What does Prof. Alessandro Natali?

These are the uro-andrological clinical fields in which Prof. A. Natali practices his profession both from the medical and surgical point of view

CLINICAL FIELDS

Prostate Cancer

What is Prostate Cancer?

Today, prostate cancer is among the most commonly diagnosed cancers, accounting for about 20% of all newly diagnosed cancers. It is currently the most common cause in man of death from cancer (around 11%), having already passed lung cancer. It is rarely found before the age of 40, as there is an increase in incidence and prevalence with increasing age.

These statements refer only to clinical carcinoma, which must be distinguished from incidental carcinoma (randomly diagnosed during an endoscopic resection or a prostatic adenomectomy) and from latent or biological carcinoma (asymptomatic mirocarcinomas diagnosed histologically). The latter is a very frequent finding in autopsy, as it can be found in 80% of autopsy investigations of subjects aged> 80 years.

The risk factors to be taken into consideration for the onset of this cancer are: age, race, familiarity, diet and prolonged exposure to substances such as zinc and cadmium. So far the most important risk factors to consider are age and familiarity, while for the other factors the real importance has not yet been clearly demonstrated. Prostate cancer originates in about 80% of cases from the peripheral or caudal area of the gland, in about 20% from the central area. Initially the cancer develops inside the gland, while the contiguity, lymphatic and haematic spreads are later.

When should be screened for prostate cancer and how is diagnosis made?

More risk factors are present, earlier a screening for this type of neoplasm should be made.
Men who are at high risk should have their first screening around 40 or 45 years old.

Men with medium risk can wait up to 50 years. Prostate cancer screening includes a rectal exploration and a PSA blood test. This test is a blood test that determines the amount of prostate specific antigen (PSA) in the blood.

All pathological situations at the prostate level can determine an increase in PSA in the blood, therefore both the cancr, but other conditions such as the benign enlargement of the prostate or an inflammation (prostatitis).

PSA is therefore considered an organ marker but not a pathology marker.
During the last five years, the Multiparametrict Magnetic Resonance (mpMRI) of the prostate has proved to be an extremely accurate method to highlight the presence of prostate cancer. The value of mpMRI lies precisely in its ability to identify above all those clinically significant prostate tumors, that is potentially dangerous for the patient's life.

On the contrary, tumors that mpMRI fails to identify are generally of low aggressiveness (ie clinically insignificant or indolent) and not detrimental to the patient's life. The current trend, in fact, is not to proceed with the execution of the biopsy in case of negativity of mpMRI since the negative predictive power of this method is close to 95%.

To date it is possible to perform biopsies aimed at the prostatic areas suspected for tumor detected at mpMRI by means of a fusion method of the ultrasound image and the magnetic resonance image (prostatic biopsies with "fusion technique").

During the execution the ultrasound image, detected with an endorectal probe, is superimposed on the image of the magnetic resonance allowing the identification of the suspicious area and the bioptic sampling of the same.

What are prostate cancer symptoms?

Unfortunately prostate cancer rarely produces symptoms of the lower urinary tract in the early stages of its onset, but eventually, only in the late stages. Here is the importance of screening and early diagnosis.

This sneaky aspect is given by the fact that developing the tumor in more than 80% of the cases in the peripheral part of the gland and not in the central part, where the urethra is located, only when it has reached considerable dimensions can it determine those obstructive disorders of the lower urinary tract, such as:

  • Increase in day and night micturition frequency
  • Difficulty starting urination
  • Weak urinary flow
  • Pain or burning during urination
  • Blood in the urine
  • Painful ejaculation
  • Blood in sperm

How is prostate cancer treated?

Treatment depends on the stage of prostate cancer at the time of diagnosis and on the general state of health of the patient.

Today with mpMRI we can establish in case of a low-aggressive prostate tumor not only to not proceed with the biopsy, but to set up a watchful waiting and an active surveillance on the tumor, without preparing any type of intervention.

If the cancer is localized to the prostate, the gold standard is represented by surgery (radical prostastectomy), which can be performed both in the open (open technique), and with a minimally invasive technique (robotics).

With both interventions if the patient is young and sexually active and the local oncological situation permits, surgical techniques can be performed that spare the vascular and nerve structures appointed to erection (nerve sparing techniques), maintaining the erective function.

As an alternative to surgery for local prostate cancer, radiotherapy can also be performed. Radiation can be delivered by a machine outside the body (external radiotherapy), today we are talking about stereotactic body radiotherapy (SBRT, Stereotactic Body Radiation Therapy), which is an innovative non-invasive radiotherapy technique that allows you to send a high dose of radiation directly on the tumor volume with extreme accuracy and precision, causing cell death (necrosis).

Even radiotherapy, like surgery, can have negative side effects on the patient's erective function If, however, at the time of diagnosis the tumor has already crossed the prostate and metastases are present, this neoplasm being a hormone-sensitive disease, it can be controlled for more or less prolonged periods, through the use of drugs that inhibit testosterone circulating in the subject's blood affected by the neoplasm, preparing the so-called Total Androgenic Block (TAB)

 

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