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URINARY > 1. Tumours of the urinary system - prostate and testicular cancer > Flashcards

1. Tumours of the urinary system - prostate and testicular cancer Flashcards

1
Q

what is the most common cancer diagnosed in men

A

prostate

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2
Q

what is the % new cases in different age groups

A 
<50 = 1% new cases
>65 = 75% new cases
<70 = 45% new cases

BUT these trends likely to change

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3
Q

what are some risk factors for prostate cancer

A

age - increasing

race/ethnicity - afro-caribbean men living in western countries

geography - NW europe, N america, caribbean, australia

family history - first degree realtive x2 risk, HPC1, BRCA1 & 2

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4
Q

what are the 4 different zones of the prostate

A

transition, central, peripheral, anterior fibromuscular stroma

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5
Q

in what zone is prostate cancer most likely to occur

A

peripheral zone

80% localised

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6
Q

how does prostate cancer present

A

mostly asymptomatic

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7
Q

how is prostate cancer diagnosed

A

through opportunistic PSA testing (NOT SCREENING)

diagnostic triad:
- PSA
digital rectal examination
- TRUS-guided prostate biopsies

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8
Q

what are some symptoms of local disease prostate cancer

A 
weak stream,
hesitancy, 
sensation of incomplete emptying,
frequency,
urgency,
urge incontinence,
UTI
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9
Q

what are some symptoms of locally invasive disease prostate cancer

A 
haematuria,
perineal and suprapubic pain,
impotence,
incontinence, 
loin pain, 
anuria resulting from obstruction of the ureters, 
renal failure symptoms, 
haemmospermia,
rectal symptoms
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10
Q

how can metastatic prostate cancer present

A 
distant mets:
bone pain,
sciatica,
paraplegia from spinal cord compression,
lymph node enlargement, 
lymphoedema,
loin pain,
anuria

widespread mets:
lethargy (due to anaemia, uraemia),
weight loss,
cachexia

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11
Q

along with screening, how do we avoid under-treatment of aggressive cancers

A

ad-hoc PSA testing

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12
Q

what is PSA

A

prostate specific antigen - also known as kallikrien serine protease

liquifies semen

produced by glands of the prostate - may leak into serum

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13
Q

what is the normal PSA serum range

A

0-4.0 micrograms/mL

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14
Q

what are the age related PSA ranges

A

Levels increase with age

< 50 years : 2.5 is upper limit

50-60 years : 3.5 is upper limit

60-70 years : 4.5 is upper limit

> 70 years : 6.5 is upper limit

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15
Q

what can cause elevations in PSA

A
  • UTI
  • chronic prostatitis
  • instrumentation (e.g. catheterisation)
  • physiological (e.g. ejaculation)
  • recent urological procedure
  • BPH
  • prostate cancer
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16
Q

what is the half life of PSA

A

2.2 days

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17
Q

if a repeat PSA needed when would you recheck

A

3 weeks time (i.e. 8 half lives)

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18
Q

what are the probability of cancer at different levels of PSA

A

0-1.0: 5%

  1. 0-2.5: 15%
  2. 5–4.0: 25%
  3. 0-10: 40%

> 10: 70%

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19
Q

how are prostate cancers graded

A

using the Gleason grading system

pathologist grades cancer from 1-5 (well to poorly differentiated) and the most likely scores are summated to give the gleason SUM score

eg
3 (most common) + 4 (second most common, but can be the same number)
= 7

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20
Q

what are the %risk of death in 15 years with each gleason score

A

2-4 4-7%

5 6-11%

6 18-30%

7 42-70%

8-10 60-87%

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21
Q

what are the 4 stages of prostate cancer

A

Localised stage
Locally advanced stage
Metastatic stage
Hormone refractory stage

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22
Q

what examinations/ investigations can be done to aid staging

A

Digital rectal examination (local staging)

PSA

Transrectal US guided biopsies

CT (regional and distant staging)

MRI (local staging)

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23
Q

what is the treatment for localised prostate cancer

A

Watchful waiting

Radiotherapy

  • External-beam
  • Brachytherapy

Radical prostatectomy

  • Open
  • Laparoscopic
  • Robotic

Others under investigation

  • Cryotherapy
  • Thermotherapy
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24
Q

what is the treatment for locally advanced prostate cancer

A

Watchful waiting

Hormone therapy followed by surgery

Hormone therapy followed by radiation

Hormone therapy alone

Intermitted hormone therapy (clinical research)

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25
Q

what is the hormone that needs to be targeted to treat prostate cancer

A

androgens - depravation

26
Q

what are the types of hormonal therapy for prostate cancer

A

surgical castration - (i.e. bilateral orchidectomy)

chemical castration - (i.e. LHRH analogue – goserelin, leuprorelin, etc.)

anti-androgens - inhibit androgen receptors

oestrogens - (i.e. diethylstilboestrol)

27
Q

how does chemical castration work

A

eventually downregulates androgen receptors by negative feedback

tumour flare in first week of therapy (hence need anti-androgen during this period)

28
Q

how do oestrogens work

A

inhibits LHRH and testosterone secretion, inactivates androgens and has direct cytotoxic effect on prostatic epithelial cells

29
Q

what are come complications of prostate cancer

A

Bone: pain, pathological fractures, anaemia, spinal cord compression

Rectal: constipation, bowel obstruction

Ureteric: obstruction resulting in renal failure

Pelvic lymphatic obstruction: lymphoedema, DVT

Lower urinary tract dysfunction: haematuria, acute retention

30
Q

what is the mainstay treatment for prostate cancer

A

hormonal therapy

31
Q

what supportive treatment can be used for prostate cancer

A

palliative radiotherapy to bony metastases, colostomy, nephrostomy, zoledronic acid, palliative care support, etc.

32
Q

what is the hormone refractory stage of treatment of prostate cancer

A

the stage in the treatment in which the hormones are no longer effective - usually 18-24 months into treatment

33
Q

what are the recommended treatment options for low risk localised prostate cancer

A

Active surveillance;
Surgery (lap, robotic or open);
EBRT (external beam radiotherapy);
Brachytherapy

alternative options:
Watchful waiting;
Focal ablative therapy (cryotherapy or HIFU)

34
Q

what are the recommended treatment options for intermediate risk localised prostate cancer

A

Surgery;
EBRT +/- HT;
Brachytherapy +/- HT

PLUS HT for 2-3yrs

alternative options:
Active surveillance;
Watchful waiting

35
Q

what are the recommended treatment options for high risk localised prostate cancer

A

EBRT + HT

PLUS HT for 2-3yrs

alternative options:
Surgery + adjuvant EBRT + HT;
Watchful waiting

36
Q

how does testicular cancer

present

A

usually
- a painless lump

less often

  • tender inflamed swelling,
  • history of trauma,
  • symptoms/signs from nodal or distant mets (para-aortic lymphs, chest, bone)
37
Q

what are some of the predisposing factors of testicular cancer

A

young men

3rd decade

race - Caucasian

higher risk in testicular maldescent; infertility; atrophic testis; and previous cancer in contralateral testis

aetiology unknown BUT Testicular Germ Cell Neoplasia In-Situ is a precursor lesion

38
Q

what is looked for in the blood immediately before and after surgery

A

tumour markers

39
Q

what are the different types of tumour markers

A

AFP (alpha-fetoprotein) (teratoma)

BetaHCG (Human Chorionic Gonadotrophin) (seminoma)

LDH (Lactate dehydrogenase) (non-specific marker of tumour burden)

40
Q

if there is a lump found in the testis what is suspected until proven otherwise

A

testicular tumour

41
Q

what are differential diagnoses for a lump in the testis

A
  • infection (i.e. epididymo-orchitis)
  • epididymal cyst
  • missed testicular torsion
42
Q

what are investigations that can be used to diagnose testicular cancer

A

MSSU
US scan
Xray
bloods - tumour markers

43
Q

what is the first line of treatment for testicular cancer

A

radical orchidectomy essential

occasionally may need biopsy of “normal” contralateral testis if high risk for tumour

further treatment depends on tumour type, stage (TNM) and grade

44
Q

in orchidectomy where is the incision made

A

above the pubic bone on the side corresponding to the testicle to be removed. This incision runs obliquely midway between the pubic tubercle and the anterior superior iliac spine

45
Q

what are the two broad groups of testicular cancer

A

germ cell tumour (GCT - 95%)

non-GCT (5%)

46
Q

what are types of GCT

A

Seminomatous GCT (classical, spermatocytic, or anaplastic)

Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT)

47
Q

what are types of non-GCT

A

(sex cord/stromal):

Leydig
Sertoli
Lymphoma rare

48
Q

what age groups are affected by seminoma and non-seminoma respectively

A

seminoma - mainly 30-40 yr olds

non-seminoma - mainly 20-30 yr olds

49
Q

what does the grading of testicular cancer assess

A

aggressiveness

50
Q

what is grading of testicular cancer based on

A

histological assessment of differentiation:

  • Low grade = well differentiated
  • High grade = poorly differentiated
51
Q

what does the staging of testicular cancer assess

A

spread

52
Q

what are the different types of spread that can occur in testicular cancer

A

Spread occurs in 3 ways:

  • local spread (i.e. local invasion to adjacent structures)
  • regional spread (lymphatic invasion)
  • distant spread (lungs, bone, liver)
53
Q

what is used to help stage testicular cancer

A

TNM system

T = size/direct extent of primary tumour
N = degree of spread to regional lymph nodes 
M = presence of distant metastasis
54
Q

briefly summarise the T part of the TNM system

A

T = size/direct extent of the primary tumour

Tx: tumour cannot be assessed

Tis: carcinoma in situ

T0: no evidence of tumour

T1, T2, T3, T4: size and/or extension of the primary tumour

55
Q

briefly summarise the N part of the TNM system

A

N = degree of spread to regional lymph nodes

Nx: lymph nodes cannot be assessed

N0: no regional lymph nodes metastasis

N1: regional lymph node metastasis present; at some sites, tumour spread to closest or small number of regional lymph nodes

N2: tumour spread to an extent between N1 and N3 (N2 is not used at all sites)

N3: tumour spread to more distant or numerous regional lymph nodes (N3 is not used at all sites)

56
Q

briefly summarise the M part of the TNM system

A

M = presence of distant metastasis

M0: no distant metastasis

M1: metastasis to distant organs (beyond regional lymph nodes)

57
Q

what investigations can be used to help determine stage

A

Local staging (via pathological assessment of orchidectomy specimen)

Nodal staging (via CT scan)

Distant staging (chest, abdomen and pelvis) (via CT scan)

Tumour markers also provide staging and prognostic information

58
Q

what are the 4 final stages of testicular cancer

A

Stage I - disease is confined to the testis

Stage II - Infradiaphragmatic nodes involved

Stage III - Supradiaphragmatic nodes involved

Stage IV - extralymphatic disease

59
Q

what is the follow on treatment for low stage, negative markers testicular cancer

A

Orchidectomy, followed by:

  • Surveillance; or
  • Adjuvant radiotherapy (SGCT only); or
  • Prophylactic chemotherapy
60
Q

what is the follow on treatment for testicular cancer with nodal disease, persistent tumour markers, or relapse on surveillance

A

Orchidectomy, followed by:

  • Combination chemotherapy (BEP); or
  • Lymph node dissection (NSGCT only)
61
Q

what is the follow on treatment for testicular cancer with metastases

A

Orchidectomy, followed by:

  • First-line chemotherapy
  • Second-line chemotherapy
62
Q

what are the prognosis’ for the different stages of testicular cancer

A

Stage 1: 5-year survival – 99%

Stage 2/3: 5-year survival – 96%

Stage 4: 5-year survival – 73%

URINARY (27 decks)

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