Oncology - Prostate Flashcards
What are 95% of prostate cancers? How does location differ to BPHP
- Adenocarcinomas of glandular tissue in posterior/peripheral prostate.
- Benign prostatic hyperplasia BPH more commonly arises in the centre of the gland
Risk factors for prostate cancer?
- radiation exposure
- diet
- anabolic steroids
- age
- race (more common in African/Caribbean men)
- family history of prostate cancer/breast cancer
- mutations of BRCA II and pTEN genes. BRCA (less understood)
What genes increase risk of prostate cancer?
BRCA2
pTEN
What symptoms might present in prostate cancer?
Prostate cancer symptoms
- Impotence
- Hesitancy (problems starting)
- Decreased flow/stream (problems during)
- Dribbling (problems afterwards)
- Frequency
- Nocturia
- 1 in 5 patients will present with metastatic prostate cancer (anaemia, bone pain, pathological fracture, MSCC)
May be asymptomatic and diagnosed on PR or PSA
What are the investigations for suspected prostate cancer? Describe what you would find.
Digital rectal exam
- Hard
- Enlarged
- Irregular/craggy
- Nodular
- Obliteration of median sulcus
- Immobile
PSA (very high)
What investigation is done to diagnose prostate cancer?
What are the risks of this procedure?
TRUS = transrectal biopsy under ultrasound guidance
- outpatients
- side effects: discomfort, bleeding (urine/semen), infection (3% sepsis)
However where clinical suspicion is very high (e.g. PSA >100 with positive bone scan) this is not required
When should you avoid treatment (observation instead) in prostate cancer?
Observation in prostate cancer
- Asymptomatic disease (confined to prostate)
- In patients where other conditions are more likely to kill
What surgery can be done for prostate cancer?
What patients should this surgery?
Surgery for prostate cancer
- ROBOTIC RADICAL PROSTATECTOMY
- Patients with localised disease (T2 disease or less-within the capsule)
What is a palliative operation for prostate cancer?
Palliative surgical techniques such as trans-urethral resections may be used to relieve prostatic symptoms or urinary obstruction in some men.
(cant have radiotherapy within 6 weeks of this-risk of strictures)
What risks are there with a prostatectomy?
Impotence
Incontinence
What scale is used for grading of prostate cancer?
What are the scores for low, intermediate and high risk?
Gleason’s Pattern Scale (scores 2-10)
- 2 parts /5 then added together
- Gleason 6 LOW RISK
- Gleason 7 INTERMEDIATE RISK
- Gleason 8-10 HIGH RISK
What else is required to form the overall risk score?
Gleason score is also combined with PSA and TNM to get overall risk
What are the treatment options for patients with low risk prostate cancer?
(Gleason<6)
Low risk (no difference in survival between groups however more metastatic disease in active surveillance
- active surveillance (PSA 3 times year, annual DREs)
- surgery
- radiotherapy
What are the treatment options for patients with intermediate/high risk prostate cancer?
Intermediate/high risk (radial treatment options)
-have a bone scan (look for mets)
-surgery (better for <70yrs/no comorbidity)
OR
-radiotherapy:
-external EBRT-just lie flat
-internal brachytherapy-younger fitter pts-requires GA)
When would you use hormone therapy in prostate cancer?
-Hormonal treatments are used for treating advanced metastatic disease OR alongside radiotherapy for localised disease.
What hormone therapies can be used in prostate cancer?
• 1st line: Luteinising hormone release hormone agonists (LHRH) (relins)
e. g. leuprorelin, goserelin
- depot injection
- initially stimulates GnRH receptors to increase LH release
- then desensitises the receptor so ↓ LH
- causes hypogonadotrophic hypogonadism
- tumour flare occurs on initiation of treatment (prior to the down regulation of gonadotropin) and is avoided by short-term concomitant anti-androgen therapy
• Anti-androgens (amides)
- e.g. bicalutamide, enzalutamide, finasteride
- compete with androgens at androgen-receptor
• Gonadotrophin-releasing hormone antagonist -(e.g. degarelix)
- depot injection
- reduces testosterone without risk of tumour flare (good for when tumour flare is really bad (MSCC)
• Oestrogen therapy
-inhibit LHRH production but rarely used due to SE (impotence, loss of libido, gynaecomastia, myocardial infarction, stroke and pulmonary emboli)
• Bilateral orchidectomy (countries without easy access to medical therapy)
What are some side effects from hormone therapy in prostate cancer?
Impotence Loss of libido Tumour flare (not with GnRH antag-relix) Loss of muscle Penis shrinkage Cardiac risk factors Osteoporosis/fractures Hot flushes, weight gain (risk of DM), mood disturbance
When would you use chemo in prostate cancer?
What chemotherapy is most commonly used in prostate cancer?
Chemo improves QOL and survival with castrate-refractory metastatic disease (androgen depletion hasn’t worked)
- Docetaxel (in combination with prednisolone)
- Cabazitaxel can also be used
When is hormone therapy used in prostate cancer?
Advanced metastatic disease
Neoadjuvant to surgery
What type of bone mets are seen in prostate cancer? What imaging is best to see these?
- Scleritic lesions are found in prostate cancer (less likely to cause hypercalceamia)
- Best seen with a ISOTOPE BONE SCAN
What imaging can be used to visualise the prostate gland before radical treatment
MRI scan can visualize the prostate well and determine any extra-capsular spread.
What factors affect the managment of prostate cancer
Management of prostate cancer is multifactorial:
- PSA
- Gleason histological grade + stage (how early in the disease it is)
- TNM stage
- age
- fitness/comorbidities
When would you use radiotherapy in prostate cancer?
What are the side effects of prostate radiotherapy?
Radiotherapy in prostate cancer
CURATIVE- radical radiotherapy is an alternative option to surgery in T1 and T2 tumours, where PSA is low, suggesting no occult metastases.
PALLIATIVE-palliate primary tumour and treat metastatic complications (bone pain from mets or haematuria from prostate
ADJUVANT- radiotherapy may also be given following radical surgery if there is concern for residual disease
Side effects can include: urinary problems (incontinance) bowel problems (bleeding, diarrhoea, incontinance) sexual problems (impotence)
prognosis of prostate cancer?
Prostate cancer
- low risk localised prostate cancer is excellent (99%) at 10 years whether they choose active surveillance, radiotherapy or surgery.
-Patients with metastatic disease have a median survival of 3.5 years
Why is PSA not the best test?
PSA raised by lots of things
Negative result:
-the PSA test can miss cancer and provide false reassurance (15%)
Positive result:
- can give abnormal result when you are fine (75% will have unnecessary tests and investigations which have their own risks)
- also it cant tell the difference between fast growing and slow growing cancers (that wont cause symptoms or shorten life)
Staging for prostate cancer?
T0: No evidence of primary tumour
T1: Can’t feel cancer on DRE. Can’t see cancer on MRI
T2: Tumour confined within prostate
T3: Tumour extends through the prostate capsule
T3a: Extracapsular extension (unilateral or bilateral)
T3b: Tumour invades seminal vesicle(s)
T4: Tumour is fixed or invades adjacent structures other than seminal vesicles (rectum/bladder)
What is the function of the prostate?
the prostate makes fluid that is a component in semen
Main treatment for advanced prostate cancer with bone mets?
- Androgen deprivation therapy is main treatment for bone mets in prostate cancer
- Palliative radiotherapy for persistent pain
- Chemo in fit men
Whats the preparation for RT in prostate cancer?
Prostate radiotherapy
- Empty bowels (daily micro enema)
- Full bladder
Where do prostate carcinomas most common metastasise to?
Bone
Lymph nodes
After an abormal PSA what further investigations may be indicated?
Abnormal PSA> refer 2 weeks>MRI> biopsy
