CASE 4 - PROSTATE CANCER Flashcards
What is the size of the prostate?
Walnut / Chestnut
What is the function of the prostate?
Makes and stores seminal fluid. It secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate.
Contains spermatozoa, which has the ability to fertilise the female ovum
What zone/area of the prostate is the most commonly implicated in prostate cancer?
Peripheral zone
75-80% of prostate cancers occur here.
Prostate cancer is the _nd most common cause of death in men
Prostate cancer is the 2nd most common cause of death in men
Name 3 non-modifiable risk factors for prostate cancer
- AGE (>40 years)
- RACE (African > Caucasian > Asian)
- FAMILY HISTORY (1 primary relative doubles your risk)
Why is screening important?
Localised (and curable) disease is ASYMPTOMATIC
What is the most common site of prostate cancer metastasis? What are some symptoms of metastases?
Bone (especially the axial skeleton)
SYMPTOMS: bone pain, pathological fractures, spinal cord compression, weight loss
What is Prostate-specific antigen (PSA)?
Protease that is produced by benign AND malignant cells of the prostate
What is the value of a DRE?
Increases the predictive value of PSA
Describe 4 considerations that must be made when performing a DRE.
- Communication: tell the patient why it’s important (e.g. it increases our ability to pick up prostate cancer)
- Consent: verbal and sustained
- Setting: ensure privacy!
- Explain findings to the patient
When and why is a prostate MRI done?
Done before a biopsy: alerts to areas of suspicion and where to target in a biopsy
What are the pros and cons of a trans-rectal vs. trans-perineal ultrasound-guided biopsy?
TRANS-RECTAL (TRUS):
- Can do it while the patient is awake (local anaesthesia)
- Is above the dentate line, and the mucosa there is relatively insensitive
- CONS: can’t sample certain areas, risk of infection since it’s moving through the rectum
TRANS-PERINEAL: passed through the skin between the scrotum and perineum
- Reduced infection risk
- Slightly improved sample
How is prostate cancer GRADED?
GLEASON GRADE: histological grade based on cellular architecture
Grades 3-5 are the only ones reported (grade 5 is the worst)
Score is calculated based on the 2 most common grades.
Why is assessment of localised disease pivotal to prostate cancer treatment?
If it has metastasized, it is no longer treatable and management is centered around extending life
Which investigations are used for the staging of prostate cancer?
- MRI - shows localised and advanced disease
- PMSA-PET CT: a prostate-specific marker is injected and allows you to see which cells contain prostate-specific membrane antigen
- WBBS (whole-body bone scan)
Outline the factors affecting management of localised prostate cancer.
- PATIENT FACTORS: co-morbidities/life expectancy, surgical suitability, patient preference
- PATHOLOGY FACTORS: Gleason grade & radiological T stage
- PROSTATE FACTORS: may preclude some treatment options
- EQUIPMENT: availability, expertise
The vast majority of men who have a small amount of low-risk prostate cancer will be fine. How should this be managed?
Focus on active surveillance. Any treatment will be overtreatment.
How is prostate cancer STAGED?
TNM STAGING: look @ images
Stage 1 is unable to be felt
Stage 2 is the start of the pathological stage. It can be felt
Stage 3: cancer has spread from the prostate into nearby TISSUES
Stage 4: cancer has spread into nearby ORGANS (e.g. bladder, rectum) - no longer treatable
A residual urine volume of more than ____mL may require further investigation.
A residual urine volume of more than 250 mL may require further investigation.
How can flank pain indicate advanced prostate enlargement?
Hydronephrosis can present with flank pain
Hydronephrosis is caused by urinary stasis due to bladder outflow obstruction
What is the normal volume of a prostate?
~20ccs.
.
.
Behavioural management of BPH
- Set times to go to the toilet
- Restrict evening fluid intake
- Avoid antihistamines and decongestants, which make urination more difficult
Outline the conservative management of BPH
- Watchful waiting: in those with mildly symptomatic BPH, or as supplemental therapy
- Behavioural modifications: fluid restriction before bed, decreasing caffeine and alcohol intake
- Pharmacology: alpha-blockers and 5-alpha-reductase inhibitors (monotherapy, or combo therapy if Sx more severe)
What is the difference between Benign Prostatic Hyperplasia (BPH) and Benign Prostatic Syndrome(BPS)?
BPH = hyperplasia of the glandular and stromal cells of the transition zone of the prostate
BPS = lower urinary tract symptoms (LUTS) arising from BPH
What is PSA, what factors can cause it to be raised, and when is malignancy suspected?
Prostate-specific antigen is produced exclusively by the prostate and is responsible for liquifying semen
Can be raised by BPH, cancer, trauma, UTI, prostatitis
Malignancy is suspected when levels > 4ng/L
What’s is TURP?
Transurethral resection of the prostate:
Most common surgical procedure for BPH (not bladder cancer).
It removes the part of the prostate which is blocking the urethra.
Give 3 examples each of irritative and obstructive symptoms of BPH.
IRRITATIVE Sx: urinary frequency, urgency, and urge incontinence, nocturia, dysuria
OBSTRUCTIVE: hesitancy, straining, poor/intermittent stream, prolonged terminal dribbling, sensation of incomplete voiding
Can be described together using the term LUTS
How common is BPH?
~50% of men >50 have BPH
What is the MOA of selective alpha-blockers? (First-line medication), e.g. doxazosin, tamsulosin
Blocks alpha-1 receptors, allowing smooth muscle relaxation in the bladder neck and prostate and decreasing resistance to urinary outflow.
Rapid response (<48 hours)
What is the MOA of 5-alpha-reductase inhibitors? e.g. finasteride
5-alpha reductase converts testosterone to DHT.
Inhibits 5‑alpha-reductase, which converts testosterone to dihydrotestosterone (a potent cellular androgen that stimulates prostate growth).
Reduces prostate size and improves symptoms and urinary flow rate.
What is the IPSS?
International Prostate Symptom Score: a scoring symptom based on the severity of BPH symptoms in the past 30 days.
Useful as a marker of disease progression and treatment response, in addition to marking candidates for surgery (e.g. if they’re really bothered by Sx).
What causes the IRRITATIVE symptoms of prostate cancer?
Detrusor muscle overactivity - involuntary contractions during bladder filling
TRUE OR FALSE? BPH is not a risk factor for prostate cancer.
TRUE