TUMORS OF THE PROSTATA
The new formations of prostata exist mainly at people of elderly and senile age.
Tumors are most various histological types, but frequently exist epithelium.
Malignant epithelium tumors are a same numerous group of new formations of
prostata.
The cancer of prostata makes 12 % malignant tumors at men. The disease exists
mainly after 50 years.
Etiology and pathogenesis. Cancer development causes aren’t finally cleared
up, but the data of experimental and clinical researches testify to that, that a
pathology is predetermined by violation of the endocrine adjusting of balance of
sexual hormones by the caused changes in the hypotalamohypophysial system (in
case of violation of hormone-education in the adrenal and sexual glands). Proof of
hormone dependence of cancer of prostata there is a reverse development of new
formations during castration and estrogenotherapy. That is why the study of
excretion of sexual hormones gives a definite information for diagnostics and
prognostication of disease consequences. A most frequent disease is shown dysuria
discords. At tumor, which grows slowly, as a result of clench of urination urine
back-end becomes more frequent at night. Then at progress of process it becomes
labored, the urine escapes by the languid stream. Remaining urine is in the urinary
bladder. The urination can be accompanied by pain. Sometimes a sick mark a pain
in crotch, sacrum’s, in lumbus or cock head. The feeling of pressure on crotch can
exist.
Macroscopic hematuria is marked approximately in 10 % sick. Sometimes it
is conditioned by the germination by the wall tumor of urinary bladder, considerably
more frequent – stasis of veins as a result of clench by tumor of veins of wall of
urinary bladder in area of his neck. In case of tumor diffusion along seminal vesicles
the intravesicle departments of ureters compress, ureterohydronephros develops, the
insufficiency of buds makes progress, cystopyelonerphritis joins.
Cancer affected different departments of prostata, but its back-end (under
capsule). For tumor character multycentrys growth. Adenocarcinoma exists in most
cases, rarely –a solid and flatcellular tumor. At the lowdifferentiated cancer
prognosis is very unfavorable.
The classification of the cancer of prostata by system of TNM:
T - prymary tumor;
Т0 - the tumor notpalpation;
Т1 - the single tumular knot doesn’t go out outside capsule of prostata;
Т2 - the tumor occupy a greater part of gland and germinate its capsule;
Т3 - the tumor occupies all prostate, increases, deforms her, but doesn’t go out
outside gland;
Т4 - the tumor germinates surrounding fabrics and organs;
М0 - remote metastases it is;
М1 - metastases in bones;
M2 - metastases in bones and inlaying organs.
Diagnostics.
In the early stage of disease the finger research of prostata
through rectum is very important. Thus some or numerous knots palpation in one of
parts. Thus the gland can be and not megascopic. Sometimes bands of infiltrate,
which goes from the prostata to seminal vesicles palpation (positive symptom of
“bovine horns”). Later the tumular conglomerate can occupy a greater part (or and
all) of gland, passes to the surrounding fabrics and bones of pelvis. The tumor has
dense, cartilagonoid or osteoid consistency. However it is necessary to remember,
that other diseases also can be shown the similar symptoms.
The analyses of urine and blood haven’t pathognomonic signs for this disease.
In majority of sick there is the megascopic ESR. An expressed anemisation exists at
the widespread process with metastatic spreading. In 20 % sick leukocytosis
exposes. As far as progress of process leukocyturia, isohyposthenuria are marked
the functions of buds and livers go down. There is a rising of maintenance in the
level blood whey prostatspeciphic antigen (PSA) of enzyme of sour phosphatase,
especially at metastases in bones, but in the early stage of disease this symptom
doesn’t exist.
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The transuretral resection of prostata settles not only to specify a diagnosis,
but also assists renewal of urination. On computer tomograms at cancer of prostata
in the Т3 and Т4 stage there are increases and deformation of gland appear,
diffusion of tumular infiltration on seminal vesicles, surrounding cellulose. It is
possible to expose the metastases in the regional lymphatic knots. In the stage of Т1
and possibilities of this method are limited, so far as closeness of normal and
tumular tissue almost identical.
Cystoscopy is an auxiliary method of diagnostics of cancer of prostata.
During the conducting cystoscopy the tumular knots can mark deviation of urine. At
cystoscopy is a successfully to expose the asymmetric deformation of neck of
urinary bladder. A changed mucus shell, fibrosis tapes, ulcers, excrescence of tumor
are determined in the tumor germination in wall of urinary bladder place. Thus it is
difficult to clear up, what tumor is primary.
An excretory urography settles to estimate a function of buds and urodynamic
overhead urinary ways. Ureterectasy and ureterohydronephros are an investigation
of clench of pelvic departments of ureters by tumor. Such changes are often from
one side. At full obstructions the ureter bud doesn’t functional and the shade on the
clench side doesn’t appear. The characteristic changes exist at sciagraphy of bones
of pelvis and lumbar department of vertebral post: osteoplastic (osteosclerotic),
considerably rarely there are the osteolitic (osteoclastic) and their combination. As a
result of duty of changed areas the bones of pelvis have a marble kind.
Lymphangioadenography settles to expose the defeat of regional lymphatic
knots, but not all they are noticeable on lymphograms.
Ultrasonic echography settles to expose the areas of heterogeneous
compression without the clear contours at the changed structure of prostata. On
pneumocystograms prostata gland megascopic, its contours are unclear. The
characteristic changes exist at genitography.
Differential diagnostics. A cancer of prostata is differentiated with prostatitis,
hyperplasia, tuberculosis, and sclerosis, stone of prostata, cancer of neck of urinary
bladder.
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At chronic prostatitis and cancer the data of finger rectal research can be
similar. About chronic prostatitis they testify an anamnesis data about carried sharp
prostatitis, duty of periods of the sharpening and fading, appearance during
palpation of pain in area of prostata, exposure of areas of the softening. In a sick on
cancer in case of finger rectal research early expose limitation of gland mobility,
tumular infiltration in areas, which are contained nearer to periphery of organ. In the
case of doubt set a diagnosis on the basis of data of punction biopsy of organ.
Stone of prostata are usually accompanied by pain in crotch and rectum, by
discord of urination. Palpations of gland causes a pain, a symptom of crepitation is
determined (as a result of friction of stone). On the surveying urogram in area of
prostata the shades of concrements appear. However it is needed to remember, that
in one sick there can be the stone and cancer of prostata simultaneously.
At tuberculosis during palpations of prostata it is possible to expose the areas
of compression on background of unchanged tissue. As a rule, the tuberculosis of
prostata exists at the sick on tuberculosis urinary organs. The characteristic changes
expose at such patients: cavities in buds, small urinary bladder, rash on the mucus
shell of urinary bladder, retraction opening of ureters. In the case of doubt the
running to the biopsy of prostata comes.
At sclerosis prostata is dense. On uretrocystogram prostata part of urine is
narrowed, on miction cystogram the neck of urinary bladder does not open up.
Medical treatment.
For the medical treatment of a sick on cancer of prostata the efficient methods
(radical and palliative) apply, hormone, chemo-, radial and imunotherapy .
The method choice relies on stage of tumular process, histological form of new
formation and hormone background in organism of a sick.
In case of disease in stage the Т1 N0M0 or Т2N0M0 radical operation is
shown (if settles a state of sick). After operation in default of metastases in the
lymphatic knots (Mx-) they conduct a course of prophylactic estrogenotherapy. In
the case of metastasic spreading (Mx+), regardless of that, remote metastases fully
or partly, they conduct castration and appoint estrogenotherapy.
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In the stage of the Т3N0-xM0 they recommend castration, setting estrogens
and (or) irradiation. If thus the primary tumor diminished to the Т1-2 stage and
contra-indications to the radical operation it is, execute prostatektomy with the
following estrogenotherapy. At stage Т1-4N1M0-2 or Т1-4N0-xM1-2 by used
castration and estrogenotherapy in combination with the irradiation and (or)
chemotherapy. It is better to begin the medical treatment of a sick on the
estrogenoresistent form of cancer of prostata (in default of regional and remote
metastases) with the irradiation of primary tumor. In the case of presence of
metastases they appoint a chemotherapy and androgens hormones. If in a sick the
delay of urine exists, additionally they execute epicystostomy, transurethral
resection or criodestruction glands.
Radical prostatektomy foresees the removal of all prostata with capsule,
seminal vesicles, by the prostate part of urine, neck of urinary bladder, adjoin tissue
and pelvic lymphatic knots. They execute this operation in the І-ІІ stage of disease,
if it is germination of tumor in the fatty cellulose and adjoins organs. The duration
of life of a sick doesn’t rely so much on their age, sizes and degree of tumor
malignant, as on degree of defeat of lymphatic knots. The frequency of application
of radical method of medical treatment makes 3-5 %, that is explained by
complication of exposure of initial stages of disease, operation weight, elderly age
of majority of sick and others like that. Index of survival of a sick after
prostatektomy during five years makes disease stages 80%, at II-76%.
Depending on access to the prostata distinguish crotch in, postpubical,
transvesicle and transabdominal prostatektomy. The transabdominal prostatectomy
in combination with the resection of neck of urinary bladder and postpubical
prostatectomy with retroperitoneal limphadenectomy are most widespread.
For the exception of hormone influence of testicles on growth of tumor sick
apply orchidectomy or subcapsular enucleation (removal of parenchyma) testicles.
Method of orchidectomy. Under local infiltration or by the explorer anesthesia
(20-40 ml 0,5 % novocaine solution in layer of seminal funiculus) execute a
inguinoscrotal - cut long 8-10 cm, avoiding a dissection of front wall of canalis
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inguinalis. Testicle with appendage on seminal funiculi separates from fabrics and
dislocates in wound. Seminal funiculi near the superficial inguino ring stitch by the
thick catgut, bandage and cross between two ligatures. After it testicle with
appendage delete. Layered sew a wound, leaving in cavity of scrotal thin rubber
drain. A similar operation is executed from other side. They impose a tight bandage
on scrotal. In cavity of albuminous shell abandon on the 2-3 days gauze or rubber
drain, where upon wound of albuminous, serosal shells and scrotal stitch sew by the
knotted catguts stitches. They execute a similar operation and from other side. On
scrotum they impose a tight bandage. So far as in majority of a sick on cancer of
prostata the widespread forms of process exist, them frequent they appoint a
hormone therapy, which is choice method. At estrogenotherapy at the beginning of
medical treatment they apply preparations in high doses, and then conduct a
supporting therapy by the little doses. For estimation of efficiency of
estrogenotherapy they use echography and computer tomography, and also they
explore urine on the estrogen satiation of organism (test after Dunayevskye Shapero). At the optimum saturation the quantity of epithelium cages in urine makes
4500-7000 in 1 ml (700-1500 in 1 мм3), in that number of mature forms about 32
%. The considerable increase of number of epithelium cages and mature forms
(about 90 %) testifies to overdosage preparation. The increase of quantity of mature
cages on background of optimum number of epithelium is the prognostic
unfavorable symptom.
The supporting therapy foresees the providing of a necessary level of estrogen
situation of organism during the protracted time. For this purpose they apply
chlortriaseny (on 0,012 gr 2-3 times per a day), microfolyni-forte (on 1 to the pill 34 times per a day), fosfastroly, dyfostylben (on 0,1 gr 1-4 times per a day).
It is not recommended to interrupt the medical treatment more how on the 2-3
weeks.
Orchydectomy apply in case of exposure of tumor resistens the concerning
estrogen, and also in the case of impossibility of the conducting a hormone therapy
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through unbear of estrogen, decompensation of function of organs of circulation of
blood, expressed functional insufficiency of liver.
The application of synthetic antiandrogen (buzerelyny, decapeptyly)
practically results in the medicinal castration, so far as they lower a level of
testosterony in the blood whey. In case of protracted introduction of estrogen the
efficiency can go down. It is explained by products of androgen by the adrenal
glands. That is why it is needed to combine androgens.
Estrogens predetermine the considerable changes in organism. Under their
influence a sick becomes the whining, conflicts, the swelling up and pallor of milk
glands are marked at him. The rise of level of triglyceride in the blood whey assists
thrombemboly. The esrtogen therapy frequent results in the deep defeat of liver –
the sharp hepatitis, dystrophy. Esrtogen correct the nephrotoxic influence - violate
urodynamic overhead urinary ways; in 58-77 % sick pielonephrytis develops.
In 10-20 % sick therapy of estrogens isn’t effective from the beginning
(primary estrogenoresistens), and in most patients it doesn’t become effective
afterwards (second estrogenresistens).
A radial therapy is enough widely used at cancer of prostata. It has a row of
advantages before other methods, in particular hormons - and by chemotherapy, in
the same time does not affect the organs of circulation of blood and system of blood
sedimentation. Especially it’s expedient application at hormone resistens forms of
cancer.
Frequently they apply a distance radial therapy with the use of megavolt
sources of radiation and electronic accelerating, and also tissue radial therapy. How
an independent method is recommended to apply a radial therapy in the Т1-3 stage,
but some authors consider, that it expedient in any stage, it is needed only to change
an irradiation method.
The irradiation considerably improves a state of sick at IV disease stages,
presence of metastases in bones (especially in spine), which are frequent shown
clench (by compression) of spinal cord with the palliative aim appoint the local
irradiation or directed on the hypophysis area. In the case of generalisation process
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sometimes the running to the total irradiation comes. Thus the pain diminishes or
disappears, and in case of clench of spinal cord the decompression exists.
The chemotherapy at cancer of prostata has only an auxiliary value through
the low sensitiveness of tumors to chemopreparations. It’s expedient it’s setting at
hormone resistens tumors. Frequently they apply adriamyciny, cyclophoshany,
ftoruracyly, cysplatyny, and metotrexaty. The temporal objective effect (reduction
of primary tumor or its metastases) exists in 8-40 % sick, and subjective (reduction
of pain, improvement of urination)-у 40-90%. Duration of remissions is 2-16
months. Chemopreparations appoint in the different combinations, same effective
there is an application of hormonocytostatics with estracytis.
The consequences of medical treatment rely on time of appeal of sick to the
doctor. About 95 % sick get in the permanent establishment and their state isn’t
operable. That’s why for the active exposure of a sick it is necessary to conduct the
planned reviews of men by age over 40 years.
At the І-ІІ stages of cancer during five years live after the radical medical
treatment 80 % sick, after the radial therapy - 80 %, after hormone 45-65 %.
The tumors from the fibrosis fabric belong to the no epithelium tumors of prostata
gland -leiomioma, leiomiosarcoma, rabdo-miosarcoma, embryo rabdomiosarcoma,
blood and lymphatic vessels-hemangioma, gemangiosarcoma, gamangiopericytoma,
melaninproduction tissue-nevus, melanoma, peripheral nerves and like to ganglionsneiurofibroma, nevrilemoma, ganglio-nevrinoma, shvanoma, neiuroblastoma, and
also from cages of the APUD system -apudoma.
Before
the
mixed
cystoadenoleiomiofibroma,
new
filoid
formations
cyctosarcoma,
of
prostata
malignant
gland
mezenchioma,
carcynosarcoma, to the tumular illnesses of bloodproduction and limfoid tissueslimfosarcoma, limfoma, retyculosarcoma, teratoma belong.
The mixed tumors exist very rarely, most malignant among them it is
sarcoma.
The sarcoma of prostata makes about 0,1-0,3 % malignant new formations in
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organ. It often strikes the children and men in age to 40 years. An etiology of this
tumor is not cleared up.
Fibro-, mio- and limfosarcoma of prostate mainly exist. At children and
teenagers in 60-75 % cases there is rabdosarcoma. It grows quickly, spreads on all
glands, and germinates adjoint organs and fabrics. By the metastasis lymphogenous
(in to the club and paraortal lymphatic knots) and gematogenous (in bones, liver,
buds, adrenal glands, lights) ways.
Diagnostics.
Basic method of diagnostics there is a finger research of prostata through
rectum. Thus a large tumor without the clear lines exposes. If a new formation
widespread on the surrounding fabrics, the setting of its source is impossible.
Ureterogydronephros is often determined at excretory urography, conditioned by the
clench of ureters by tumor. On cystograms it is possible to expose a deformed or
displaced upwards urinary bladder. A diagnosis is specified by transrectal biopsy of
tumor.
The metastases in the bone system have an osteolitic nature. A sarcoma of
prostata is differentiated with other new formations, inflammatory processes, stone
of prostata.
Medical treatment.
In that cases, when it is still possible to delete a tumor, they execute the total
prostatektomy. After operation they conduct radial and cytostatic therapy. The
consequences of radical prostatektomy are satisfactory. At the neglected tumular
process, if settles a state of sick, they execute the palliative interference’s –
transuretral
resection
of
prostata,
epicystostomy,
nephrostomy
or
ureterocutaneostomy. Then they apply the irradiation or cytostatic therapy. A
hormone medical treatment is not effective.
Prognosis is unfavorable. A sick dies from urosepsis and cachexies in a year.
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