3: Prostate Cancer Flashcards
what is the epidemiology of carcinoma of the prostate
- commonest cancer in men
- rare in men <50
- 2nd commonest cause of death from cancer in men
- majority are adenocarcinomas
what are the risk factors of carcinomas of the prostate
- inc age
- family history and BRACA2 gene mutation
- ethnicity (black –> white –> asian)
label the zones of the bladder
what zone of the prostate is carcinoma most commonly found
peripheral zone
(compared to more central zone of BPH)
what do patients present with in prostate carcinoma
- symptoms of UTI
- LUTS: weak urinary stream, increased urinary frequency and urgency
- prostatism or metastatic disease of the bone causing bone pain, haematuria, dysuria, suprapubic or loin pain
- raised PSA in otherwise asymptomatic men, biopsy
how can carcinoma of the prostate be found
- opportunistic finding from DRE: evidence of asymmetry, nodularity or fixed irregular mass
- incidental finding at transurethral resection of the prostate
what can cause a raised PSA
- prostate cancer
- infection
- inflammation
- large prostate
- urinary retention
does a normal PSA always indicate an absence of prostate cancer
no - you can have a normal PSA but an abnormal feeling prostate on DRE
how is prostate carcinoma graded
Gleason classification - grades tumours on histological appearance
- grade 5: anaplastic diffuse tumour with cells showing great variation in their structure and high mitotic rate
- grade 3-5
- biopsy = sum of 2 highest scores
- radical prostatectomy = 2 most prevalent scores
- low = Gleason 3+3=6
- intermediate = 3+4=7
- high= 4+3=7, 8,9,10
how is prostate carcinoma staged
TNM following CT chest-abdo-pelvis and PET-CT nuclear medicine scan
- T1: 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
how is prostate carcinoma diagnosed
- DRE: hard, irregular prostate
- US: prostatic mass
- inc PSA in blood: normal result does not exclude the presence of cancer
- biopsy: used to provide a histological diagnosis
- radiographs and bone scans: used to stage the tumour
what feature is present in advanced prostate cancer
- osteosclerotic lesions (seen on radiographs)
- inc isotope uptake on bone scans seen as ‘hot spots’
what is the treatment for localised prostate cancer
- depends on the stage of the tumour
surgery
hormone therapy
radiotherapy
before treatment for prostate cancer starts, what needs to be done
histological diagnosis of prostatic carcinoma is required as treatment depends on the stage of the tumour
- T1/T2 radical surgical resection of the prostate (or radical prostatectomy) may be curative. TURP may be required
- Local radiotherapy can be used if the patient is unfit for surgery, and to treat localordistant spreadofthetumour
- Surveillance
what are the side effects of a prostatectomy
- urinary incontinence
- erectile dysfunction
- infertility
- bladder neck stenosis
what are side effects of RT in localised prostate cancer
- discomfort around RT site
- diarrhoea
- loss of pubic hair
- tiredness
- inflammation of bladder lining
- erectile dysfunction (impotence)
what are some emerging treatments for prostate cancer
- Brachytherapy
- High-Intensity Focused Ultrasound (HIFU) –uses ultrasound waves to target and destroy cancerous prostate tissue, sparing nearby structures
- Cryotherapy – cryoneedlesinserted into prostate gland through wall of rectum. Freeze prostate gland
describe treatment of advanced prostate cancer
- Advanced tumours: hormonal manipulation is beneficial since testosterone promotes tumour growth
- Testosterone
- Dihydrotestosterone - Surgical castration
- Medical castration
- LHRHagonists
- GnRH agonists - Palliative care
what are some side effects of castration
- hot flushes
- impotence
- thinning of bones
- diminshed muscle mass
- inc in breast size
- weight gain
- mood changes
- testosterone suppressed
what is the prognosis of prostate cancer
depends on stage
- 5 year survival rate for T1 tumours = 75-90% but this falls to 30-45% if there is local or metastatic spread
what are the 2 types of prostate adenocarcinoma
- acinar: originates in glandular cells that line prostate gland
- ductal: originate in cells that line the ducts of prostate which tends to grow and metastasise faster
what is PSA
serum protein that is produced by both malignant and normal healthy cells in prostate gland
what are normal age-adjusted serum PSA levels
what is the function of PSA
- dissolution of the seminal fluid coagulum
- important role in fertility
what are the overall risks and benefits of PSA screening for prostate cancer
- significant reduction in prostate cancer mortality at 11 years
- over diagnosis and over treatment
what is the current standard method for diagnosing prostate cancer
biopsy of prostatic tissue
1. transperineal: template biopsy or freehand guided by both intra-procedure USS and mpMRI (decreased risk of infection)
2. TransRectal UltraSound-guided biopsy (TRUS): sample prostate transrectally using us then sample in systematic manner
what is waitful watching
symptom-guided approach to prostate cancer management where therapy is deferred and initiated at time of symptomatic disease
- generally reserved for older pt w lower life expectancy
- can be offered at any stage
- largely guided by patient goals and maintaining QoL
what is active surveillance
monitoring of pt w 3-monthly PSA, 6-12 monthly DRE and re-biopsy at 1-3 yearly intervals
- assessing for progression and intervening at appropriate time
- low risk disease
what is the mainstay surgical treatment for prostate cancer
radical prostatectomy: removal of prostate gland, resection of seminal vesciles +/- tissue dissection of pelvic lymph nodes
- open, lap, robotic
what does external-beam RT and brachytherapy involve
curative intervention for localised prostate cancer
- brachytherapy: transperineal implantation of radioactive seeds (Iodine-125) directly into the prostate gland
- external beam: uses focused radiotherapy to target prostate and limit damage to surrounding tissues
what is the mainstay of management of metastatic prostate cancer
androgen deprivation therapy (ADT)
- prostate cancer cells will undergo apoptosis when deprived of testosterone
- anti-androgens e.g. bicalutamide for 28 days
- GnRH receptor agonists e.g. goserelin and antagonsists e.g. degarelix
- surgical castration
- enzalutamide and abiraterone lower levels of serum T
- chemo: docetaxel or cabazitaxel
what is castrate-resistant disease
- rising PSA despite hormone therapy
- dexamethasone
- docetaxel chemo
what is the current 1st line investigation in suspected prostate cancer
multiparametric MRI
