239. Prostate and Prostate Cancer

Question 1

epidemiology of PCa

• prevalence
• RFs (5)

Answer 1

#1 cancer in M, #2 cause of cancer death in M
MOST COMMON GU Malignancy

RFs:
Age > 65
Hereditary: +FamHx (15% prevalence), germline mutations in MMRs - BRCA 1/2 assoc with youger dx age
Race: AA > White > Asian (multifactorial), AA have higher incidence and death rates
Inflammation/Infection: prostatitis/STD, IBD
Diet/Obesity: higher dietary fat = more aggressive cancer

Question 2

What is the ddx of prostate nodule on DRE (3)

Answer 2

1. PCa
2. BPH focal nodule
3. Calculous stone in blood vessel

Question 3

How is PCa Screened? Screening guidelines? Controversy? Ways to enhance screen?

Answer 3

PSA - can rise anytime prostate irritated (Age, BPH, infection, UTI, urinary retention, prostate massage, recent ejac)
No screening = higher grade presentation and higher chance of mets
Controversy: catch cancers that would not have impacted pts life, but screening proven to reduce some PCa mortality

Guidelines:
Shared decision making if pt 55-69 yo (q2yrs or annually or not at all)
Routine screening not recommended ages 70+ unless expectancy >10yrs

Enhance accuracy with prostate imaging: advanced MRI of peripheral/transition zone

Question 4

How to confirm Prostate Cancer Dx

Signs of High Grade Prostatic Intraepithelial Neoplasia

Signs of Prostate Adenocarcinoma

Answer 4

Dx: IHC stain for PSA - not contained in lumen
Multiparametric MRI of Prostate: overlay MRI on US in real-time to sample from abnormality

High Grade PIN: neoplastic cells w/in pre-existing glands - NOT Ca (NOT CIS), precursor to prostate cancer

Prostate Adenocarcinoma: infiltrating glands, small glands, prominent nucleoli, extracellular pink material

Question 5

Staging of Prostate Cancer

T1-T4

Answer 5

T1: confined to prostate, normal DRE
T2: palpable tumor confined to prostate
T3: protrudes beyond capsule (3A) or into seminal vesicle (3B)
T4: fixed and pushed into adjacent structures

Question 6

Mgmt of Organ-Confined Disease

- prognostic factor

Answer 6

1. Surveillance if low progression risk, low life expectancy, gleason <6
2. Radical prostactectomy + Pelvic LNs (high risk urinary incontinence, erectile dysfx)
3. Radiation tx (for local-advanced disease, may cause sexual dysfx and miss tumor cells)

Brachytherapy, Cryoablation, High intensity focused US, MRI guided focal laser ablation

Question 7

Mgmt of Metastatic Disease

- best 3

Answer 7

1. Androgen Deprivation Therapy - MAINSTAY TX (PCa is hormonally dependent) - goal to lower T via GnRH agonist/antagonist, anti-androgens, androgen biosynthesis inhibitors
2. Chemotherapy: TAXANE - disrupt microtubular network in cells
3. CHEMOHORMONAL TX: Combo anti-androgen tx and TAXANE chemo = BETTER SURVIVAL BENEFIT