DIAGNOSIS
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It
is of utmost importance that you understand your diagnosis and what it means.
All of the terms used will be foreign to you and the medical people often will
not have time to explain them all. We list below some of the common terms
you will come across and give you links to find more information on a specific
term. The terms are listed in the sequence in which you might come across
them, as you go through the diagnostic process, from the first visit to your doctor.
COMMON
TERMS
DRE
- Digital Rectal Examination:
Much
feared by most men, for no good reason other than embarrassment. Women tell us
it is nothing compared to some of their examinations. Because the prostate gland
is so well hidden, the only way it can be reached is via the rectum. A finger
is inserted into the rectum and the doctor can then feel the gland to see if there
are any signs of abnormality.
BPH
[Benign Prostatic Hyperplasia or Hypertrophy]
:
This
is a non-cancerous condition of the prostate gland. It results in the growth of
both glandular and connective tumour-like tissue. This enlarges the prostate and
causes obstruction to the passing of urine. The symptoms are slowing of the stream,
needing to urinate during the night and an urgency to urinate. It is a benign
growth that is present to some degree in all men over 50 years of age. The
most common cause of the PSA score being elevated is BPH and urinary tract infections.
TURP
- Transurethral Resection Of The Prostate:
If
BHP (see above description) is serious enough, it can cause the prostate to restrict
the flow of the urine. TURP
is usually a minor surgical procedure whereby an instrument called a resectoscope
is inserted into the penis to relieve the pressure of the prostate on the urethra.
There are, however, variations on this procedure, using heat, termed TUNA
(Transurethral needle ablation) or TUMT (Transurethral microwave thermotherapy)
and lasers PVP (Photoselective Vaporisation of the Prostate) or Laser
GreenLight™ to achieve the same result.
PSA
- Prostate Specific Antigen:
This
refers to the standard test which indicates the possibility of cancer in the prostate.
Very severe cases will have a PSA count in the hundreds or even the thousands,
but the threshold of concern is generally a reading of 4.0 ng/ml. Some specialists
believe a lower figure to be appropriate. You should be aware of the fact that
it is NOT cancer specific and that your PSA count can be raised by many things,
apart from cancer. In fact only about 35% of men with an elevated PSA will be
found to have prostate cancer. The most common causes of an elevated PSA
reading is are DRE, BPH, bladder or prostate infections and sexual activities.
For more detail on the subject go to PS 101 .
Men who have had surgery will often use Ultra-Sensitive
PSA tests, which are also subject to a fair degree of inaccuracy.
BIOPSY:
A
biopsy involves taking a very small specimen of tissue for microscopic examination
with a very fine needle. The prostate is well hidden so it is difficult to take
specimens. In the past the standard needle biopsy saw the use of six spring-loaded
needles, but twelve is a more common number now - some doctors use more. In some
cases a 'saturation' biopsy is used which involves 50 or more needles. You should
ensure that this will serve a valuable purpose before agreeing to this.
The
needles are usually shot into the prostate via the rectum although more rarely,
and for saturation biopsy procedures they are aimed though the perineum - the
area between testicles and anus. It sounds worse than it is. For most men it is
rather like getting a hard kick in the backside each time a needle goes in. Other
men may have lower pain thresholds and should ask for some form of pain relief
- for some reason this is rarely offered.
If
you have had this procedure you will know that urine and semen are usually blood
stained for some time afterwards. There can be other more serious side effects
but they are rarely reported. Many mn are concerned that biopsy procedures may
cause the cancer, if there is any within the gland, to spread beyond the gland.
There is no evidence that this will occur and, since there are literally hundreds
of thousands of biopsy procedures carried out each year, if the disease was spread
by the procedures, there wold be the expectation that the number of cases of advanced
cancer would soar. This has not happened.
You
should ask the doctor, before the procedure if the specimens will be well
labelled - showing where they come from in the prostate. This is not done in all
cases and can reduce the knowledge required for a good decision on the best treatment.
PIN
- Prostatic Intraepithelial Neoplasia:
This
is described as a pre-cancerous change to the cells of the prostate, which resemble
adenocarcinoma as to a number of other changes. It is called 'pre-cancerous' because
it is thought by some experts that that it may 'evolve' into cancer over a period
of time - some reports indicate more than five years. There are no studies that
show this evolution. It is important for pathologists to distinguish between PIN
and PCa in their reports.
PCa
- Prostate Cancer
This
is also frequently referred to as PC or CaP. There is little to be said here about
the disease since anyone diagnosed will be focussing on it in all its complexities.
It is important to remember that it is usually a slow growing cancer, except in
very late stages and that there is usually an ample amount of time to research
available options. No one diagnosed with PCa should have to undertake treatment
until they understand what the treatment involves and what the outcomes and side
effects of the treatment will be. As will be seen in the note on Gleason Scores,
the recommendation is to get a second
opinion on this very important issue from a recognised
expert. One of these experts is Dr Jonathan Oppenheimer who has this to say
on his blog:
For
the vast majority of men with a recent diagnosis of prostate cancer the most important
question is not what treatment is needed, but whether any treatment at all is
required. Active surveillance is the logical choice for most men (and the families
that love them) to make.
GLEASON
GRADES AND SCORES :
The
system of judging the aggressiveness of the tumour is based on the Gleason
Grade assigned to the cancerous material - and is called a Gleason
Score. It is the main factor by which the likelihood of the cancer
spreading beyond the prostate capsule is judged and therefore which treatment
option is most appropriate. A sample of tissue taken from the prostate is examined
under a microscope. Two areas where the cells are not normal are selected [these
are referred to as foci]. Each is allocated a Grade on a scale which
used to be 1 through 5, where 1 was well differentiated [good] and 5 was poorly
differentiated [bad]. The two grades added together gave a Score
on a scale of 2 to 10, where 6 was the mid-point. The most common Grades
were 2 and 3 and the most common Scores were 5 and 6.
Since
the advent of PSA testing in 1987 there has been a gradual change in the interpretation
of Gleason Grades and the lower Grades - 1 and 2 - are no
longer labelled as adenocarcinoma or cancer. This means that the scale of Gleason
Scores now runs from 6 (the lowest and least aggressive) to 10 (the highest
and most aggressive). The most common Scores are 6 and 7, with the
7 Scores being broken down into Scores of 3+4 and
4+3. The former are more similar in behaviour to tumours with a Score
of 6. For a more detailed description go here.
The
Gleason Score is a critical item; it drives the decision making process. It is
however, a subjective system, with signficant variances reported and therefore
it is important to get a second opinion from a recognised
expert.
STAGING:
This
is the system used to describe the extent of the cancer or the degree to which
it has progressed. The old system had four stages - ABCD to describe the stage
of the disease but the currently recommended system is known as the TNM system.
The T refers to the stage of PC within the prostate. The N refers to the status
of the lymph nodes near to the prostate - whether the PC has spread there or not.
The M stage indicates if there are any mets. The result is a formula such as T2aN0MX.
This would indicate a stage 2 (a) cancer in the prostate with no sign of spread
to the lymph nodes and an inability to ascertain the presence or absence of any
mets.
The
initial staging is known as the clinical stage and is signfied by the letter c
in front of the formula mentioned above - the most common staging being cT1cN0M0.
If the gland is removed in surgery, another pathology report is prepare. The pathological
staging is usually different to the clinical staging and is prefixed by the letter
p for example pT2cN0M0. For a more detailed description go here.
METS:
Metastases.
These are the cancer sites away from the prostate and are sometimes referred to
as secondaries. As PC grows within the prostate it starts to spread throughout
the body and becomes much more difficult to control. This is the rationale for
early diagnosis - to catch the PC before it metastasises.
PARTIN
TABLES
:
These
tables are used to try and calculate the likelihood of the spread of PC out of
the capsule of the prostate using your PSA, Gleason Ratings and Staging. Although
they look complicated at first, they are understandable with a bit of patience.
As part of your understanding of your condition you should do your best to do
this. This page prepared by
the Brady Urological Institute gives a very good explanation and allows you to
make your own calculation of the probablities. to do this you will need your staging,
your PSA and your Gleason Score.
BONE
SCAN
:
This
test is to establish whether there are any mets to the bones - in other words
if the cancer has escaped from the prostate capsule and spread to the bones. It
is generally considered unlikely that there will have been a spread if the PSA
reading is under 10 - some feel that this applies to readings under 20.
MRI - Magnetic Resonance Imaging :
A
comparatively new method of scanning the prostate to detect any signs of PC.There
is a good explanation of what this test does and how it works at
RadiologyInfo.
ADENOCARCINOMA
:
The
word generally used to describe epithelial tissue in a gland that has become malignant.
It is identified in a pathology laboratory and given the name of the tissue affected.
eg the prostate gland tumour gets the name 'prostate adenocarcinoma', because
its cells resemble the cells of the prostate. There are many sites on the topic,
but are narrowed by only dicussing the action of particular treatment options,
eg, radiation therapy or hormone therapy.
We
have only listed some of the most common terms. There are many comprehensive Glossaries
on the internet giving many more of the terms used. We give below two links to
Glossaries.
