How You Might Feel
When prostate cancer is advanced, it can no longer be cured. But treatment can control it for some time and help to relieve symptoms.
Finding out that your cancer cant be cured is distressing and can be a shock. Its common to feel uncertain and anxious. It’s normal not to be able to think about anything else.
Lots of information and support are available to you, your family and your friends. It can help to find out more about your cancer and the treatments you might have. Many people find that knowing more about their situation can make it easier to cope.
Talk to your doctor or nurse to understand:
- what your diagnosis means
What Treatments Are Available
If you have advanced prostate cancer, treatment wont cure your cancer. But it can help keep it under control and manage any symptoms.
If youve just been diagnosed with advanced prostate cancer, you may be offered the following treatments:
- chemotherapy with hormone therapy
- clinical trials.
Research has found that having radiotherapy together with one of the main treatments listed above can help some men with advanced prostate cancer to live longer. But radiotherapy isnt suitable for all men with advanced prostate cancer.
If you live in Scotland, you may also be offered a type of hormone therapy called abiraterone acetate together with standard hormone therapy. In the rest of the UK, abiraterone is currently only given to men with advanced prostate cancer that has stopped responding to other types of hormone therapy. The National Institute for Health and Care Excellence is currently deciding whether to make it available for men who have just been diagnosed with advanced prostate cancer.
Before you start treatment
Before you start any treatment, make sure you have all the information you need. Its important to think about how you would cope with the possible side effects. Speak to your doctor or nurse about this.
It can help to write down any questions you want to ask at your next appointment. It may also help to take someone with you, such as your partner, a family member or friend.
If you have any questions, speak to our Specialist Nurses.
How Is Prostate Cancer Diagnosed
A blood test called a prostate-specific antigen test is the most common way to check for prostate cancer. A higher level of PSA may mean that you have prostate cancer or that your prostate cancer has come back.
Your doctor also may do a biopsy. In this test, your doctor takes samples of tissue from your prostate gland or from the area where the cancer may have spread and sends the samples to a lab for testing. A biopsy is the only way to know for sure that you have prostate cancer.
If you have had prostate cancer before, your doctor may also order a bone scan, CT scan, or MRI to see if it has come back or spread.
Learning that you have cancer that has spread or come back can be very hard. Some people find that it helps to talk about their feelings with their family and friends. You may also want to talk with your doctor or with other people who have had this kind of cancer. Your local Canadian Cancer Society chapter can help you find a support group.
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The Case For Rn1 Patients
Lymph node recurrent PCa after the primary treatment is considered an unfavorable situation, and systemic hormone therapy is the gold standard in this patient population.96 However, there are very few data on irradiation of recurrent LN disease. Elective LN irradiation combined with SRT boosts to the recurrent LN could reduce the risk of regional LN progression. This hypothesis has recently been strengthened by the results from a surgical study.58 In this study, only LNM detected by choline PET/CT were removed by the surgeon and no adjuvant therapy was delivered. All of the patients had a PSA response and 3 out of the 6 patients included had a lasting complete PSA remission after a median follow-up of 24 months. Preliminary results from a small study on stereotactic radiotherapy for isolated LN relapses diagnosed with 11C-choline PET-CT have also been published recently.97 Total doses ranged from 20 to 45 Gy given in 25 fractions. Rates of toxicity were low. After 19 months of follow-up, 8 of the 14 patients had no evidence of disease. Patients with progression had no in-field relapse. These pioneering results need to be confirmed, but are extremely promising. However, until more data on radiotherapy or surgery for recurrent LN disease are available, aggressive regional approaches should be considered investigational.
Symptoms Of Prostate Cancer Spread To The Lymph Nodes
Lymph nodes are part of a system of tubes and glands in the body that filters body fluid and fights infection.
There are lots of lymph nodes in the groin area, which is close to the prostate gland. Prostate cancer can spread to the lymph nodes in the groin area, or to other parts of the body. The most common symptoms are swelling and pain around the area where the cancer has spread.
Cancer cells can stop lymph fluid from draining away. This might lead to swelling in the legs due to fluid build up in that area. The swelling is called lymphoedema.
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Gleason Score Vs Grade Groups
The International Society of Urological Pathology released a revised prostate cancer grading system in 2014. The grade group system seeks to simplify Gleason scores and give a more accurate diagnosis.
One of the major problems with the Gleason score is that some scores can be made up in different ways. For example, a score of 7 can mean:
- 3 + 4. The 3 pattern is the most common in the biopsy and 4 is the second most common. This pattern is considered favorable intermediate risk.
- 4 + 3. The 4 pattern is the most common in the biopsy and 3 is the second most common. This pattern is considered unfavorable and may mean local or metastatic spread.
So, although both situations give a Gleason score of 7, they actually have very different prognoses.
Heres an overview of how the two grading systems compare:
| Cancer grade | |
|---|---|
| grade group 5 | 910 |
Not all hospitals have switched to the grade group system. Many hospitals give both grade group and Gleason scores to avoid confusion until grade groups become more widely used.
How Prostate Cancer Is Diagnosed And Staged
Cancer staging helps you and your doctor understand how advanced your cancer is and how much it has spread at the time of diagnosis. Knowing your cancer stage also helps your doctor determine the best treatment options for you and estimate your chance of survival.
The most widely used staging system for cancer is the TNM system that classifies cancer from stage 1 to stage 4.
TNM stands for:
- Tumor: the size and extent of the tumor
- Nodes: the number or extent of nearby lymph node involvement
- Metastasis: whether cancer has spread to distant sites in the body
The TNM scale is used for many types of cancer. When a doctor uses it to determine your prostate cancer stage, theyll consider several other factors as well, including:
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What Is The Best Treatment For Prostate Cancer
Depending on each case, treatment options for men with prostate cancer might include:
- Observation or Active Surveillance for Prostate Cancer.
- Surgery for Prostate Cancer.
- Radiation Therapy for Prostate Cancer.
- Cryotherapy for Prostate Cancer.
- Hormone Therapy for Prostate Cancer.
- Chemotherapy for Prostate Cancer.
Detecting Prostate Cancer Spread To Lymph Nodes Using Choline
By: Dan Sperling, MD
Advanced imaging is finding new uses in prostate cancer detection, and potentially contributing to saving lives in cases previously thought untreatable. An interesting example is the use of C-Choline-PET/CT scans to identify prostate cancer that has spread to the nearby lymph nodes.
Lets begin by understanding what lymph nodes are, and why they are a likely target for the early spread of prostate cancer that has left the gland. Just as your body has a network of arteries and veins that move blood around, it also has a separate network of vessels that contain a clear watery fluid called lymph. Lymph bathes cells, providing oxygen and nutrients, and it carries away waste. It also contains white blood cells that fight infection. Scattered throughout the lymph vessels are hundreds of filter points, called nodes, that hold substances picked up in the lymph fluid. After the fluid is cleansed it slowly continues on its way to the chest where it rejoins the bloodstream, leaving the offending substances in the nodes.
One area rich in lymph nodes is the region in the pelvic cavity, close to the prostate gland. If prostate cancer is left untreated, or if treatment misses some of the cancer, as cancer cells infiltrate beyond the edge of the capsule they will be picked up in the lymph and carried to regional nodes that try to combat them. Thus, a single lymph node or group of nodes in that area may swell or enlarge as they work to filter out the bad cells.
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Stage 2 Prostate Cancer
In stage 2, the tumor is still confined to your prostate and hasnt spread to lymph nodes or other parts of your body. A doctor may or may not be able to feel the tumor during a prostate exam, and it may appear on ultrasound imaging. The survival rate is still near 100 percent.
The PSA score for stage 2 is less than 20 ng/mL.
Stage 2 cancer is further divided into three phases depending on the grade group and Gleason scores:
- Gleason score: 6 or less
Correlation Of Dominant Tumor Location And Positive Lymph Node Location
On review of RP specimens, 50 dominant tumor masses were located in the right lobe, 44 in the left lobe and 31 in bilateral lobes. Fifteen of 50 right lobe dominant cases showed positive LNs on the left side . Conversely, 18 of 44 left lobe dominant cases showed positive LNs on the right side .
15/50 right lobe dominant cancers had positive lymph nodes in the left pelvis 18/44 left lobe dominant cancers showed positive lymph nodes in the right pelvis .
Unifocal large volume high grade tumor with lymph node metastasis only on the right side Multifocal small volume low grade tumor with bilateral lymph node metastases Anterior dominant, relatively small volume grade 4+3=7 tumor with lymph node metastasis on the right side.
Dominant tumors were located in posterior/posterolateral prostate in 102 , both anterior and posterior in 18 and anterior only in 5 cases, respectively. Sixty dominant RP tumors extended from apex through base, 45 cases were located primarily in the apex to mid gland and 19 cases in the mid to base. Thirteen of 16 cases without EPE or SVI had dominant tumors localized to the apex-mid prostate.
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Does Sugar Feed Prostate Cancer
A recent study found a link between dietary sugar intake and risk of prostate cancer. The study found a higher risk among those in the top third and fourth quartiles. However, these findings do not prove that dietary sugar is a cause of prostate cancer. Rather, they suggest that sugar can feed the growth of prostate cancer in some men.
Studies have also linked high vegetable and fruit intake with a reduced risk of prostate cancer. In fact, high consumption of vegetables was linked with lower risks of aggressive prostate cancer. However, the effect of fruit and vegetable consumption on sugar intake was negligible. Nonetheless, a balanced diet is important to lower the risk of prostate cancer and improve the quality of life of men diagnosed with the disease.
Although sugar comes in many forms, its simplest form is glucose, which is used by all cells. All carbohydrates, including refined foods and added sugars, contain glucose, the primary fuel for the body.
Treatments To Help Manage Symptoms
Advanced prostate cancer can cause symptoms, such as bone pain. Speak to your doctor or nurse if you have symptoms there are treatments available to help manage them. The treatments above may help to delay or relieve some symptoms. There are also specific treatments to help manage symptoms you may hear these called palliative treatments. They include:
This is the team of health professionals involved in your care. It is likely to include:
- a specialist nurse
- a chemotherapy nurse
- a diagnostic radiographer
- a therapeutic radiographer
- other health professionals, such as a dietitian or physiotherapist.
Your MDT will meet to discuss your diagnosis and treatment options. You might not meet all the health professionals straight away.
Your main point of contact might be called your key worker. This is usually your clinical nurse specialist , but might be someone else. The key worker will co-ordinate your care and help you get information and support. You may also have close contact with your GP and the practice nurses at your GP surgery.
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The Sentinel Lymph Node Techniques In Prostate Cancer
The sentinel lymph node dissection techniques rely on the principle that by detecting the primary nodal landing sites where tumor cells would spread by following the lymphatic pathway and by analyzing if there is a tumor invasion in these site a limited and less invasive lymph node dissection could be performed, thereby reducing the morbidity caused by an extensive lymph node dissection. In uro-oncology, the sentinel lymph node technique was first described for the penile cancer in 1977 . In PCa the first study was reported in 1999 by Wawroschek et al. .
Albeit current international guidelines do not recommend performing SLN techniques for PCa , this is a field of active research, especially with the introduction of indocyanine green and fluorescence guided surgery. The two most widely used SLN techniques are the radio-isotope injection of 99mTc-nanocolloid and fluorescence imaging with the indocyanine green.
Radio-Isotope SLN Technique
In a recent systematic review of SLN in PCa, the overall median pre-operative and intraoperative detection rates were 97.8 and 96.1%, respectively, with an overall median false negative rate of 7.1% .
Fluorescence Imaging
Patients With A Positive Mrl
For patients with a positive MRL, the prognostic value of tumor-related factors was investigated using Kaplan-Meier analysis: T-stage, Gleason score , PSA .
Next, MRL-related factors were investigated: number of positive lymph nodes, largest diameter of the largest lymph node , short axis diameter of the largest lymph node .
For these factors, ROC analysis was performed to determine their predictive potential and to find the threshold with the highest accuracy. This threshold was used to dichotomize the patients for Kaplan-Meier analysis.
Further, the prognostic value of the presence or absence of positive lymph nodes outside the pelvis was determined. Positive lymph nodes above the L5/S1 interspace were considered to be outside the pelvis.
Last, it was investigated whether patients in whom all MRL-positive lymph nodes had been removed had a better prognosis compared to patients in whom only part of the MRL-positive lymph nodes had been removed. To determine whether all MRL-positive lymph nodes had been removed, a comparison between the surgical report, the pathology report, and the MRL result was made.
Multivariate analysis could not be performed, due to the relatively small number of MRL-positive patients.
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Lymphangiogenesis & Lymph Node Metastasis
During embryogenesis lymphatic vessels develop from blood vessels . Therefore, lymphangiogenesis and angiogenesis are stimulated by the same family of growth factor proteins. VEGF-A/VPF is the most potent growth factor for angiogenesis . Other VEGF family members, such as VEGF-C and VEGF-D, are potent lymphangiogenic factors . Flt-4, also known as VEGF receptor-3 , is the tyrosine kinase receptor for VEGF-C or -D in lymphatic endothelial cells. Upon activation, this receptor triggers signaling events to initiate the proliferation and migration of lymphatic endothelial cells . Neuropilin-2, a nontyrosine kinase receptor, is also expressed in lymphatic endothelial cells and acts as a coreceptor for VEGF-C during lymphangiogenesis . Both VEGF-C and -D are expressed by tumor cells and, therefore, promote lymphangiogenesis from the tumor-associated surrounding lymphatics . Importantly, cancer cells have also been shown to express neuropilin-2 and/or VEGFR-3, thus suggesting autocrine regulation of lymphangogenic growth factors . Our laboratory has reported one such autocrine regulation of VEGF-C and its receptor neuropilin-2 in prostate cancer this autocrine function promotes the survival of prostate cancer cells during oxidative stress and, thereby, is important for metastatic progression .
What Stage Is Cancer In Lymph Nodes
The pathologist will use a grading system to determine the stage of your prostate cancer. This will determine how far the disease has spread. The TNM staging system outlines the extent of the primary tumour, the presence of metastasis to lymph nodes near the prostate, and whether or not the cancer has spread elsewhere in the body. The TNM staging system is the most common grading system used in the United States.
If your prostate cancer has spread to lymph nodes, it is considered locally advanced prostate cancer. This means that the cancer has spread to nearby lymph nodes but hasnt spread to distant organs or bones. Localized prostate cancer can be cured, but may require several treatments. Stage 4 prostate cancer, on the other hand, has spread to distant lymph nodes and bones. Patients with this type of cancer are at risk for poorer survival compared to those with stage 1 prostate cancer.
Although prostate cancer can spread to other parts of the body, it usually spreads to lymph nodes near the prostate. Some patients may need to have these lymph nodes removed during a prostatectomy. However, this isnt necessary for everyone. In some patients, lymph node removal can lead to lymphedema, a buildup of fluid in fatty tissue beneath the skin. Fortunately, lymphedema is a rare complication associated with node removal.
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