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CCC > Oncology - Prostate > Flashcards

Oncology - Prostate Flashcards

1
Q

What are 95% of prostate cancers? How does location differ to BPHP

A
  • Adenocarcinomas of glandular tissue in posterior/peripheral prostate.
  • Benign prostatic hyperplasia BPH more commonly arises in the centre of the gland
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2
Q

Risk factors for prostate cancer?

A
  • 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)
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3
Q

What genes increase risk of prostate cancer?

A

BRCA2

pTEN

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4
Q

What symptoms might present in prostate cancer?

A

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

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5
Q

What are the investigations for suspected prostate cancer? Describe what you would find.

A

Digital rectal exam

  • Hard
  • Enlarged
  • Irregular/craggy
  • Nodular
  • Obliteration of median sulcus
  • Immobile

PSA (very high)

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6
Q

What investigation is done to diagnose prostate cancer?

What are the risks of this procedure?

A

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

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7
Q

When should you avoid treatment (observation instead) in prostate cancer?

A

Observation in prostate cancer

  • Asymptomatic disease (confined to prostate)
  • In patients where other conditions are more likely to kill
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8
Q

What surgery can be done for prostate cancer?

What patients should this surgery?

A

Surgery for prostate cancer

  • ROBOTIC RADICAL PROSTATECTOMY
  • Patients with localised disease (T2 disease or less-within the capsule)
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9
Q

What is a palliative operation for prostate cancer?

A

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)

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10
Q

What risks are there with a prostatectomy?

A

Impotence

Incontinence

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11
Q

What scale is used for grading of prostate cancer?

What are the scores for low, intermediate and high risk?

A

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
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12
Q

What else is required to form the overall risk score?

A

Gleason score is also combined with PSA and TNM to get overall risk

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13
Q

What are the treatment options for patients with low risk prostate cancer?
(Gleason<6)

A

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
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14
Q

What are the treatment options for patients with intermediate/high risk prostate cancer?

A

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)

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15
Q

When would you use hormone therapy in prostate cancer?

A

-Hormonal treatments are used for treating advanced metastatic disease OR alongside radiotherapy for localised disease.

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16
Q

What hormone therapies can be used in prostate cancer?

A

• 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)

17
Q

What are some side effects from hormone therapy in prostate cancer?

A 
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
18
Q

When would you use chemo in prostate cancer?

What chemotherapy is most commonly used in prostate cancer?

A

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
19
Q

When is hormone therapy used in prostate cancer?

A

Advanced metastatic disease

Neoadjuvant to surgery

20
Q

What type of bone mets are seen in prostate cancer? What imaging is best to see these?

A
  • Scleritic lesions are found in prostate cancer (less likely to cause hypercalceamia)
  • Best seen with a ISOTOPE BONE SCAN
21
Q

What imaging can be used to visualise the prostate gland before radical treatment

A

MRI scan can visualize the prostate well and determine any extra-capsular spread.

22
Q

What factors affect the managment of prostate cancer

A

Management of prostate cancer is multifactorial:

  • PSA
  • Gleason histological grade + stage (how early in the disease it is)
  • TNM stage
  • age
  • fitness/comorbidities
23
Q

When would you use radiotherapy in prostate cancer?

What are the side effects of prostate radiotherapy?

A

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)
24
Q

prognosis of prostate cancer?

A

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

25
Q

Why is PSA not the best test?

A

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)
26
Q

Staging for prostate cancer?

A

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)

27
Q

What is the function of the prostate?

A

the prostate makes fluid that is a component in semen

28
Q

Main treatment for advanced prostate cancer with bone mets?

A
  • Androgen deprivation therapy is main treatment for bone mets in prostate cancer
  • Palliative radiotherapy for persistent pain
  • Chemo in fit men
29
Q

Whats the preparation for RT in prostate cancer?

A

Prostate radiotherapy

  • Empty bowels (daily micro enema)
  • Full bladder
30
Q

Where do prostate carcinomas most common metastasise to?

A

Bone

Lymph nodes

31
Q

After an abormal PSA what further investigations may be indicated?

A

Abnormal PSA> refer 2 weeks>MRI> biopsy

CCC (15 decks)

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