Download Methodological Instructions to Lesson 10 for Students

Methodological Instructions for Students
Theme: Cancer of prostate.
Aim: How to diagnose specific clinical findings carcinoma of prostate, teach plan of
investigation of patient, diagnosis and differential diagnosis of carcinoma of glands, form plan of
treatment.
Professional Motivation:
In observation of men older than 50 years benign prostatic hyperplasia is noted in everyone
of two men. Till now benign prostatic hyperplasia is 10% in glands, before urinary bladder and
40% patients with carcinoma have metastases.
Basic Level:
1. Anatomy, physiology of prostate and urinary bladder.
2. To know how to collect anamnesis (life history) and should know to do physical method
of investigation. •
3. – X-ray, functional, instrumental, laboratory, endoscopial, morphological methods of
investigation to diagnose of carcinoma of prostate.
4. You should know the usage of hormones in the treatment of this disease.
Student's Independent Study Program
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Anatomy, physiology of prostatic glands.
Of the three zones that comprise the prostate-peripheral, transition, and central-the
transition zone in the central part of the organ is the area affected in BPH. Stromal nodules
appear in the periurethral area of that zone as glandular hyperplasia develops. In contrast,
prostate cancer generally develops in the peripheral zone of the organ. In the normal prostate,
cell growth is regulated by a balance between cell death (apoptosis) and cell growth
(proliferation). Investigators examining prostate tissue at the cellular level have found a
substantial decrease in the total number of both glandular and basal epithelial cells dying in
hyperplastic tissue compared with normal tissue. This suggests a deregulation of apoptotic cell
death mechanisms in prostate tissue that results in a growth imbalance in favor of cell
proliferation in the presence of BPH. The implications of these findings for clinical treatment are
under investigation.
2. Etiology and pathogenesis of carcinoma prostatic glands.
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-regulation in the adrenal and sexual glands). Proof of
hormone dependence of cancer of prostata there is a reverse development of neu formations
during castration and estrogenotherapy.
3. Classification of carcinoma prostatic glands.
The classification of the cancer of prostata by system of TNM:
Т – primary tumour;
Т0 – the tumour not palpated;
Т1 – the single tumular knot doesn’t go outside capsule of prostata;
Т2 – the tumour occupies a greater part of gland and germinates its capsule;
Т3 – the tumour occupies all prostate, increases, deforms it, but doesn’t go out outside
gland;
Т – the tumour germinates surrounding fabrics and organs;
М0 – remote metastases ;
М1 – metastases in bones;
M2 – metastases in bones and inlying organs.
4. Main clinical symptoms of carcinoma prostatic glands.
Sustained bladder outlet obstruction plus hypertrophy or overdistention of the bladder may
cause vesicoureteral reflux or obstruction of the upper tracts, resulting in hydroureteronephrosis.
Flank pain may occur during the act of micturition. When obstruction is severe enough to
produce renal failure, symptoms of uremia orazotemia occur: nausea and vomiting, somnolence
or disorientation, fatigue, and weight loss. Acute urinary retention may occur after a prolonged
period of putting off urination, allowing the bladder to become overdistended and atonic. Local
extension of the tumor may cause rectal or perineal pain. Hematospermia and hematuria may
accompany BPH, but their presence in patients over age 50 should always warrant a careful
assessment to rule out malignant disease.
5. Diagnosis of carcinoma prostatic glands.
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
tumour has dense, cartilagonoid or osteoid consistency. However it is necessary to remember,
that other diseases also can be shown the similar symptoms. Ultrasonic echography settles to
expose the areas of heterogeneous compression without the clear contours at the changed
structure of prostata.
6. Tract of metastases of carcinoma prostatic glands.
Approximately 15-40 % of patients present with symptoms caused by metastasis. In an
elderly man, complaints of persistent bone paine ( either localized or multifocal and especially in
the spine or pelvis ) should always prompt a search for prostatic cancer. fatigue, weight loss, and
malaise are nonspecific indications of extensive disease.
7. Endovesical symptoms of carcinoma prostatic glands.
Cystoscopy is an auxiliary method of diagnostics of cancer of prostata. During the
conducting cystoscopy deviation of urine can be marked by the tumular knots. At cystoscopy is a
successfully to expose the asymmetric deformation of neck of urinary bladder. A changed mucus
shell, fibrosis tapes, ulcers, excrescence of tumour are determined in the tumour germination in
wall of urinary bladder place. Thus it is difficult to clear up, what tumour is primary
8. X-ray symptoms of carcinoma prostatic glands.
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 tumour. Such changes are often from one side. At full obstructions the
ureter bud doesn’t functionate 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.
9. Differential diagnosis of carcinoma prostatic glands.
A cancer of prostata is differentiated with prostatitis, hyperplasia, tuberculosis, sclerosis,
stone of prostata, cancer of neck of urinary bladder.
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 palpations 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.
10. Chemical therapy of carcinoma prostatic glands.
The chemotherapy at cancer of prostata has only an auxiliary value through the low
sensitiveness of tumours to chemopreparations. It’s expedient its setting at hormone resistens
tumours. Frequently they apply adriamyciny, cyclophoshany, ftoruracyly, cysplatyny,
metotrexaty. The temporal objective effect (reduction of primary tumour 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.
11. X-ray treatment of carcinoma prostatic glands.
When tunors are confined to the prostate and periprostatic tissue, tumoricidal doses of
6500-7000 rads are generaiiy delivered at a rate of 275-200 rads daily. Teletherapy using Co
linear accelerators or betatron can produce photon beams with energy of 6-25 million eletron
volts. The higher the energy, the greater the depth of penentration of the maximum dose,
makingit possible to deliver a tumoricidal dose to the prostate deep in the pelvis while sparing
surrounding tissue.
12. Operative treatment of carcinoma prostatic glands.
Radical prostatectomy 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 nodes.
They execute this operation in the І-ІІ stage of disease, if it is germination of tumour in the fatty
cellulose and adjoint organs. The duration of life of a sick doesn’t rely not so much on their age,
sizes and degree of tumour malignant, as on degree of defeat of lymphatic nodes. 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 prostatectomy. 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 tumour sick apply orchidectomy or subcapsular enucleation (removal of
parenchyma) testicles.
II. Tests and Assignments for Self-assessment
1. What method of examination gives the complete information of carcinoma prostatic
glands?
A. Function of prostate.
B. Doppler graphy.
C. Retrograde cystography.
D. Cystoscopy.
E. Cystography.
Multiple choice. Choose the correct answer/statement:
Real life situation to be solved:
1. Patient K., at the age of 74, admitted with complaints of excretion of urine in drops, with
out sensation of urinary secretion, blood of urine, thirst and weakness. Objective: above the lap
when the percussive sound is dumb and when touched it is painful. Symptom of Pasternatzkiy is
doubling in two sides, prostate is bulged 6/6,5 cm, bumpy.
What is your diagnosis? What should we do to the patient to confirm diagnosis and tactics
in treatment?
III. Answers to the Self-assessment.
The correct answers to the tests:
l. A.
The correct answers to the real life situations:
l. cancer of prostate, we should keep permanent catheter if the patient is doing well, we
should do orchepididimectomy and hormones. X-ray treatment.
Visual Aids and Material Tools:
1. Slides.
a) retrograde cystography;
b) excretory urography.
2. X-ray photographs. a) retrograde cystography;
Students' Practical Activities:
Students must know:
1. Classification of cancer prostate in stages.
2. Symptomatology of cancer prostate.
3. Clinical sings of cancer prostate.
4. Diagnose of cancer prostate.
5. Differential diagnosis of cancer prostate.
6. Direction ofmetastases cancer ofprostatic glands.
7. Treatment of cancer prostate.
Students should be able to:
1. Know main symptoms of cancer prostate.
2. Make differential diagnosis of cancer prostate with cancer of urinary bladder, acute and
chronic prostatitis, tuberculosis ofprostatic glands, structure ofurether.
3. Diagnose different stages of cancer prostate, to form diagnosis.
4. Know tactics of treatment of cancer prostate in different stages.
5. Provide palpation ofprostatic glands, to do catheterization of urinary bladder with elastic
catheter.