Acinar adenocarcinoma della prostata Gleason score 9

Il Grado di Differenziazione nel Carcinoma della Prostata

Trattamento di prostatite nanotecnologie

The median age at diagnosis of carcinoma of the prostate is 66 years. The rate of tumor growth varies from very slow to moderately rapid, and some patients may have prolonged survival even after the cancer has metastasized to distant sites, such as bone.

Side effects of various forms of treatment should be considered in selecting appropriate management. Many patients—especially those with localized tumors—may die of other illnesses without ever having suffered disability from the cancer, even if managed conservatively without an attempt at curative therapy. Because diagnostic methods have changed over time, any analysis of survival after treatment of prostate cancer and comparison of the various treatment strategies is complicated by the evidence of increasing diagnosis of nonlethal tumors.

Nonrandomized comparisons of treatments may be confounded not only by patient selection factors but also by time trends. For example, a population-based study in Sweden showed that, from to the late s, before the use of PSA for screening purposes, long-term relative survival rates after the diagnosis of prostate cancer improved substantially as more sensitive methods of diagnosis were introduced.

Another issue complicating comparisons of outcomes among nonconcurrent series of patients is the possibility of changes in criteria for the histologic diagnosis of prostate cancer. Controversy exists regarding the value of screening, the most appropriate staging acinar adenocarcinoma della prostata Gleason score 9, and the optimal treatment of each stage of the disease. Acinar adenocarcinoma della prostata Gleason score 9 new cases and deaths from prostate cancer in the United States in [ 15 ][ A Snapshot of Prostate Cancer ].

Enlarge Figure 1. Anatomy of the male reproductive and urinary systems. The issue of prostate cancer screening is controversial. In the United States, most prostate cancers are diagnosed because of screening, either with a PSA blood test or, less frequently, with a digital rectal examination.

Randomized trials have yielded conflicting results. Refer to the PDQ summary on Prostate Cancer Screening for a detailed summary of evidence regarding the benefits and harms of screening for prostate cancer. Prostate adenocarcinomas are frequently multifocal and heterogeneous in patterns of differentiation. Prostatic intraepithelial neoplasia [PIN] noninvasive atypical epithelial cells within benign appearing acini is often present in association with prostatic adenocarcinoma.

PIN is subdivided into low grade and high grade. The high-grade form may be a precursor for adenocarcinoma. Several rare tumors account for the remaining few percentages of cases. These include the following:. The histologic grade of prostate adenocarcinomas is usually reported according to one of the variations of the Gleason scoring system, which provides a useful, albeit crude, adjunct to tumor staging in determining prognosis. The classical score is derived by adding the two most prevalent pattern grades, yielding a score ranging from 2 to Because there is some evidence that the least-differentiated component of the specimen may provide independent prognostic information, the score is often provided by acinar adenocarcinoma della prostata Gleason score 9 separate components e.

There is evidence that, over time, pathologists have tended to award higher Gleason scores to the same histologic patterns, a phenomenon sometimes termed grade inflation. For example, prostate biopsies from a population-based cohort of 1, men diagnosed with prostate cancer from through were re-read in to As a result, Gleason-score standardized prostate cancer mortality rates for these men were artifactually improved from 2. A number of tumor markers have been reported to be associated with the outcome of prostate cancer patients, including the following:[ 2122 ].

However, none of these has been prospectively validated, and they are not a part of the routine management of patients. In the United States, most prostate cancers are diagnosed as a result of screening; therefore, symptoms of cancer are infrequent at acinar adenocarcinoma della prostata Gleason score 9 time of diagnosis. These symptoms acinar adenocarcinoma della prostata Gleason score 9 nonspecific and more indicative of benign prostatic hyperplasia than cancer.

Although rare in the current era of widespread screening, prostate cancer may also present with symptoms of metastases, including bone pain, pathologic acinar adenocarcinoma della prostata Gleason score 9, or symptoms caused by bone marrow involvement. Needle biopsy is the most common method used to diagnose prostate cancer. Most urologists now perform a transrectal biopsy using a bioptic gun with ultrasound guidance.

Less frequently, a transperineal ultrasound-guided approach can be used in patients who may be at increased risk of complications from a transrectal approach. Prophylactic antibiotics, especially fluoroquinolones, are often used before transrectal needle biopsies. There are reports of increasing rates of sepsis, particularly with fluoroquinolone-resistant E.

The survival of patients with prostate cancer is related to several factors, including the following:[ 30 - 34 ]. Refer to the Surveillance, Epidemiology, and End Results' 5-year and year survival rates. When the cancer is confined to the prostate gland, long-term prognosis is excellent. Patients with locally advanced cancer are not usually curable, but 5-year survival is still very good.

If prostate cancer has spread to distant organs, current therapy will not cure it. Median survival is usually 1 to 3 years, and most of these patients will die of prostate cancer. Even in this group of patients, indolent acinar adenocarcinoma della prostata Gleason score 9 courses lasting for many years may be observed. Poorly differentiated tumors are more likely to have metastasized before diagnosis and are associated with a poorer prognosis.

The most commonly used method to report tumor differentiation is the Gleason score. Refer to the Pathology section of the General Information About Prostate Cancer section of this summary for more information. Any benefits of definitive local therapy with curative intent may take years to emerge. Therefore, therapy with curative intent is usually reserved for men with a sufficiently long-life expectancy. For example, radical prostatectomy is often reserved for men with an estimated life expectancy of at least 10 years.

PSA, an organ-specific marker, is often used as a tumor marker. However, it is an imprecise marker of risk. For example, baseline PSA and rate of PSA change were associated with subsequent metastasis or prostate cancer death in a cohort of men with clinically localized prostate cancer who were managed by watchful waiting or active surveillance in the control arm of a randomized trial comparing radical prostatectomy with watchful waiting or active surveillance.

Elevations of serum acid phosphatase are associated with poor prognosis in both localized and disseminated disease. Several nomograms have been developed to predict outcomes either before radical prostatectomy [ 43 - 46 ] or after radical prostatectomy [ 4748 ] with intent to cure.

Preoperative nomograms are based on clinical stage, PSA level, Gleason score, and the number of positive and negative prostate biopsy cores. One independently validated nomogram demonstrated increased accuracy in predicting biochemical recurrence-free survival by including preoperative plasma levels of transforming growth factor B1 and interleukin-6 soluble receptor. Postoperative nomograms add pathologic findings, such as capsular invasion, surgical margins, seminal vesicle invasion, and lymph node involvement.

The nomograms, however, were developed at academic centers and may not be as accurate when generalized to nonacademic hospitals, where the majority of patients are treated. In addition, the nomograms may be affected by changing methods of diagnosis or neoadjuvant therapy. The optimal follow-up strategy for men treated for prostate cancer is uncertain.

Men should be interviewed and examined for symptoms or signs of recurrent or progressing disease, as well as side effects of therapy that can be managed by changes in therapy. However, using surrogate endpoints for clinical decision making is controversial, and the evidence that changing therapy based on such endpoints translates into clinical acinar adenocarcinoma della prostata Gleason score 9 is weak.

Often, rates of PSA change are thought to be markers of tumor progression. However, even though a tumor marker or characteristic may be consistently associated with a high risk of prostate cancer progression acinar adenocarcinoma della prostata Gleason score 9 death, it may be a very poor predictor and of very limited utility in making therapeutic decisions.

Although the PSA test is nearly universally used to follow patients, the diversity of recommendations on the provision of follow-up care reflects the current lack of research evidence on which to base firm conclusions.

A systematic review of international guidelines highlights the need for robust primary research to inform future evidence-based models of follow-up care for men with prostate cancer.

These observations should be independently confirmed in prospective study designs and may not apply to patients treated with hormonal therapy. In addition, there are no standardized criteria of surrogacy or standardized cutpoints for adequacy of surrogate endpoints, even in prospective trials.

After radical prostatectomy, a detectable PSA level identifies patients at elevated risk of local treatment failure or metastatic disease;[ 37 ] however, a substantial proportion of patients with an elevated or acinar adenocarcinoma della prostata Gleason score 9 PSA level after surgery remain clinically free of symptoms for extended periods.

For example, in a retrospective analysis of nearly 2, men who had undergone radical prostatectomy with curative intent and who were followed for a mean of 5. The median time to the development of clinical metastasis after biochemical recurrence was 8 years. After the men developed metastatic disease, the median time to death was an additional 5 years.

For patients treated with radiation therapy, the combination of clinical tumor stage, Gleason score, and pretreatment PSA level is often used to estimate the risk acinar adenocarcinoma della prostata Gleason score 9 relapse. After radiation therapy with curative intent, persistently elevated acinar adenocarcinoma della prostata Gleason score 9 rising PSA may be a prognostic factor for clinical disease recurrence; however, reported case series have used a variety of definitions of PSA failure.

The implication of the various definitions of PSA failure for OS is not known, and, as in the surgical series, many biochemical relapses rising PSA only may not be clinically manifested in acinar adenocarcinoma della prostata Gleason score 9 treated with radiation therapy.

Other PDQ summaries containing information related acinar adenocarcinoma della prostata Gleason score 9 prostate cancer include the following:. Most men are diagnosed with prostate cancer at an early clinical stage and do not have detectable metastases.

Therefore, they generally do not have to undergo staging tests, such as a bone scan, computed tomography CTor magnetic resonance imaging MRI. A radionuclide bone scan is the most widely used test for metastasis to the bone, which is the most common site of distant tumor spread. Serum PSA can predict acinar adenocarcinoma della prostata Gleason score 9 results of radionuclide bone scans in newly diagnosed patients. MRI with an endorectal coil appears to be more accurate for identification of organ-confined and extracapsular disease, especially when combined with spectroscopy.

MRI is more sensitive than radionuclide bone scans in the detection of bone metastases, but it is impractical for evaluating the entire skeletal system.

PLND remains the most accurate method to assess metastasis to the pelvic nodes, and laparoscopic PLND has been shown to accurately assess pelvic nodes as effectively as an open procedure.

The determining factor in deciding whether any type of PLND is indicated is when definitive therapy may be altered. For example, radical prostatectomy is generally reserved for men without lymph node metastasis.

Likewise, preoperative seminal vesicle biopsy may be useful in patients with palpable nodules who are being considered for radical prostatectomy unless they have a low Gleason score because seminal vesicle involvement could affect the choice of primary therapy and predicts for pelvic lymph node metastasis.

In patients with clinically localized stage I or stage II prostate cancer, Gleason pathologic grade and enzymatic serum prostatic acid phosphatase values even within normal range predict the likelihood of capsular penetration, seminal vesicle invasion, or regional lymph node involvement.

Whether to subject all patients to a PLND is debatable, but in patients undergoing a radical retropubic prostatectomy, nodal status is usually ascertained as a matter of course. The most common means to establish a diagnosis and determine the Gleason score in cases of suspected prostate cancer acinar adenocarcinoma della prostata Gleason score 9 by needle biopsy. Less frequently, a transperineal ultrasound-guided approach can be used for those patients who may be at increased risk of complications from a transrectal approach.

TRUS may facilitate diagnosis by directing needle biopsy; however, ultrasound is operator dependent and does not assess lymph node size.

A prospective multi-institutional study of preoperative TRUS in men with clinically localized prostate cancer eligible for radical prostatectomy showed that TRUS was no better than digital rectal examination in predicting extracapsular tumor extension or seminal vesicle involvement.

CT scans can detect grossly enlarged lymph nodes but poorly define intraprostatic features;[ 12 ] therefore, it is not reliable for the staging of pelvic node disease when compared with surgical staging. Historically, two systems have been in common use for the staging of prostate cancer. Local treatment modalities are associated with prolonged disease-free survival DFS for many patients with localized prostate cancer but are rarely curative in patients with locally extensive tumors.

Because of clinical understaging using current diagnostic techniques, even when the cancer appears clinically localized to the prostate gland, some patients develop disseminated tumors after local therapy with surgery or radiation. Treatment options for each stage of prostate cancer are presented in Table 6.