10.2 Carcinoma Of The Prostate

Question 1

What is the commonest cancer in men?

Answer 1

Prostate cancer

Question 2

How common is prostate cancer?

Answer 2

Commonest cancer in men
2 nd commonest cause of death from cancer in men
1 in 8 men will be diagnosed with prostate cancer in their lifetime

Question 3

What are the risk factors of prostate cancer?

Answer 3

Male
Increasing age (over 50)
Family history (and BRACA2 gene mutation)
Ethnicity – Black>White>Asian

Question 4

What are the 4 zones of the prostate?

Answer 4

Transitional zone
Peripheral zone
Central zone 
Anterior zone 
 PACT

Question 5

Where are prostate cancers most commonly found?

Answer 5

Lesions are most commonly found in the periphery of the posterior part of the prostate compared with the more central location of BPH

Question 6

How do patients with prostate cancer present?

Answer 6

symptoms of UTI
Inability to void/ obstruction
prostatism or metastatic disease in the bone (usually the spine) causing bone pain
investigation of elevated prostate-specific antigen (PSA) in
otherwise asymptomatic men

Question 7

Why are prostatic cancers usually detectable with a digital rectal examination?

Answer 7

As prostate cancers commonly affect the posterior part of the peripheral zone of the prostate, which can be felt through the anterior rectal wall

Question 8

Why can elevated PSA (prostate specific antigens) not be used to diagnose prostate cancer?

Answer 8

1. Many other causes of raised PSA

2. Can have a normal PSA with prostate cancer

Question 9

Other than prostate cancer, what else can cause an elevated PSA?

Answer 9

Infection (UTI) - up to 6 weeks past infection
Inflammation
Argue prostate
Urinalysis retention

Question 10

What prostate screening does NHS support?

Answer 10

Opportunistic screening - PSA test if patient presents with symptoms of prostate cancer (urinary retention/UTI/change to urine stream/bone pain)

Question 11

Why doesn’t the NHS support mass population screening for prostate cancer?

Answer 11

As the screening by PSA test is not specific enough. Can have raised PSA for a number of reasons and not all prostate cancers cause a raise in PSA levels

Question 12

How do patients with prostate cancer present?

Answer 12

Urinary symptoms
Bone pain (sclerotic metastasis in the bones)
Raised PSA, biopsy
Opportunistic finding from DRE (e.g if patient has constipation)
Incidental finding at transurethral resection of prostate

Question 13

How are prostatic tumours graded?

Answer 13

Gleason classification - grades tumours on histological appearance

Question 14

What does a grade 1 tumour on the Gleason scale look like?

Answer 14

Well differentiated tumour composed of uniform tumour cells

Question 15

What does a grade 5 tumour on the Gleason scale look like?

Answer 15

Anaplastic diffuse tumour with cells showing great variation in their structure and high mitotic rate

Question 16

How is a prostatic cancer graded?

Answer 16

TNM system
T 1: unsuspected impalpable tumour
T2: the tumour is confined to the prostate
T3: there is local extension of the tumour beyond the prostatic capsule
T4: the tumour has fixed to other
structures

Question 17

How do we diagnose a prostate cancer?

Answer 17

Distal rectal examination: hard and irregular prostate Ultrasound: used to define a prostatic mass
↑PSA level in the blood: however, a normal result does not exclude the presence of cancer
Biopsy of the prostate: used to provide a histological diagnosis
Radiographs and bone scans: used to stage the tumour.

Question 18

What area of the body is commonly affected in bone metastasis?

Answer 18

Bone metastasis - sclerotic bone legions

Osteosclerotic lesions on radiographs and increased isotope uptake on bone scans are seen if there is metastatic spread.

Question 19

How do we treat prostate cancer?

Answer 19

Depends on stage of prostate cancer via histological diagnosis
T1/T2: radical surgical resection of the prostate may be curative. TURP may be required (transurethral resection of prostate)
Local radiotherapy can be used if the patient is unfit for surgery, and to treat local or distant spread of the tumour
Surveillance

Question 20

Why might surveillance be the best treatment option for cancer?

Answer 20

Some cancers grow very slowly
Surgery can cause impotence and erectile dysfunction.
May be more beneficial to monitor

Question 21

How is advanced prostate cancer treated?

Answer 21

Hormonal manipulation is beneficial since testosterone promotes tumour growth (Testosterone and Dihydrotestosterone)
- Surgical castration - remove testis
- Medical castration
• LHRH agonists
• GnRH agonists
Both LHRH and GnRH stimulate testosterone initially before stopping testosterone release ( provide androgen blockers to stop growth of bone mets)
- Palliative care

Question 22

What is the prognosis of prostate cancer?

Answer 22

Prognosis depends on the stage. The 5-year survival
rate for T1 tumours is 75-90%. However the 5-year
survival falls to 30-45% if there is local or metastatic
spread

Question 23

What are the side effects of castration?

Answer 23

Hot flushes
Impotence
Thinning of bone
Diminishing muscle mass
Increased breast size
Weight gain
Mood changes

Question 24

What is castration?

Answer 24

Suppression of testosterone and dihydrotestosteron