Lecture 25 Tumours of the Urinary System Prostate and Testicular Cancers Flashcards
What is the most commonest cancer diagnosed in young men
Prostate
The majority of prostate diagnosis are in what age group
> 65 years
Name risk factors for prostate cancer
Age Ethnicity Geography Family history- first degree relative 2x likely Food- omega 3 fatty acids, vitamin E Finasteride
What genes are linked to prostate cancer
HPC1; BRCA1 & 2
How to most prostate cancers present
Asymptomatic
Localised
How is prostate cancer initially diagnosed
PSA
Digital rectal exam
TRUS- guided prostate biopsies
What are localised prostate cancer presenting symptoms
- Weak stream
- Hesitancy
- Sensation of incomplete emptying
- Frequency
- Urgency
- Urge incontinence
- Urinary tract infection
What are locally invasive disease presenting symptoms
- Haematuria
- Perineal and suprapubic pain
- Impotence
- Incontinence
- Loin pain or anuria
- Symptoms of renal failure
- Haemospermia
- Rectal symptoms including tenesmus
Distant metastatic presenting symptoms
Bone pain Sciatic pain Paraplegia- cord compression LN enlargement Lymphoedema Loin pain Anuria
Widespread metastatic symptoms
Weight loss
Lethargy (anaemia, uraemia)
What is the commonest mode of presentation for prostate cancer?
a) Frank haematuria
b) Asymptomatic (i.e. incidentally noted)
c) Acute urinary retention
d) Symptoms of benign prostatic enlargement and obstruction
e) Bone pain
b) Asymptomatic (i.e. incidentally noted)
What is the normal serum level for PSA
Normal serum range 0-4.0 g/mL
What can cause elevated PSA
- UTI
- Chronic prostatitis
- Catheterisation
- Ejaculation
- Recent urological procedure
- BPH
- Prostate cancer
What is the half life of PSA
2.2 days
If you are repeating a PSA blood test, when should you recheck
At lease 3 weeks (half life 8)
Gleason sum score 3+3=6 ISUP grade group
1
Gleason sum score 3+4 =7 ISUP grade group
2
Gleason sum score 4+3= 7 ISUP grade group
3
Gleason sum score 8 ISUP grade group
4
Gleason sum scare 9 and 10 ISUP grade group
5
What are the stages of prostate cancer
- Localised
- Locally advanced
- Metastatic
- Hormone refractory
How is prostate cancer staged
- Digital rectal examination (local staging)
- PSA
- Transrectal US guided biopsies
- CT (regional and distant staging)
- MRI (local staging)
How is localised prostate cancer treated
• Watchful waiting • Radiotherapy – External-beam – Brachytherapy • Radical prostatectomy – Open – Laparoscopic – Robotic • Others under investigation – Cryotherapy – Thermotherapy
How is locally advanced prostate cancer treated
- Watchful waiting
- Hormone therapy followed by surgery
- Hormone therapy followed by radiation
- Hormone therapy alone
- Intermitted hormone therapy
Name types of hormonal therapy for prostate cancer
Surgical castration- LHRH antagonists/analogues
Anti-androgens- inhibits androgen receptors
Oestrogens- inhibits LHRH and testosterone secretion. direct cytotoxic effect on prostatic epithelial cells
Treatment of metastatic prostate cancer
HT + Chemotherapy; HT + Abiraterone; or HT alone
Treatment for refractory prostate cancer
- Max HT + steroids, oestrogens, Chemotherapy,
* Abiraterone
The following are reasonable treatment options for low-risk localised prostate cancer except:
a. External beam radiotherapy b. Active surveillance c. Brachytherapy d. Radical prostatectomy e. Radical chemotherapy
e. Radical chemotherapy
The following statements about screening for prostate cancer are true except
a) PSA is the best available screening test
b) Compared with ad-hoc opportunistic PSA testing, screening for prostate cancer is beneficial because it saves lives
c) If screening is advocated, it should be performed for men at risk of prostate cancer rather than the entire male population
d) Screening for prostate cancer is not currently advocated
e) For suspicious cases detected by screening, there is a need to undergo a definitive test to confirm or exclude presence of prostate cancer
b) Compared with ad-hoc opportunistic PSA testing, screening for prostate cancer is beneficial because it saves lives
What is the presentation of testicular cancer normally
Painless lump
What is the presentation of testicular cancer less often
• tender inflamed swelling
• history of trauma (although trauma NOT a risk factor)
• symptoms/signs from nodal or distant metastasis
o para-aortic lymph nodes
o chest
o bone
Describe the incidence of testicular cancer amongst men
- One of the commonest cancers in young men
- Peak incidence 3rd decade
- High risk in Caucasians
Name risk factors for testicular cancer
o Testicular maldescent
o Infertility
o Atrophic testis
o Previous cancer in contralateral testis
What is the precursor lesion for testicular cancer
testicular germ cell neoplasia in-situ
What tumour markers are associated with testicular cancer
– AFP (alpha-fetoprotein) (teratoma)
– HCG (Human Chorionic Gonadotrophin) (seminoma)
– LDH (Lactate dehydrogenase) (non-specific marker of tumour burden
How is testicular cancer diagnosed
Examination for lump
MSSU
Testicular US and CXR
Tumour markers
How is testicular cancer treated
- Radical orchidectomy is essential- remove your testicle and the spermatic cord
- Occasionally may need biopsy of ‘normal’ contralateral testis if high risk for tumour
What does further treatment depend on in testicular cancer
tumour type, stage (TNM) and grade
For testicular cancer, the main lymphatic spread to regional lymph nodes occurs in which group of lymph nodes?
a. Scrotal lymph nodes b. Inguinal lymph nodes c. Pelvic lymph nodes (i.e. internal iliac chain) d. Mediastinal lymph nodes e. Para-aortic lymph nodes
e. Para-aortic lymph nodes
- When performing radical inguinal orchidectomy for testicular cancer:
i. Where is the incision made?
ii. Why is the incision made here?
Just above the pubic tubercle (pubic bone) near the inguinal ligament.
. This incision facilitates access to both the testicle and the proximal inguinal canal.
Name the 2 types of germ cell tumours in testicular cancer
Seminomatous GCT
Non-seminomatous GCT
Name the 3 types of non-germ cell tumour
Leydig
Sertoli
Lymphoma
Seminomatous main affects what age group
30-40 year olds
Non-seminomatous normally affects what age group
20-30 year olds
What is grading assessing in testicular cancer
Aggressiveness
- Low grade = well differentiated
- High grade = poorly differentiated
What is staging assessing in tetsticular cancer
Spread
What 3 ways ca testicular cancer spread
Local- local invasion to adjacent structures
Regional- lymph nodes
Distant- lungs, bone, liver
Stage 1 testicular cancer
Disease confined to testic
Stage II testicular cancer
Infradiaphragmatic nodes involved
Stage III testicular cancer
Supradiaphragmatic nodes involved
Stage IV testicular cancer
extralymphatic disease
What is the treatment for low stage, marker negative testicular cancer
- Surveillance
* Adjuvant radiotherapy (SGCT only)
What is the treatment for nodal disease, persistent tumour markers or relapse surveillance
- Combination chemotherapy
* Lymph node dissection (NSGCT only)
What is the treatment for metastatic testicular cancer
- First line chemotherapy
* Second line chemotherapy
