THE PROSTATIC NODULE: A CHALLENGE AND A PROBLEM*

Abstract

AbstractCancer of the prostate begins as a microscopic lesion without signs or symptoms—carcinoma “in situ.” It can be an incidental finding at prostatectomy or at autopsy. The terms “latent,” “occult,” “incipient” and “early cancer” of the prostate are also evaluated.As the prostatic neoplasm grows, a desmoplastic reaction follows and the accumulation of malignant cells and connective‐tissue elements unite to form a palpable hard nodule. There are still no subjective symptoms unless benign prostatic hypertrophy is also present. Though this palpable nodule (about 1 cm in diameter) is the earliest detectable evidence of cancer, it already contains millions of cells. Fortunately, invasion through the capsule into neighboring tissue and/or metastasis has not necessarily occurred, and in some cases ablative treatment still can be successful. At this stage of the disease, the challenge is to detect the nodule. For this reason it is important that every male over 40 have a periodic digital rectal examination, performed carefully and gently. Prostatic lesions other than cancer can produce a hard nodule. For definitive diagnosis and documentation, a perineal prostatic biopsy is necessary. If the biopsy results are positive, malignancy is proved, but if the biopsy results are negative, malignancy is not ruled out since significant tissue areas may have been missed. Anaplasia may suggest extension but does not ensure that this has taken place. Perineural invasion often occurs, without spread. The pathological findings must be correlated with the results of digital rectal examination, radiography, and determinations of the serum acid phosphatase level. There are two stages of prostatic cancer in which the serum acid phosphatase level may not be elevated: 1) the early stage—carcinoma “in situ” or the small localized nodule—and 2) the late stage when the cells are anaplastic and no longer functioning. Otherwise the level is high.Objectives in therapy are: 1) removal of the cancer (radical prostatectomy), but only if the patient's physical condition permits, and 2) palliation by decreasing the endogenous adrogen level (bilateral orchiectomy) and/or increasing the estrogen level (orally or by injections). Although prostatic cancer is hormonally dependent in the early stages, there is a tendency toward autonomy. What to do for the hormonally independent cancer is the problem.