Snapshot A 58-year-old man presents to his primary care physician for an annual examination. He does not have any acute complaints and feels otherwise healthy. He has a past medical history of hypertension that is adequately controlled with lisinopril. Family history is remarkable for prostate cancer in his father. Digital rectal examination is notable for an asymmetric, nodular prostate. Prostate-specific antigen level is elevated at 15 ng/mL. Introduction Overview malignancy arising from the prostate most prostate cancers are adenocarcinomas arises most commonly in the posterior lobe (peripheral zone) Epidemiology Incidence most common cancer in men more common in older men (> 65 years of age) Risk factors increasing age family history black race Presentation Symptoms asymptomatic in most cases lower urinary tract symptoms e.g., urinary retention Physical exam digital rectal exam (DRE) prostate nodules, induration, or asymmetry Studies Serum labs prostate-specific antigen (PSA) not specific for malignancy (e.g., can be elevated in benign prostatic hyperplasia) Invasive studies biopsy indication confirms the diagnosis and important for pathologic staging provides a Gleason grade Differential Benign prostate hyperplasia differentiating factors symmetric enlargment and firmness of the prostate Treatment Treatment dependent on pathological features, metastasis, and the patient's life expectancy e.g., if patient is already on maintenance GnRH therapy, external beam radiation therapy is used to treat symptomatic metastasis Complications Obstructive uropathy Metastatic spinal cord compression prostate cancer can metastasize to the spine, causing epidural spinal cord compression if metastatic spinal cord compression is suspected or confirmed in a patient with neurologic deficits, initial management includes administration of high-dose steroids to reduce edema and inflammation in patients with suspected spinal cord compression but no neurologic deficits, steroid therapy may not be necessary if neoplastic spinal cord compression is suspected, work-up includes: MRI is first-line imaging modality CT myelography is second-line imaging modality, for patients with contraindications to MRI