Snapshot A 68-year-old man presents to his primary care physician for an annual examination. He reports new-onset lower back pain. He also endorses unintentional weight loss and night sweats. Family history is remarkable for prostate cancer in his father. He has tenderness upon palpation in his lumbar spine. Digital rectal examination is notable for an asymmetric and nodular prostate. Prostate-specific antigen level is elevated at 35 ng/mL. Radiography of his lumbar spine demonstrates lytic bone lesions. Introduction Overview malignancy arising from the prostate most prostate cancers are adenocarcinomas arises most commonly in the posterior lobe (peripheral zone) Epidemiology incidence most common cancer in men more common in older men (> 65 years of age) risk factors increasing age family history black race Presentation Symptoms asymptomatic in most cases lower urinary tract symptoms e.g., urinary retention back or bone pain suggestive of bone metastases Physical exam digital rectal exam (DRE) prostate nodules, induration, or asymmetry Studies Serum labs prostate-specific antigen (PSA) not specific for malignancy (e.g., can be elevated in benign prostatic hyperplasia) elevated alkaline phosphatase level suggestive of bony metastases Invasive studies biopsy indication confirms the diagnosis and important for pathologic staging provides a Gleason grade Differential Benign prostate hyperplasia differentiating factors symmetric enlargment and firmness of the prostate Treatment Treatment dependent on pathological features, metastasis, and the patient's life expectancy e.g., androgen deprivation therapy e.g., if patient is already on maintenance GnRH therapy, external beam radiation therapy is used to treat symptomatic metastasis Complications Obstructive uropathy
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