前列腺癌

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前列腺癌
分類系統及外部資源
ICD-10 C 61
ICD-9 185
OMIM 176807
DiseasesDB 10780
MedlinePlus 000380
eMedicine radio/574

前列腺癌是出自前列腺的惡性腫瘤。若其中有細胞的基因突變導致增殖失控,就成為症。惡性細胞除了體積擴大或侵犯鄰近器官,也可能轉移到身體其他部位,尤其是骨頭淋巴結。前列腺癌可能造成疼痛、排尿困難、勃起功能不全等症狀。

前列腺癌發病遍布世界各地。發病率各地不同。美國的發病率是世界最高,歐洲次之(歐洲各地發病率也不同),東亞與南亞最低。從人種來看,黑人前列腺癌發病率最高,白種人其次,黃種人前列腺癌發病率最低。生活在本土的黃種人比移居北美地區者發病率低。[1]但美國的數字較高也許是因為美國地區的偵測率提高了[2]

一般認為只有男性會罹患前列腺癌,最常發生於50歲以上的人。在西方國家,前列腺癌是男性第二常見的癌症,因而喪生的人數僅次於肺癌。然而許多前列腺癌的患者終其一生沒有症狀,從未治療,死因也不是前列腺癌。許多因素,包括基因和飲食,據信和前列腺癌有關,但截至2006年為止,尚無法預防此一疾病。但是在2011年發現女性也可能有前列腺,同樣有病變的可能[1]

前列腺癌大多是在例行的健康檢查或抽血篩檢發現的。有關前列腺特異抗原(即 PSA )的準確性和效果目前仍有一些疑慮,不過它仍是現今最廣泛廣用的前列腺癌篩選工具。發現疑似前列腺癌的個案時,應做切片檢查(取一小片前列腺組織,處理後用顯微鏡檢查)才能確立診斷。其他進一步檢查如X光電腦斷層掃描骨骼掃瞄等,有助於了解前列腺癌是有否有外擴散。

前列腺癌的治療方法包括手術、放射治療、荷爾蒙治療,有時也做化學治療,這幾種療法可以合併運用。患者本身的年齡和健康狀況、癌細胞的擴散程度、顯微鏡所見的細胞形態,和初期治療的效果都關係到患者的預後。由於前列腺癌主要發生於老年男性,而前列腺癌的進展速度在癌症裡算是慢的,所以許多患者在癌細胞造成症狀之前就已經死於其他原因。對適當的治療方案的選擇(包括選擇是否打算治癒),即為病患對於治療方案的正面與負面效果之間的取捨。

前列腺[編輯]

前列腺屬於男性生殖系統,主要功能是製造與貯存前列腺液,並在射精時成為精液的一部份。成年男子的前列腺約有3厘米長,重約20公克。它位於骨盆腔,膀胱之下,直腸之前。尿道出膀胱後穿過前列腺,射精時,精液也同樣從尿道射出體外。前列腺由許多小腺體構成,它們分泌的前列腺液佔精液的20-30%體積。前列腺細胞的增殖要靠各種男性荷爾蒙來調節,包括產自睾丸睾固酮(testosterone)、來自腎上腺的 脫氫表雄酮DHEA (dehydroepiandrosterone)和前列腺本身製造的二氫睾固酮 (DHT,dihydrotestosterone)。男性荷爾蒙也掌管第二性徵的表現,如臉部的鬍鬚和多於女性的肌肉量。

症狀[編輯]

早期的前列腺癌大多沒有症狀。往往是在例行健康檢查發現 PSA 值升高,進一步追查才發現[3]。然而有時前列腺癌也會引起症狀,而且和良性前列腺增生症的症狀很類似,包括頻尿、夜間多尿、排尿困難、尿流細小、血尿、排尿痛等。前列腺癌也可能造成性功能障礙,例如勃起困難、射精疼痛難耐。

較嚴重的前列腺癌若侵犯身體其他部位,就可能引起相對應的症狀。其中骨痛最常見,多半發生在脊椎、骨盆或肋骨,只要是癌細胞轉移之處都可能會痛。承受重量的骨頭如脊椎若因癌細胞侵犯而變得脆弱,也可能造成骨折而壓迫到脊髓神經,造成下肢無力或大小便失禁[4]

(A)正常細胞若損壞而無法修復時,會自行凋亡。(B)癌細胞不會凋亡,結果持續增殖而不受控制。

流行病學[編輯]

造成前列腺癌的原因迄今未知。[5] 男性的致病危險因子包括了年齡遺傳種族節食、生活習慣、藥物等等。主要的因子在於年齡。前列腺癌在四十五歲以下是少見的,危險性隨著年齡而增加。而平均被檢測出來的年齡是七十歲。[6] 不過,很多人終其一生不知道自己有前列腺癌。對中國、德國、以色列、牙買加、瑞典以及烏干達的其他死因男性進行屍檢發現,50歲以上男性中30%前列腺內存在癌細胞,而70歲以上者,此比率甚至高達80%[7]。 美國2005年預計將新確診前列腺癌患者230,000例,並且將有30,000人死於前列腺癌[8]

篩檢[編輯]

肛門指檢[編輯]

檢查者帶上手套,塗上潤滑劑,將手指伸入肛門內的直腸檢查前列腺的大小形狀與質地。形狀不規則、質地硬或軟可能是腫瘤,需進一步檢查。這個檢查只檢查前列腺背面,不過85%的前列腺癌是發生在此區。能在肛門指檢中摸出來的癌症通常更為嚴重[9]。只用肛門指檢的篩檢方式從來沒有表現出防止前列腺癌致命的能力[10]

前列腺特異抗原 PSA[編輯]

確立診斷[編輯]

唯一能確立前列腺癌診斷的方法是切片檢查,也就是切下一小片前列腺用顯微鏡觀察。但是切片檢查之前還有幾個方法能提供更多資訊。一是尿道鏡,是將一個細小的攝影機伸入尿道,進入膀胱。一是直腸超音波檢查,是將探測器伸入肛門直腸,作出前列腺超音波成像。

治療[編輯]

前列腺癌的治療包括觀察等待手術放射治療化學治療荷爾蒙治療,或以上幾種療法合併運用。哪種療法較適合,要看腫瘤侵犯的範圍 (稱為分期)、癌細胞惡性程度 (依葛里森評分法 Gleason score)、血中PSA濃度等因素一起考慮。當然也要顧及患者的年齡、體能,並尊重患者的選擇。由於部份療法可能伴隨著嚴重的副作用,如勃起功能失調、尿失禁等,選擇治療方法時要在療效與生活品質間求取平衡。

觀察等待[編輯]

手術[編輯]

前列腺切除術常用於早期前列腺癌,或放射治療效果不佳的患者。最常用的術式是恥骨後前列腺根除術,醫師從下腹部的切口切除前列腺、精囊和鄰近組織。另一種方式是經會陰前列腺根除術,傷口位於會陰,也就是陰囊和肛門之間。約有 70% 的患者可藉手術將前列腺癌治癒。

前列腺根除術對於癌細胞侷限於前列腺內的患者相當有效。但是手術過程中難免會傷到一些神經,而影響到患者的生活品質,最常見的併發症是尿失禁陽萎。約有 40% 的患者手術後有尿失禁的狀況,大多是在打噴嚏、咳嗽或大笑的時候。陽萎是指患者陰莖無法勃起,或無法維持足夠的硬度,以致無法進行性生活。患者陰莖的知覺大致正常,受到刺激也能達到高潮,但是勃起和射精的功能卻很不理想。服用一些藥物如威而鋼(Viagra)、犀利士(Cialis)、樂威壯(Levitra)可使患者的性功能恢復一些。若是患者非常在乎勃起功能,也可以考慮植入陰莖假體(俗稱人工陰莖),以維持性生活的品質。如果患者癌細胞侵犯的範圍很小,也可以用較小規模的手術,設法減少神經的傷害,以避免尿失禁和陽萎。

放射治療[編輯]

放射治療是以集中的輻射線破壞前列腺內的癌細胞。所謂的游離性輻射能破壞DNA的結構,使癌細胞無法持續增長(手機或電器產生的電磁波不會改細胞內的分子結構,稱為非游離輻射)。用於前列腺癌的放射治療又可分為外部照射近接治療

外部照射是用輻射源(如鈷-60)或直線加速器產生的輻射線對準前列腺,並採用多個不同的入射角,以減少對皮膚和週邊組織的傷害。一般多將總輻射劑量計算好之後,分為 30-40 個療程,每天到治療室照射一段時間。

近接治療是將放射源的針或顆粒依矩陣方式排列,置入前列腺內,在體內持續發揮治癌效果。所用的放射源最早是用,現今則多使用碘-125鈀-133,用管狀針經由會陰推入前列腺,在超音波監視下推到定位,並永久留在體內。新式放射源的半衰期約 60 天,釋出伽馬射線(γ-ray),穿透性低,所以家屬不用耽心被輻射線傷害。患者可以自由行動,不必天天上醫院報到。

冷凍治療[編輯]

治前列腺癌也可以用冷凍治療。冷凍治療較不具侵略性,也較不需全身麻醉。作法是從會陰皮膚插入一根金屬棒,以超音波導引伸到前列腺,然後使用液態氮冷卻棒子,將周圍組織冰凍於攝氏零下196度。前列腺細胞內的水若是結凍,細胞也就死了。尿道另外插入一支充滿溫液體的導尿管以免尿道結凍。冷凍治療可以減少排尿問題,但是勃起困難的可能則提高到90%。冷凍治療用來作前列腺癌的起始治療,效果不如手術或是放射治療。[11]但用來治療放射治療後復發的癌症則比根治式攝護腺切除術好。

荷爾蒙療法[編輯]

攝護腺癌的荷爾蒙治療。圖表中顯示在荷爾蒙治療中,重要的不同器官(紫色字體)、荷爾蒙(黑色字體與箭頭)、和治療(紅色字體與箭頭)。

荷爾蒙療法(Hormone therapy)是用內科或外科的方法,使攝護腺癌細胞無法獲得雙氫睾酮(Dihydrotestosterone,DHT)、在攝護腺中產生的一種荷爾蒙、使大部份攝護腺癌細胞能夠生長與擴散。阻止雙氫睾酮,通常使得攝護腺癌停止生長甚至萎縮。 但是荷爾蒙療法很少治癒攝護腺癌,因為癌症最初對荷爾蒙療法有反應,但在一到二年以後癌症對治療有抗性。因此荷爾蒙療法,通常用於已經擴散的攝護腺癌。它也用於某些作放射治療或手術的病人,幫助防止攝護腺癌復發。攝護腺癌荷爾蒙療法為瞄準身體生產雙氫睾酮的路徑。反饋環路包括睾丸下丘腦腦下垂體腎上腺和攝護腺控制雙氫睾酮的血中濃度。首先,雙氫睾酮的低血液濃度,刺激下丘腦生產促性腺激素釋放激素(Gonadotropin-releasing hormone,GnRH)。性腺激素釋放素GnRH,然後刺激腦下垂體生產黃體生成素(Luteinizing hormone,LH),並且刺激睪丸生產睾酮(Testosterone)。最終,睾酮從睾丸和脫氫表雄酮(Dehydroepiandrosterone,DHEA)從腎上腺,刺激攝護腺生產更多雙氫睾酮。荷爾蒙療法用中斷這條路徑在任何一點,可以減少雙氫睾酮的濃度。

有幾種形式的荷爾蒙療法:

  • 睾丸摘除術 - 外科手術摘除睾丸。
  • 抗雄性激素劑藥物治療

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  1. ^ Dietrich, Wolf; Susani, Martin, Stifter, Lukas, Haitel, Andrea. The Human Female Prostate-Immunohistochemical Study with Prostate-Specific Antigen, Prostate-Specific Alkaline Phosphatase, and Androgen Receptor and 3-D Remodeling. The Journal of Sexual Medicine. 2011-09-01: no–no. doi:10.1111/j.1743-6109.2011.02408.x. 


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