1. Tumours of the urinary system - prostate and testicular cancer Flashcards
what is the most common cancer diagnosed in men
prostate
what is the % new cases in different age groups
<50 = 1% new cases >65 = 75% new cases <70 = 45% new cases
BUT these trends likely to change
what are some risk factors for prostate cancer
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
what are the 4 different zones of the prostate
transition, central, peripheral, anterior fibromuscular stroma
in what zone is prostate cancer most likely to occur
peripheral zone
80% localised
how does prostate cancer present
mostly asymptomatic
how is prostate cancer diagnosed
through opportunistic PSA testing (NOT SCREENING)
diagnostic triad:
- PSA
digital rectal examination
- TRUS-guided prostate biopsies
what are some symptoms of local disease prostate cancer
weak stream, hesitancy, sensation of incomplete emptying, frequency, urgency, urge incontinence, UTI
what are some symptoms of locally invasive disease prostate cancer
haematuria, perineal and suprapubic pain, impotence, incontinence, loin pain, anuria resulting from obstruction of the ureters, renal failure symptoms, haemmospermia, rectal symptoms
how can metastatic prostate cancer present
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
along with screening, how do we avoid under-treatment of aggressive cancers
ad-hoc PSA testing
what is PSA
prostate specific antigen - also known as kallikrien serine protease
liquifies semen
produced by glands of the prostate - may leak into serum
what is the normal PSA serum range
0-4.0 micrograms/mL
what are the age related PSA ranges
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
what can cause elevations in PSA
- UTI
- chronic prostatitis
- instrumentation (e.g. catheterisation)
- physiological (e.g. ejaculation)
- recent urological procedure
- BPH
- prostate cancer
what is the half life of PSA
2.2 days
if a repeat PSA needed when would you recheck
3 weeks time (i.e. 8 half lives)
what are the probability of cancer at different levels of PSA
0-1.0: 5%
- 0-2.5: 15%
- 5–4.0: 25%
- 0-10: 40%
> 10: 70%
how are prostate cancers graded
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
what are the %risk of death in 15 years with each gleason score
2-4 4-7%
5 6-11%
6 18-30%
7 42-70%
8-10 60-87%
what are the 4 stages of prostate cancer
Localised stage
Locally advanced stage
Metastatic stage
Hormone refractory stage
what examinations/ investigations can be done to aid staging
Digital rectal examination (local staging)
PSA
Transrectal US guided biopsies
CT (regional and distant staging)
MRI (local staging)
what is the treatment for localised prostate cancer
Watchful waiting
Radiotherapy
- External-beam
- Brachytherapy
Radical prostatectomy
- Open
- Laparoscopic
- Robotic
Others under investigation
- Cryotherapy
- Thermotherapy
what is the treatment for locally advanced prostate cancer
Watchful waiting
Hormone therapy followed by surgery
Hormone therapy followed by radiation
Hormone therapy alone
Intermitted hormone therapy (clinical research)
what is the hormone that needs to be targeted to treat prostate cancer
androgens - depravation
what are the types of hormonal therapy for prostate cancer
surgical castration - (i.e. bilateral orchidectomy)
chemical castration - (i.e. LHRH analogue – goserelin, leuprorelin, etc.)
anti-androgens - inhibit androgen receptors
oestrogens - (i.e. diethylstilboestrol)
how does chemical castration work
eventually downregulates androgen receptors by negative feedback
tumour flare in first week of therapy (hence need anti-androgen during this period)
how do oestrogens work
inhibits LHRH and testosterone secretion, inactivates androgens and has direct cytotoxic effect on prostatic epithelial cells
what are come complications of prostate cancer
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
what is the mainstay treatment for prostate cancer
hormonal therapy
what supportive treatment can be used for prostate cancer
palliative radiotherapy to bony metastases, colostomy, nephrostomy, zoledronic acid, palliative care support, etc.
what is the hormone refractory stage of treatment of prostate cancer
the stage in the treatment in which the hormones are no longer effective - usually 18-24 months into treatment
what are the recommended treatment options for low risk localised prostate cancer
Active surveillance;
Surgery (lap, robotic or open);
EBRT (external beam radiotherapy);
Brachytherapy
alternative options:
Watchful waiting;
Focal ablative therapy (cryotherapy or HIFU)
what are the recommended treatment options for intermediate risk localised prostate cancer
Surgery;
EBRT +/- HT;
Brachytherapy +/- HT
PLUS HT for 2-3yrs
alternative options:
Active surveillance;
Watchful waiting
what are the recommended treatment options for high risk localised prostate cancer
EBRT + HT
PLUS HT for 2-3yrs
alternative options:
Surgery + adjuvant EBRT + HT;
Watchful waiting
how does testicular cancer
present
usually
- a painless lump
less often
- tender inflamed swelling,
- history of trauma,
- symptoms/signs from nodal or distant mets (para-aortic lymphs, chest, bone)
what are some of the predisposing factors of testicular cancer
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
what is looked for in the blood immediately before and after surgery
tumour markers
what are the different types of tumour markers
AFP (alpha-fetoprotein) (teratoma)
BetaHCG (Human Chorionic Gonadotrophin) (seminoma)
LDH (Lactate dehydrogenase) (non-specific marker of tumour burden)
if there is a lump found in the testis what is suspected until proven otherwise
testicular tumour
what are differential diagnoses for a lump in the testis
- infection (i.e. epididymo-orchitis)
- epididymal cyst
- missed testicular torsion
what are investigations that can be used to diagnose testicular cancer
MSSU
US scan
Xray
bloods - tumour markers
what is the first line of treatment for testicular cancer
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
in orchidectomy where is the incision made
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
what are the two broad groups of testicular cancer
germ cell tumour (GCT - 95%)
non-GCT (5%)
what are types of GCT
Seminomatous GCT (classical, spermatocytic, or anaplastic)
Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT)
what are types of non-GCT
(sex cord/stromal):
Leydig
Sertoli
Lymphoma rare
what age groups are affected by seminoma and non-seminoma respectively
seminoma - mainly 30-40 yr olds
non-seminoma - mainly 20-30 yr olds
what does the grading of testicular cancer assess
aggressiveness
what is grading of testicular cancer based on
histological assessment of differentiation:
- Low grade = well differentiated
- High grade = poorly differentiated
what does the staging of testicular cancer assess
spread
what are the different types of spread that can occur in testicular cancer
Spread occurs in 3 ways:
- local spread (i.e. local invasion to adjacent structures)
- regional spread (lymphatic invasion)
- distant spread (lungs, bone, liver)
what is used to help stage testicular cancer
TNM system
T = size/direct extent of primary tumour N = degree of spread to regional lymph nodes M = presence of distant metastasis
briefly summarise the T part of the TNM system
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
briefly summarise the N part of the TNM system
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)
briefly summarise the M part of the TNM system
M = presence of distant metastasis
M0: no distant metastasis
M1: metastasis to distant organs (beyond regional lymph nodes)
what investigations can be used to help determine stage
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
what are the 4 final stages of testicular cancer
Stage I - disease is confined to the testis
Stage II - Infradiaphragmatic nodes involved
Stage III - Supradiaphragmatic nodes involved
Stage IV - extralymphatic disease
what is the follow on treatment for low stage, negative markers testicular cancer
Orchidectomy, followed by:
- Surveillance; or
- Adjuvant radiotherapy (SGCT only); or
- Prophylactic chemotherapy
what is the follow on treatment for testicular cancer with nodal disease, persistent tumour markers, or relapse on surveillance
Orchidectomy, followed by:
- Combination chemotherapy (BEP); or
- Lymph node dissection (NSGCT only)
what is the follow on treatment for testicular cancer with metastases
Orchidectomy, followed by:
- First-line chemotherapy
- Second-line chemotherapy
what are the prognosis’ for the different stages of testicular cancer
Stage 1: 5-year survival – 99%
Stage 2/3: 5-year survival – 96%
Stage 4: 5-year survival – 73%
