The only feasible method at present for detecting prostatic cancer in its asymptomatic and possibly early stages is digital examination through the rectum.

Such an examination with the index finger should be part of the routine examination of every adult male. The technique is described on p. 61.

The management of any suspicious prostatic finding is outlined later under steps to the diagnosis and initial management of the prostatic cancer suspect.

Laboratory tests (e.g., cytologic or histochemical studies of prostatic secretion or determination of the serum acid phosphatase, etc.) are not helpful in screening for the presence of the disease in its early stages.

Generally speaking, prostate cancer does not readily exfoliate and provide cells for cytologic examination, and the acid phosphatase level in the blood becomes elevated only when the disease is relatively advanced.

Clinical Features Of Cancer Of The Prostate.Localized Lesion Symptoms

1. Genuinely "early" prostatic cancer is usually asymptomatic.

2. If urinary symptoms are present, they are often clue to an associated benign prostatic hypertrophy.

Signs

1. The early prostatic cancer still confined within the capsule usually presents as a:

(a) Discrete solitary nodule

(b) Localized area of induration

2. The lesion may be "stony hard" in keeping with the classical description, but this quality is by no means always demonstrable.

Advanced Lesion

Without distant metastases Symptoms

1. Due to bladder neck obstruction by tumor:

(a) Dysuria

(b) Frequency

(c) Alteration in stream

(d) Nocturia

2. Due to ureteral obstruction by tumor or metastases:

(a) Flank pain

(b) Evidence of infection

3. Due uncommonly to rectal obstruction:

(a) Tenesmus

(b) Cramps

(c) Constipation or obstipation

Signs

1. Complete obliteration of normal outline and replacement with hard or indurated tissue.

2. Evidence of invasion of the seminal vesicle anil bladder base, possibly also the rectum.

With distant metastases Symptoms and signs

These are the same as those just listed plus those produced by:

1. Metastases to bone, especially the lumbar spine, pelvis, sacrum, and hips

(a) Bone or low back pain and tenderness

(b) Sometimes pathologic fractures

(c) Symptoms related to anemia or purpura

2. Metastases to regional lymph nodes

3. Metastases to other organs, especially liver or lungs

Steps In The Diagnosis And Initial Management Of The Prostatic Cancer Suspect. Digital Examination

1. In most cases of clinically significant prostatic cancer, examination of the gland with the index finger will be at least moderately suspicious. This is certainly true of anything past the very early stage.

2. Latent prostatic cancer is quite another story, as has been indicated.

3. A rather good estimation of the local extent of the disease is possible by digital examination.

Acid Phosphatase

1. The serum acid phosphatase is

(a) Usually normal in localized early prostatic cancer.

(b) Usually elevated in widely disseminated prostatic cancer.

(c) Equivocal in the case of advanced but apparently localized disease. It may be elevated or normal, usually the latter.

2. Although a high acid phosphatase value usually is diagnostic of disseminated prostatic cancer, some caution must be exercised in its interpretation since:

(a) It may be normal in the face of metastatic prostatic cancer

(b) It is rarely, if ever, elevated in the presence of genuinely localized disease

3. Attempts to separate a "prostatic fraction" from the acid prosphatase to further refine the usefulness of the test have yielded conflicting results in different hands.

4. An elevated serum acid phosphatase is found in virtually no other condition but cancer of the prostate (prostatic infarction and Gaucher's disease are the only others).

5. Massage or vigorous palpation of even a normal prostate gland may produce a transitory rise in serum acid phosphatase. It is best, therefore, to obtain the blood sample before any gross manipulation of the gland or twenty-four hours or more later.

Alkaline Phosphatase

1. This is usually elevated only when there is clear-cut evidence of bony metastases, particularly of the osteoblastic variety.

2. This test is quite nonspecific and may reflect bone or liver disease completely unrelated to prostatic cancer. An elevation, therefore, is significant only if bone or liver disease is ruled out first.

Cytology

1. A positive cytology can usually be obtained on prostatic secretion only when the disease is so obvious that little beyond digital examination is required for diagnosis.

2. This is not surprising in view of the posterior location of most prostatic cancers. Exfoliation and detection of malignant cells are rendered quite unlikely.

X-Ray Examination

1. Of the pelvis (KUB film). Demonstration of calcification in the region of a prostate nodule makes the diagnosis of cancer less likely but by no means rules it out.

2. Of the bones. Survey of the bones, especially in the lumbosacral spine, pelvis, sacrum, and hips, may uncover evidence of unsuspected osteolytic or osteoblastic metastases (usually combined, with the latter predominating).

3. Of the kidneys. An intravenous pyelogram is necessary in the evaluation of a prostatic cancer suspect to rule out the possibility of ureteral and corresponding upper urinary tract obstruction due to tumor. It may also suggest bladder base invasion and bladder neck obstruction, but these are better evaluated by endoscopy.

4. Of the chest. To rule out pulmonary metastases.

Cystoscopy

1. This may be helpful in evaluating the extent of local spread and invasion of the disease from the prostate.

2. Occasionally, too, it may show that a tumor is not primary in the prostate but rather originated in the bladder and invaded the prostate.

Needle Biopsy (Hospitalization Usually Preferred)

For the early, localized or equivocal lesion, the recently developed technique of transrectal needle biopsy, directed to the area of suspicion by palpation, has proved to be accurate in 75% or more of cases. It is relatively simple to perform and with this level of accuracy provides valuable information that enables the surgeon to plan therapy definitely and to instruct the patient prior to the operative procedure. Furthermore, when unequivocal evidence of a benign lesion is obtained by transrectal biopsy, relatively major perineal or suprapubic surgery may be avoided.

Because of technical difficulties, transperineal needle biopsy is helpful in arriving at a diagnosis in only 50% (or less) of cases and therefore is less useful than transrectal biopsy as a preoperative diagnostic measure.

There is no substantiated evidence that needle biopsy of the prostate is con-traindicated because of the hazard of disseminating cancer.

Open Biopsy (Hospitalization Required)

This is the procedure of choice whenever the diagnosis is in doubt following needle biopsy. This is best done in the operating room with all preparations made for appropriate surgery if the frozen section is positive. Approximately 50% of suspicious prostatic nodules in patients past the age of 50 years will prove on biopsy to be cancer.