Bone Pain And Testicular Lump Flashcards
why is bone pain associated with prostate cancer?
prostate cancer is prone to spread in the axial skeleton owing to its lymphatic drainage (para-aortic nodes) -> it causes OSTEOSCLEROSIS
(lung/breast cancers are lytic)
what is the most common type of testicular cancer
95% of testicular cancers are germ cell tumours:
Seminomas (most common) & Teratomas
Teratomas (20-30) tend to present in slightly younger men than seminomas (30-40)
list some risk factors for TGCT
cryptorchism
testicular atrophy
inguinal hernia
hydrocele
syndromes of abnormal testicular development (Klinefelter’s, XY dysgenesis, Down’s)
? genetic involvment - monozygotic > dizygotic - no gene identified so far
which genes/ chroosomal changes have been implicated in TGCTs
probably more than one genetic locus
p53
RB
list some testicular atrophic events
- cryptorchism
- chemicals (oestrogens in pesticides, solvents - dimethylformamide)
- trauma
- idiopathic
- viruses - mumps
- other infective agents
what percentage of CIS in the testes will be invasive by 5 years
50%
spontaneous disappearance is never observed!
Untreated probably all invasive eventually
why should all men presenting with gynaecomastia have a testicular exam
5% of testicular cancers present with gynaecomastia
which tumour markers are investigated in testicular cancer
AFP
beta-hCG
LDH
(NSE and CEA)
what might a seminoma display on tumour marker tests
raised LDH
mildy raised HCG
NEVER raised AFP
what might a teratoma display on tumour marker tests
80% will express raised AFP or HCG
what is alpha fetoprotein
embryonal protein produced by the yolk sac and foetal liver
marker of hepatocellular carcinoma and non-seminomatous tumours
NOT produced by pure seminomas
what is rising LDH an indicator of in testicular cancer
relapse
under what circumstances should a contralateral testicular biopsy be done
- testicular volume <30 years old
what would be the management for stage one seminoma
orchidectomy plus adjuvant chemo/radiotherapy as 15-20% relapse if orchidectomy alone
what is the management of stage I NSGCT dependant on
vascular invasion - if positive need adjuvant chemo
what management options are available for metastatic seminoma
radiotherapy - dog leg
Chemo- PEB/
what are the management options for metastatic NSGCT
chemo unless raised tumour markers and/or nerve sparing retroperitoneal lymph node dissection
list some differentials for intra-testicular masses
generally malignant: malignant primary tumours malignant secondaries (old lymphoma, children leukaemia) benign tumours -> epidermoid Infection Trauma Torsion
extra-testicular masses are much more common, list some differentials
Hydrocoele Epididymal cysts Spermatocoeles Varicocoele Epididymitis/orchitis
which nodes are involved in advance penile carcinoma
inguinal nodes
Penile cancer
relatively rare squamour cell carcinoma usually from inner prepuc and glans
what are the risk factors associated with penile cancer
not being circumcised (poor penile hygeine) HPV - 50% associated Genital warts smoking Psoralen and UVA Penile injury
what are the definitive risk factors of prostate cancer
Age
Race
Family history
in the UK and US which ethnicities are a more risk for prostate cancer
black males have a higher risk than Whites
Chinese and Janapese have lowest incidence
geographical variations as well:
- higher in north america and europe
- lowest in far east
Migration changes risk within 2 generations
which gene is associated with increased risk of prostate cancer
BRCA2 increases risk 5x
2.1-4.9 times higher in those with Lynch syndrome
10% of prostate cancer has a genetic base
which LUTs are associated with prostate cancer
- obstructive voiding
- irritative symptoms
- haemospermia
- impotence
what symptoms of locally advanced disease might be present in prostate cancer
bony pain
anaemia
lymphoedema
renal failure
what are the indications for a PSA test
- LUTS suggestive of BPH
- abnormal prostate on DRE
- patient concerned about prostate cancer
under what circumstances should a PSA NOT be performed
retention/infection
<10 year life expectancy
following instrumentation to the lower urinary tract
PSA is also increased following: ejaculation, cycling, BPH, prostatic biopsy, prostatitis, prostatic massage,
which investigations are used to detect prostate cancer
- DRE
- PSA
- TRUS biopsy
which scale is commonly used to grade pathology
Gleasons pattern scale
how are prostate cancers staged?
TNM
clinically - DRE
Radiologically - CT/MRI
what curative therapies are available to men with localised prostate cancer
surgery
radiotherapy
adjuvant hormones
what therapies are available to men with locally advanced disease
surgery + neoadjuvant hormone therapy
radiotherapy and hormone therapy
hormone therapy
what therapies are available to men with metastatic prostate cancer
hormones
chemotherapy
osteoprotective medications
steroids
what is a theory behindthe pathogenesis of BPH
stromal-epithelial interaction leading to embryonic awakening
presentation of BPH
frequency of urination (nocturia) hesitation post void dribbling retention/overflow incontinence smooth on DRE
what methods are available for hormone deprivation in the treatment of prostate cancer
GnRH analogues
Androgen receptor blockers (block CYP17)
Surgical castration (orichidectomy)
