Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : PC07 - PC10 Full Version

Clinicopathological Profile of Prostate Cancer Patients: A 10 years Retrospective Study from a Tertiary Care Centre, North East India


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57485.17161
Stephen Lalfakzuala Sailo, Laltan Puii Sailo, Veracious Corner Stonewann

1. Professor, Department of Urology, North-eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India. 2. Assistant Professor, Department of Anaesthesiology, Zoram Medical College, Aizawl, Mizoram, India. 3. Associate Professor, Department of Urology, North-eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India.

Correspondence Address :
Dr. Stephen Lalfakzuala Sailo,
A-19, Faculty Quarters, North-eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India.
E-mail: stephensailo@gmail.com

Abstract

Introduction: Prostate cancer is the second most common cancer and ranked fifth among the top causes of death among men. There is limited data on the clinical profile of prostate cancer in India, especially from North East India.

Aim: To determine the clinicopathological profile of prostate cancer patients treated at a tertiary care centre in North East India.

Materials and Methods: This retrospective hospital-based study was conducted in the Department of Urology, North-eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India from January 2006 to January 2016. It included 66 consecutive prostate cancer patients treated over 10 years. Relevant information regarding age at presentation, presenting symptoms, investigation, stage of the disease, histological report, treatment, follow-up and death were collected from hospital records and analysed using Microsoft excel software 2019. Continuous variables were presented as mean and standard deviation or range while categorical variables were expressed as frequencies and percentages.

Results: The mean age of the patients was 70.7 years, the majority (81.8%) were in the age group of ≥61 years. All patients except one were symptomatic at presentation. The mean Prostate Specific Antigen (PSA) was high (264 ng/mL). Histologically, 65 tumours (98.5%) were adenocarcinoma and Gleason score between 8-10 was the most common. A total of 51 patients (77.3%) had stage IV prostate cancer. Total bilateral orchidectomy was the most common treatment, performed in 84.3% of stage IV patients. Nine patients died during the study.

Conclusion: Prostate cancer was uncommon in the present study population but a majority of the patients presented with metastatic disease. Adenocarcinoma was the predominant histological type and total bilateral orchidectomy was the most common treatment, performed in the majority of the patients with stage IV disease.

Keywords

Adenocarcinoma, Gleason score, Orchidectomy, Survival

Prostate cancer is a disease of old age and a major cause of morbidity and mortality among men worldwide. The risk factors for prostate cancer are advanced age, ethnicity, genetic factors, and family history (1). It is the second most common cancer and ranked fifth among the top causes of death among men. In 2020, there were an estimated 1.4 million new cases of prostate cancer causing 375,000 deaths globally. The incidence rates of prostate cancer differ from place to place from a low of 6.3 to a high of 83.4 per 100,000 men. The highest rates are detected in Northern and Western Europe, and the lowest rates are seen in Asia and Northern Africa (2). The highest incidence of prostate cancer in the world is seen in Guadeloupe (France) and the highest mortality rate is in Barbados (3). Prostate cancer constitutes 10.6% of newly diagnosed cancer in the United States with 192,000 cases being estimated in 2020 (4). The incidence rate of prostate cancer is estimated to be 9 per 100,000 men in the whole of India, 12.4 in Delhi, and 5.86 in Pune Metropolitan Region (5),(6),(7). The incidence rates of prostate cancer in the states of North East India are low and the incidence rates per 100,000 men are 3 in Mizoram, 1.6 in Meghalaya, 1.5 in Manipur and 1 in Tripura (6). There is limited published literature regarding the clinical profile of prostate cancer in India and in particular, from North East India (8).

The aim of this retrospective study was to find out the clinicopathological profile of prostate cancer, type and outcome of treatment of prostate cancer in a newly set-up tertiary care centre in North East India.

Material and Methods

This retrospective hospital-based study was conducted in the Department of Urology, North-eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, India, from January 2006 to January 2016. The analysis of the data was done between July 2018 and December 2018. During the study period of 10 years, 71 patients with prostate cancer attended the department. Ethical approval was obtained from the Institute’s Scientific and Ethics Committee in June 2018 (approval no. NEIGR/IEC/M5/F9/18).

Inclusion criteria: Patients with pathologically confirmed prostate cancer, who underwent initial treatment and follow-up in the Department of Urology, NEIGRIHMS, Shillong, India during the study period were included in the study.

Exclusion criteria: Patients who had initial diagnosis and treatment in other hospitals and who came to NEIGRIHMS, Shillong only for follow-up were excluded from the study.

Out of 71 patients who enrolled, 66 patients fulfilled the inclusion criteria and were included in the analysis. Five patients were excluded from the analysis based on the exclusion criteria. The majority of the patients were diagnosed at the study institute. Few patients who were diagnosed elsewhere and referred to this department for further management were also included in the study. The biopsy slides of these patients were re-examined by the pathologists and these reports were considered final. If the biopsy slide was inadequate for the definitive report, these patients underwent repeat prostate biopsy.

Study Procedure

Diagnosis of prostate cancer was suspected on clinical grounds like Lower Urinary Tract Symptoms (LUTS), Acute Urinary Retention (AUR), haematuria, nocturia associated with hard and fixed prostate with or without raised Prostate Specific Antigen (PSA) (≥4 ng/mL), and prostate ultrasound findings (9). Transrectal ultrasound-guided sixcore biopsy along with biopsy of the obvious nodule was performed as these patients had hard and fixed prostates or locally advanced cancers. Extended biopsy was performed only in three cases. Five patients were diagnosed to have prostate cancer after Transurethral Resection of the Prostate (TURP).

Based on microscopic appearance, prostate cancers were divided into Gleason grades from 1-5, grade 1 being the most welldifferentiated tumour and grade 5, being the least differentiated tumour. One Gleason grade for the most predominant pattern in the biopsy and a second Gleason grade for the second most predominant pattern are added together to determine the Gleason score (10). The prostate cancers were divided into well-differentiated
(Gleason score of ≤6), moderately differentiated (score of 7), and poorly differentiated (score of 8-10) tumours (11).

All 66 patients underwent complete blood count, kidney and liver function tests, urinalysis and culture, and chest X-ray. The majority of patients underwent ultrasound of the abdomen and a few patients also underwent Kidney, Bladder, and Ureter (KUB) X-ray. Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and bone scan were performed in 6, 15 and 22 patients respectively, depending on the clinical indication for diagnostic and staging purposes.

Based on histopathological and imaging findings, clinical staging of prostate cancer was done as follows (12),(13),(14):

• Stage 1: Incidentally detected prostate cancer after TUPR or prostate cancer found on needle biopsy due to raised PSA;

• Stage 2: Localised prostate cancer;

• Stage 3: Locally advanced prostate cancer;

• Stage 4: Metastatic prostate cancer.

The patients with metastatic disease (stage 4) underwent Androgen Deprivation Therapy (ADT) with either total bilateral orchidectomy or Luteinising Hormone-Releasing Hormone (LHRH) agonists. Channel TURP was done for patients with bladder outlet obstruction. Patients with locally advanced disease (stage 3) were offered radiotherapy and ADT. Patients with local disease (stages 1 and 2) were offered the option of active surveillance, open radical prostatectomy, or referred for robotic prostatectomy (since robotic surgery facility was not available at the institute). After discharge, the patients were followed-up every six months. At each follow-up, results of uroflowmetry, complete blood count, serum PSA, kidney and liver function tests, and appropriate radiologic imaging were noted. Any deaths reported by the relatives and the patients who died in NEIGRIHMS, Shillong were also recorded. Relevant information regarding age at presentation, clinical presentation, investigation, and stage of the disease, histological report, treatment given, duration of follow-up, and deaths were recorded.

Statistical analysis

Continuous variables were presented as mean and standard deviation or range while categorical variables were expressed as frequencies and percentages. Data analysis was done using Microsoft excel software version 2019.

Results

The age range of the study sample was from 47-93 years with a mean age of 70.7 years (Table/Fig 1). The modal age group of the presentation was 71-80 years, accounting for 34.9% of cases (Table/Fig 2). A total of 35 patients (53%) had symptoms lasting for more than one year. Not a single patient had a history of vasectomy. The most common symptoms were LUTS in 27 (40.91%), AUR in 22 (33.33%), and haematuria in 14 (21.21%) patients. Five patients also complained of bone pain, weakness in lower limbs, and paraesthesia. Nocturia was the main symptom in two patients. Serum PSA was estimated in 63 patients and the average value of PSA was 264 ng/mL. It was below 10 ng/mL in 2 (3.2%) patients, between 10-20 ng/mL in 5 (7.9%) patients, between 20-100 ng/mL in 19 patients (30.2%) and more than 100 ng/mL in 37 patients (58.7%).

For staging, ultrasonography was the most common investigation, which was performed in 52 patients (78.8%). Ultrasonography detected liver secondaries, enlarged lymph nodes, ascites and ureteric involvement in 24 patients (46.15%). A bone scan, done in 22 patients, detected bone secondaries in 15 patients (68.18%). MRI and CT scans (skeletal survey) were done in suspected bone secondaries if the patients could not afford bone scanning. At the time of the study, the facility for the bone scan was not available in Shillong and patients had to go to another city for bone scanning. MRI, done in 15 patients, detected secondaries in 13 patients; CT scan, done in six patients, detected secondaries in four patients. Local invasion was detected by CT and MRI in seven patients.

Out of 66 patients in this study, 65 patients (98.5%) were diagnosed to have adenocarcinoma; one patient was reported to have small cell carcinoma. Gleason score was available in 53 patients. The most common Gleason score was 8-10 (poorly differentiated) which was reported in 33 patients (62.3%), followed by a score 7 (moderately differentiated) in 17 patients (32.1%) and a score of 6 or less (well differentiated) in 3 patients (5.7%).

Total 51 patients (77.3%) had stage 4 disease, seven patients (10.6%) stage 3 and five patients (7.6%), stage 2 and three patients (4.5%), stage 1 diseases (Table/Fig 3). For androgen deprivation therapy, a total of 46 patients (69.7%) i.e., 43 patients with stage 4 disease and three patients with stage 3 disease, underwent bilateral orchidectomy and eight patients received LHRH agonist (Leuprolide or Triptorelin). Sixteen patients received tablets of Bicalutamide and two patients received the tablet of Abiraterone along with orchidectomy or Luteinising Hormone-releasing Hormone (LHRH) agonists. None of the patients received injection of docetaxel and LHRH antagonist during the study period.

Three patients had stage 1 cancer. One patient had screeningdetected prostate cancer and he underwent High-Frequency Focused Ultrasound (HIFU) treatment at another centre. The other two patients opted for robotic prostatectomy and they were referred to another centre as a robotic surgery facility was not available in this centre. In the present study, no patient received radiation therapy in this centre, as this facility was not available at the time of the study A total of 33 patients came for the first follow-up at six months (stage 4-23 patients, stage 3-4 patients, stage 2-3 patients, and stage 1-3 patients). Serum PSA was done in 20 patients and mean PSA was 60 ng/mL (range, 0.04-544 ng/mL), and the mean maximum urine flow rate (done in six patients) was 10 mL/sec (range, 6-23 mL/sec). Total of 18 patients came for a second follow-up at 12 months (stage 4-12 patients, stage 3-2 patients, stage 2-1 patients, and stage 1-3 patients). The mean PSA (done in 14 patients) was 41.1 ng/mL (range, 0.04-284 ng/mL) and no urine flow rate result was available. Only six patients came for a third follow-up at 18 months (all were in stage 4). The mean serum PSA was 31.4 ng/mL (range, 0.07-153 ng/mL) and only one urine flow rate result was available (maximum flow rate of 6 mL/sec). During these follow-up visits, imaging (bone scan and ultrasound) revealed that two patients who were initially diagnosed to have stage 2 and 3 diseases had progressed to stage 4 disease.

A total of nine patients died during the study, which were reported by their relatives and some were recorded in the hospital. Of these nine patients, three, one, four and one patients died within one, two, three and four years of diagnosis, respectively.

Discussion

Prostate cancer still remains relatively rare among the North-eastern Indians. As demonstrated in the present study, only 66 patients in a 10 year study period, showed an incidence of 6.6 cases per year. This concurs with the low age-adjusted incidence rates of prostate cancer in the States of North East India (6). The present study is having special significance as the patients were mostly from rural areas while most of the prostate cancer registries in India are mostly urban-based and very little data came from rural India (15).

There is a marked variation in the incidence of prostate cancer worldwide, with African Americans having the highest rate and lowest incidence in Asian countries (16). In Asia, the incidence of prostate cancer was lowest in Bhutan (1.1/100,000) and highest in Singapore (33/100,000) (17). The high incidence in Western countries has been attributed to the extensive application of PSA testing, prostate biopsy and racial differences (17),(18). Though the incidence in Asian countries was low, the incidence of prostate cancer is rising in most Asian countries, probably due to PSA testing, better cancer registration system and environmental risk factors (19).

In this study, the majority of patients (80.3%) were in the 7th to 9th decade of life with the mean age at diagnosis of 70.7 years. The present study finding is similar to those of previous studies from India (8),(16),(17),(18). In a study of 471 prostate cancer patients by Ghagane S et al., the mean age of the patients was 70 years (13). Similarly, Tyagi et al., Singh AN et al., and Rajput A et al., reported the mean ages of prostate cancer patients in their studies to be 69.7 years, 67.6 years and 67 years, respectively (8),(20),(21).

The global incidence of familial prostate cancer is 9% and it is 3% in India (22),(23). In this study, a family history of prostate cancer was reported in one patient (1.5%) only. Two studies from the Indian subcontinent reported family history in 0.84% and 2% of patients, respectively (13),(14).

The most common presenting symptoms in this study were LUTS, AUR and haematuria. All patients except one presented with symptomatic prostate cancer. The large proportion (98.5%) of symptomatic patients in the present study is similar to the previous studies from developing countries (8),(13),(14). In a prospective study of 278 patients from Sri Lanka, it was reported that 98% of the patients presented with symptoms, the most common symptom being LUTS, seen in 50% of the patients (14). In a study of 471 prostate cancer patients in a tertiary institute in Karnataka, it was reported that 84.5% of patients presented with bothersome symptoms (13). Similarly, in a study of 332 patients at a tertiary care cancer centre, Rajput A et al., reported that 83.4% of the patients had LUTS (8).

All biopsy specimens except one were reported as adenocarcinoma, and one was reported as small cell carcinoma. In this study, the majority (58.7%) of patients had PSA above 100 ng/mL, and two patients (3.2%) had PSA below 10 ng/mL. The average PSA (264 ng/mL) in this study was higher than the average PSA (19.6 ng/mL and 37.71 ng/mL) reported in two studies in India [8,13]. A study from Sri Lanka reported that 81% of patients had PSA above 20 ng/mL
(14). In contrast, a study from Trinidad and Tobago reported that only 22.7% of patients had PSA above 100 ng/mL and the mean PSA in a study from the USA was 5.7 ng/mL (11),(24).

In the present study, the most common Gleason score of 8-10 was observed in 33 patients (62.3%), followed by a Gleason score of 7 in 17 patients (32.1%) and a score of 2-6 was, seen in 3 patients (5.7%). A similar pattern was reported in studies from the Indian sub-continent (13),(14). However, a recent study by Rajput A et al., reported that the majority (52.4%) of the patients had a Gleason score of 7 or less (8). Also, studies by Loeb S et al., and, Coard KC and Skeete DH reported a Gleason score of 6 or less to be the most common score, seen in 76.7% and 37.8% of patients, respectively (24),(25).

The majority of patients (87.9%) in this study, presented with an advanced stage (stage 3 and 4). The local invasion was present in seven (10.6%) patients and distant metastasis, in 51 (77.3%) patients. The patients came from all the states of North East India and the majority of these states did not have any urology service at the time of the present study. The shortage of urologic service in this region probably contributed to late diagnosis in the study patients. A similar presentation in the advanced stage was reported by other studies (13),(14),(26). However, a recent study of 332 patients with tertiary care centre from India (Delhi) showed that 61% of the patients had localised prostate cancer (8). This could be due to more PSA testing and better awareness among patients about prostate cancer and the availability of urologic services in this region.

A previous study showed that in India, 85% of all prostate cancers are presented in the late stages (3 and 4) while only 15% were presented in the advanced stage in the United States (27). In many Western countries where prostate cancer screening is practiced routinely, patients with prostate cancer are diagnosed at an early stage (11),(24). In India, prostate cancer screening is not practiced routinely and knowledge of prostate cancer is poor among the public. These facts probably lead to the late presentation and diagnosis of prostate cancer patients in India.

As the majority of patients in this study presented in metastatic stage, the most common type of treatment was ADT with total bilateral orchidectomy, which was performed in 84.3% (43/51) of stage IV patients. Only eight patients (15.7%) with metastatic cancer opted for medical castration using leuprolide or triptorelin. Six of these patients later underwent orchidectomy due to financial constraints.

Thus, an overwhelming majority of metastatic patients in the present study underwent surgical orchidectomy as a means of androgen ablation. Similar treatment history is reported by studies in developing countries as patients opted for this type of treatment because of financial constraints (14),(28). On the other hand, the majority of patients with metastatic prostate cancer in developed countries opted for medical castration (29). The follow-up was poor, which could be due to various reasons like financial problems, patients staying at a long distance from the hospital, and ignorance.

Mass screening for prostate cancer still remains a controversial topic. In developed countries, where prostate cancer screening is practiced, the majority of prostate cancer patients are diagnosed at an early stage (24). In India, prostate cancer screening is not practiced routinely, so patients present with advanced disease. However, with the low incidence of prostate cancer in this region, screening for prostate cancer may not be justified.

Limitation(s)

Limitations of the study included the retrospective nature of the study. Also, the small number of patients in the study and the large proportion of patients lost to follow-up were the major limitations of the study. Loss of follow-up of large number of patients may underestimate the number of deaths. Also, this study included patients treated at a single institution, so it might not reflect the whole population in the region.

Conclusion

Though the incidence of prostate cancer was 6.6 cases per year of prostate cases in the present study population, most patients were symptomatic at presentation, and the majority presented with an advanced stage of the disease. The most common histologic type was adenocarcinoma. The majority of the patients with an advanced stage of the disease underwent total bilateral orchidectomy for androgen deprivation therapy.

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DOI and Others

DOI: 10.7860/JCDR/2022/57485.17161

Date of Submission: May 01, 2022
Date of Peer Review: Jun 15, 2022
Date of Acceptance: Sep 12, 2022
Date of Publishing: Nov 01, 2022

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 06, 2022
• Manual Googling: Sep 05, 2022
• iThenticate Software: Sep 08, 2022 (14%)

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