GU Cancer: Prostate Cancer

Question 1

Definition

Answer 1

Adenocarcinoma of the outer zone of peripheral prostate gland

Question 2

Epidemiology

Answer 2

Men
Advancing age

Question 3

Risk factors

Answer 3

Age
Afro-Caribbean
Family history - genetic = BRCA 2, HOXB13
Tall stature
Anabolic steroids
Obesity
High fat, low fibre diet

Question 4

Aetiology

Answer 4

Exact cause is unknown
High association with mutations with BRCA 2, HOXB13

Question 5

Pathophysiology

Answer 5

Adenocarcinoma usually arise from peripheral zone
Results in the luminal cells dividing uncontrollably + forming tumour.
Early on depend heavily on androgens, but eventually can survive without. Usually the spread occurs along the capsular surface of the prostate, metastasising via lymphatics + blood.
They can spread via:
- local spread to seminal vesicles, bladder and rectum
- via lymph to nearby lymph nodes
- via blood vessels to bones such as vertebrae + pelvis = hip and lower back pain

Question 6

Signs

Answer 6

Asymmetrical, hard, nodular prostate with loss of median sulcus on DRE
Palpable lymphadenopathy (METS)
Urinary retention
- Presents with lower abdominal pain and tenderness, inability to urinate and a palpable bladder

Question 7

Symptoms

Answer 7

Initially asymptomatic as most cancers in posterior peripheral zone which is for away from urethra
LUTS: (Nocturia, Hesitancy, Voiding, Poor stream, Terminal dribbling)
Painful urination + ejaculation
E.D.
Haematuria
Systemic systems:
- weight loss
- fatigue
- night pain
- bone pain

Question 8

Typical metastasis areas

Answer 8

BONE (sclerotic lesions) - lumbar back pain
LIVER
LUNG
BRAIN

Question 9

Diagnosis

Answer 9

Digital rectal exam:
- normal = smooth + symmetrical with maintained central sulcus
- infected = enlarged, tender, warm
- cancerous = hard, asymmetrical, irregular, loss of central sulcus (anterior cancers may go unnoticed)
FIRST LINE = multi-parametric MRI
- Likert score > 3 = offer multi parametric MRI-influenced prostate biopsy
- Likert score < 3 = discuss pros and cons of biopsy
GOLD STANDARD = Prostate biopsy
- Use biopsy to work out Gleason score
PSA: Secreted in semen with small amounts entering the blood. In cancer = loads
- false positives:
- BPH
- Prostatitis
- UTI
- Vigorous exercise (esp cycling)
- Recent ejaculation or prostate stimulation

Question 10

Gleason score

Answer 10

Identifies two most common cell patterns + gives them both a score between 1-5 and add them together
1 = well differentiated
5 = poorly differentiated
Low grade < 6
Intermediate grade 7
High grade 8-10

Question 11

Management

Answer 11

Local: prostatectomy if < 70 years old
Active surveillance if > 70 years old to ensure cancer remains local
Metastatic:
- External beam radiotherapy: radiation given outside the body (side effects: proctitis - inflammation of rectum = prednisolone suppositories)
- Hormone therapy: Aim to lower androgen levels
= Bilateral orchidectomy
= LHRH (aka GnRH) agonists - Gaserelin
= Androgen receptor blockers = Bicalutamide
* both radiotherapy and anti-androgen therapy must be offered in intermediate disease *
- Brachytherapy (side effects: cystitis - inflammation of bladder, or proctitis

Question 12

Side effects of hormone therapy include:

Answer 12

Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis

Question 13

DDx

Answer 13

BPH
Prostatitis
Bladder tumours