experience difficulty, straining when urinating. Often there is urination in a sluggish, thin stream with interruptions, sometimes drops, with a feeling of incomplete emptying of the bladder. The last sensation is sometimes interpreted by patients as dissatisfaction with the act of urination. Often this sign is combined with the presence of one or another amount of residual urine. Sometimes, despite the feeling of incomplete emptying of the bladder, there is no residual urine. Unlike prostate adenoma, urinary retention in cancer is very rarely the first symptom of the disease.

Hematuria in prostate cancer is observed infrequently. Apparently, as with adenoma, it depends on venous stasis due to compression of the bladder veins in the cervical region by the tumor. However, hematuria can sometimes be a manifestation of tumor invasion of the bladder wall.

Prostate cancer usually does not grow into the rectum. With intensive growth of the tumor in the direction of the rectum, the lumen of the latter may narrow, which leads to constipation, pain during defecation, and false urges.As the tumor grows, and sometimes at the very beginning of the disease, painful sensations appear in the anus, a feeling of pressure on the perineum, pain in the sacrum, lower back and legs.

A characteristic feature of prostate cancer is metastasis to the bone system. Numerous observations have shown that metastases of prostate cancer in the internal organs without bone metastases are extremely rare. Metastases are localized most often in the pelvic bones, sacrum, lumbar spine, in the femoral neck. Much less often, metastases affect the upper spine, ribs, skull

Metastases of prostate cancer in the bones in some patients appear quite early and cause lumbosacral pain. These pains are sometimes the first and only symptom of the disease. At the same time, it is necessary to observe patients with bone metastases for a long time, which are completely asymptomatic. Occasionally, metastases occur in the inguinal lymph nodes.

Late manifestations of prostate cancer include upper urinary tract symptoms. They arise as a result of the spread of the tumor along the bottom of the bladder to the mouths of the ureters, which are subjected to compression at the site of their confluence with the bladder. The consequence of this is a violation of the dynamics of emptying the urinary tract and subsequent functional failure of the kidneys. At the same time, there are pains in the kidney area, dry mouth, thirst.

The following classification of prostate cancer is appropriate:

I stage - single cancer nodes do not go beyond the capsule; no metastases; Stage II - the tumor occupies most of the prostate gland and germinates its capsule; no metastases; Stage III: a) the tumor occupies the entire prostate gland and grows into the surrounding tissues and organs; no metastases; b) the cancerous process in the prostate corresponds to stage I or II; there are metastases in the lymph nodes. Stage IV - the tumor grows into the surrounding tissues and organs; there are multiple metastases; cachexia.

As long as prostate cancer proceeds without metastases, without complications in the form of a purulent infection of the urinary organs and without compression of the ureters, the general condition of patients does not suffer and their ability to work is not impaired. Deterioration of the general condition is observed with advanced tumors, when the influence of cancer intoxication affects, with metastatic lesions of the skeleton, when patients suffer from pain, convulsions and paralysis, and, finally, with frequent difficult and painful urination.

A sharp deterioration in the condition of patients occurs with symptoms of azotemia. The latter arises either from compression of the ureters, or from purulent pyelonephritis. The increase in azotemia leads patients to death with debilitating vomiting and progressive weight loss. Another part of patients with widespread metastases die from cancer intoxication and cachexia.

Diagnosis. The main data for the diagnosis of prostate cancer can be obtained by finger palpation of the prostate gland through the rectum. In the initial stages of the disease, one or more limited seals, sometimes of a cartilaginous consistency, are palpated in the prostate gland. The gland as a whole for a certain time may be only slightly enlarged or not increase at all. Some patients have a focus of cartilage density in one of the lobes of the gland, while the other lobe appears normal.

Sometimes a tumor of the prostate gland during palpation is determined in the form of a cone, the top facing the rectum. In a certain number of observations, iron, which has lost its clear outline, appears as a diffuse infiltrate, almost devoid of mobility. The rectal mucosa, despite the massive tumor infiltrate, almost always remains mobile.

Along with the indicated form of prostate cancer infiltration in some patients, it is possible to palpate strands of infiltrate extending from the upper edge of the prostate gland, according to the direction of the seminal vesicles. However, it is impossible to rely only on palpation data, since chronic prostatitis, tuberculosis and prostate stones can give similar palpation sensations. This is where additional diagnostic tools come to the rescue.

Clinical analyzes of urine and blood in the early stages of prostate cancer usually do not represent pathology. Isohyposthenuria and an increase in residual nitrogen in the blood are observed only in the later stages of the disease and depend on compression of the pelvic ureters or associated pyelonephritis. The amount of acid phosphatase is increased in the blood serum of some patients with advanced prostate cancer without metastases and in most patients with bone metastases.

The cytological analysis of prostate juice is immeasurably more important in the recognition of cancer.The detection of atypical cells in it is indisputable proof of prostate cancer. In cases where juice cannot be obtained, it is recommended to perform a cytological examination of the urine sediment released immediately after prostate massage.

With the help of cystoscopy, you can see changes in the neck of the bladder, often occurring in prostate cancer. With the spread of prostate cancer to the bladder neck without germination of the mucous membrane of the latter, a pale pink tumor is visible, located in the neck area, which appears to be scalloped, covered with edematous, sometimes hyperemic mucosa. Cystoscopic examination makes it possible to detect and germination of prostate cancer in the bladder cavity. However, it is sometimes difficult to decide whether there is prostate cancer that has grown into the bladder, or bladder cancer that has infiltrated the prostate gland.

X-ray diagnostics for prostate cancer consists of two sections: radiography of the skeletal system and urographic examination. Among malignant neoplasms that metastasize to the skeletal system, prostate cancer ranks first. Metastasis of prostate cancer in the bone is expressed as single foci or multiple lesions. Prostate cancer is characterized by osteoplastic or mixed (osteoblastic with osteolytic elements) form of metastases. On the radiograph, osteoblastic metastases have the character of a structureless mass. In this case, there may be single osteosclerotic foci located against the background of a normal bone pattern.

Most often, however, mixed forms of bone metastases are observed, when, along with the osteoblastic process, there is an osteolytic bone lesion. In this case, the variegation of the pattern is extremely characteristic, due to the alternation of compaction and rarefaction of bone tissue. The X-ray picture of prostate cancer metastases is so peculiar that it makes it possible to indicate the primary focus even in cases where there are no other symptoms of prostate cancer.

Urographic examination in prostate cancer determines the function of the kidneys, the dynamics of the emptying of the renal pelvis and ureters, as well as changes in the contours of the bottom of the bladder. On the urogram, produced after intravenous infusion of 40 ml of a 40% solution of sergosin, at the initial stage of compression of the ureter, the contrast agent is visible throughout its entire length, the ureter is somewhat dilated, the pelvis is not yet changed. The increasing compression of the ureter leads to its increasing expansion; the renal pelvis and calyces gradually expand. With complete obstruction of the ureter, the kidney is turned off, which is expressed on the urogram by the absence of a contrast agent on the side of the lesion.

A cystogram with small cancerous nodes in the prostate gland is usually normal. The germination of prostate cancer in the bladder gives a filling defect on the cystogram.

In the case of a decrease in kidney function, a small bladder capacity, or, conversely, a large amount of residual urine, in which the concentration of sergosin drops significantly, a clear descending cystogram cannot be obtained. In this case, X-ray examination can be supplemented by retrograde cystography. After filling the bladder with oxygen or a 5% solution of sergosin, a direct x-ray is taken and a x-ray is taken in the position of the patient on the table in three quarters.

If prostate cancer is suspected, when there are no metastases in the skeleton, and atypical cells are not found in the juice of the gland, the only method to clarify the diagnosis is a biopsy. It is easier and more reliable to take a piece from a suspicious area of the prostate using a special trocar inserted through the rectum under finger control. Diagnosis using transrectal biopsy is reliable in approximately 90% of cases.

For the diagnosis of prostate cancer, the following objective data should be considered reliable:

1) the presence of bone metastases typical of prostate cancer; 2) detection of atypical cells in the cytological examination of prostate juice; 3) a positive result of a histological examination of a piece from the prostate gland.

Any of the listed signs is necessary for the diagnosis and at the same time sufficient. Prostate cancer has to be differentiated from banal chronic prostatitis, tuberculosis, adenoma and prostate stones.

In chronic prostatitis, there is often a history of acute prostatitis; in the juice of the prostate gland, pus is found, there are few lycetin grains. Tuberculosis of the prostate gland is often combined with tuberculosis of the vulva and seminal vesicles.It is not difficult in typical cases to distinguish cancer from prostate adenoma, which is an adenomatous growth of the paraurethral glands. With adenoma, finger palpation through the rectum reveals a uniformly enlarged prostate gland of a densely elastic consistency with a smooth surface and clear contours.

Difficulties arise when it is necessary to differentiate cancer from adenoma, accompanied by inflammation of the prostate itself, and likewise with simultaneous disease with adenoma and prostate cancer. In the latter case, it is not possible to obtain atypical cells in the juice of the prostate gland, and in the absence of bone metastases, the correct diagnosis can only be made with the help of a biopsy. In order to avoid mistakes, if you suspect a simultaneous disease with adenoma and cancer, you should not go deep into the prostate gland with a trocar, but take a piece from its superficial part.

Distinguishing prostate stones from cancer is helped by an overview image taken with the tube tilted so that the central beam falls on the prostate area at an angle of 50-55 to the horizontal plane. By tilting the tube, it is possible to avoid the coincidence of images of the pubic bones with the area of the prostate.

Treatment. A radical operation for prostate cancer consists in removing the entire prostate gland together with the capsule, seminal vesicles with the bladder neck - total prostatectomy. It is possible to count on a favorable result of the operation only in the first stage of the disease. However, a cancerous tumor at this stage proceeds in the overwhelming majority of cases asymptomatically and is usually detected by chance. Therefore, radical surgery can be performed only in 5% of patients with prostate cancer.

Total prostatectomy has not yet become widespread also because the operation is technically difficult, traumatic, gives a high postoperative mortality and often leads to urinary incontinence and narrowing of the urethra. The introduction of hormonal treatment into practice, thanks to which some patients can be transferred from an inoperable state to an operable state, expands the circle of patients who can undergo radical surgery.

The technique of total prostatectomy for prostate cancer is significantly different from prostatectomy for adenoma. Methods of total prostatectomy differ from each other depending on the operational access to the affected organ. There are perineal, ischiorectal, sacral and retropubic methods.

With the perineal method, the patient is in a position, as in an operation for hemorrhoids. A catheter is passed through the urethra first, which serves as a guide and protects the urethra from damage during the operation. The skin incision on the perineum is made at an angle, the top of which is directed upwards. You can also use an arcuate incision with a bulge facing the scrotum. When approaching the posterior surface of the prostate gland, the rectum is retracted downward with a hook. After the exposure of the prostate gland and the membranous part of the urethra, the latter is dissected in the transverse direction. A special "tractor" is introduced through the hole formed into the bladder, both blades of which are bred in the cavity of the bladder by turning the handle of the instrument.

Pulling the "tractor" facilitates the separation of the prostate gland and seminal vesicles from the surrounding tissues. The vas deferens intersect. Above the upper edge of the tumor, the anterior wall of the bladder is dissected. After the mouths of the ureters become visible, the incision continues along the bottom of the bladder from the mucosal side downwards from the mouths of the ureters. The prostate gland is removed en bloc along with the capsule, seminal vesicles and bladder neck. The edges of the bladder incision are sutured on a catheter to the distal part of the urethra. The advantage of the perineal approach is the possibility of excising a piece of the tumor for an urgent biopsy at the very beginning of the surgical intervention.

In a retropubic total prostatectomy, an arcuate incision is made above the pubis. After dissection of the pubo-prostatic ligaments, the prostate gland is isolated from the surrounding tissues and the membranous part of the urethra is crossed. At the side walls of the pelvis, the vas deferens are found, after crossing which the seminal vesicles are isolated. In this case, special attention is paid to maintaining the integrity of the ureters. The tumor is partly acute, partly bluntly separated from the anterior wall of the bladder, after dissection of which the orifices of the ureters become visible. The tumor of the prostate together with the seminal vesicles and the neck of the bladder is separated from the bottom of the bladder below the mouths of the ureters and removed. A bundle of drains is inserted into the lower corner of the wound.The advantage of the descent method is to remove pelvic lymph nodes with a single block along with prostate gland and seed bubbles.

Sedal-direct and sacral accesses are extremely rare. The overwhelming majority of patients in all stages of the disease show hormonal treatment, which should be started with the removal of testicles (castration). A few days after castration, the first course of treatment with large doses of estrogen is carried out.

2% synestrol solution (or diethyl beastrol) of 3-5 ml (60-100 mg) is introduced intramuscularly (60-100 mg) daily for 1 1 / 2-2 months. Depending on the tolerance of the drug, side effects (nausea, the loss of appetite, the painful swelling of the chest glands, swelling) and changes that occur in the primary focus and metastases, the treatment of synestrol or diethylstilbastrol can be extended in the same dosage for another 3-4 weeks or reduce to 20-40 mg per day.

With intense pains associated with bone metastases, hormonal treatment can be with a symptomatic goal is supplemented with radiotherapy - irradiation of affected sections of the skeleton.

In prostate cancer in the first year of treatment, the imported drug Honban (diethyl wastrol phosphorous ether) can also be applied. Honvan is introduced intravenously 500 mg per day for 2-3 days. In the case of good tolerability of the drug, the daily dose is gradually adjusted to 1000 mg and introduce it daily for 3-5 weeks. Instead of Hongvan, a domestic drug phosphorestrol can be applied.

After reaching the clinical effect, as a result of the first course of treatment with synestrol, diethylstilbastrol, Honvan or phosphorezol of patients translated on supporting therapy. The latter consists in the appointment of significantly smaller doses of the same estrogen. For this purpose, estrogens are prescribed inside or intramuscularly at the rate of 5-15 mg per day with small interruptions throughout the life of the patient.

Very effective and at the same time convenient for the patient is the introduction of a synestrol saw into the subcutaneous tissue (5 g). This method in the patient's body creates a depot of estrogen, from which 30-40 mg of the drug is absorbed per day. Such an introduction can be repeated every 4-5 months. If a clinical deterioration comes against the background of supportive treatment or the level of acid phosphatase increases, large doses of estrogen are necessary for the type of first courses of treatment. After reaching the effect, we reappear on supporting treatment.

As a result of hormonal treatment, the state of the majority of patients is improved, and the normal urination is restored. The tumor of the prostate gland decreases, becomes softer, and sometimes it stops trying at all. Metastases are stabilized, and in some cases exposed to reverse development. Along with the sensitivity of the prostate cancer, the primary tumor resistance is observed when estrogens do not act on the tumor at the very beginning of treatment, and secondary resistance at which estrogens cease to be effective at a stage of treatment. The primary resistance of the prostate cancer, in contrast to the secondary, occurs very rarely.

The cause of resistance is unknown. It is assumed that secondary resistance observed in many patients depends on the enhanced androgen products of adrenal crusts after castration and estrogenaterapy. In this regard, upon the occurrence of secondary resistance to suppress the function of the adrenal cortex, it is recommended to combine the treatment with estrogen with the irradiation of pituitary adrenal glands or the prescribing of cortisone.

In cases of germination, the tumor of the bladder cervix, which leads to a complete urine delay in difficulty catheterization, has to be superimposed with a gang of urinary fistula. With compression, the tumor of the pelvic departments of both ureters, threatening the patient of Anuria, shows the imposition of pyelo or nephrostomy. Along with these palliative interventions, hormone therapy should be extended.

Forecast with prostate cancer bad. The patients left without treatment die during the year from the moment the appearance of the first signs of the disease. The exceptions are rare observations of the so-called benign flow, when patients, usually deep old people, for several years after recognition of prostate cancer feel satisfactory.

Hormonal treatment significantly improves the forecast, although rarely leads to full cure. According to various authors, 20-60% of patients with prostate cancer, treated with hormonal methods, live over 3 years.