Pathology: prostate Flashcards by Eliot Carrington-windo

What are the risk factors for BPH?

Fhx
Obesity
Advancing age
T2 DM

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In which part of the prostate is BPH most common?

Median lobe
Transitional zone

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What non interventional tx are available to treat BPH?

Conservative
Bladder training, no drinks before bed

Medical
Selective alpha 1 blockers (tamsulosin, alfulosin)
5 alpha reductase inhibitors: prevent conversion of testosterone to dihydrotestosterone

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What medications should be avoided in patients with BPH

avoid calcium channel blockers (relaxes bladder, worsens symptoms)
avoid pseudephidrine (nasal decongestant)

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What interventional options are available for BPH?

Trans-urethral needle ablation
High intensity US
Embolisation
TURP

Gold standard: above 80g increases risk of TURP syndrome–> open prostatectomy

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What irrigating fluids are used for TURP?

Osmotically active solutes: sorbitol, glycine, mannitol
Saline can be used with bipolar diathermy

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What type of diathermy should be used with each irrigating fluid?

GLycine: monopolar
Saline: bipolar

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What are the signs and symptoms of TURP syndrome?

Dilutional hyponatraemia
–> seizure
–> confusion
–> cerebral oedema

Hypotension
Bradycardia

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How can TURP syndrome be avoided?

Reduce operating time <60 mins
Finasteride pre-op to reduce bleeding
Giving set low down to avoid increased fluid pressure
Reduce intraoperative bleeding
Reduce hypo/hypertension

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What features would be concerning on prostatic DRE?

Irregular firm nodules
Loss of median sulcus
Induration
Craggy prostate

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What type of cancer is most common in prostate?

Adenocarcinoma (95%)
Small cell
TCC

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In which part of prostate is cancer most common?

Posteiror lobe
peripheral zone

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Name some risk factors for prostate ca

Fhx
Advancing age
High fat diet

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What genes are associated with prostate ca?

Brca 1, brca 2, homeobox 33

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What investigations would you consider for suspected prostate ca?

DRE
PSA
MRI
US guided biopsy: trans rectal/transperineal

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What is a normal PSA level in an adult?

40-49 <2.5ng/ml
50-59: <3.5
60-69: <4.5
>70: <6.5

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What is the gleason score?

6-12 biopsies taken
Grade 1-5: most common cell type added to next most common cell type. If there are 3 patterns, the most common is added to the most aggressive.
Total score: 10 most aggressive and most likely to spread

Name options to treat prostate ca

Watchful waiting
Active surveillance
Surgery–> radical prostatectomy
Radiotherapy/chemo for mets
Hormone therapy

What does active surveillance entail?

PSA every 3-4 months for 1 year, then rectal exam + MRI
2nd year: PSA every 6 mths, annual rectal exam

What is brachytherapy and what are the indications in prostate ca?

Insertion of radiation seeds into prostate, slowly emitting radiation

Indication:
–PSA +++, pt not suitable for surg
–High gleason score

Name some hormonal approaches to treat prostate ca

GNRH agonist (suppresses axis) (goserelin)
Antiandrogens (flutamide)
Orchidectomy

LUTS differentials

Bladder outlet obstruction
-Prostate ca
-BPH
-Urethral stricture

Bladder dysfunction
-Bladder oversensitivity/overactivity
-Detrusor overactivity

What is bladder outlet obstruction?

Urodynamic condition implying high pressure low flow rate

What is PSA?

Prostate specific antigen
Glycoprotein released from prostate to liquefy semen allowing sperm to move freely and dissolves cervical mucous
Elevated in certain prostatic conditions

Approach to ++ PSA

Repeat Us guided biopsy MRI +/- isotope bone scan/spine radiograph Urology MDT

What is the difference between grading and staging?

Stage: how far tumour has spread Grade: level of cell differentiation. Higher grade indicates faster growing ca

How frequently should PSA be checked after radical prostatectomy?

after 6 weeks Then every 6 months for first 2 years Annual thereafter

Complications turp

UTI, bleeding Sexual dysfuncion retrograde ejaculation urethral strciture Turp syndrome

What is the cause of prostate enlargement in BPH?

Androgens

What investigations would you do for BPH>

-PSA -MSU analysis -U + E

Why do you take multiple prostate biopsies?

-Prostate cancer can be focal, so important to take samples from different sites -There is often only scant amount of tissue available for histologic examinations in needle biopsies -Malignant glands may be mixed with numerous benign glands -histological findings pointing to malignancy can be subtle, leading to underdiagnosis

How would you differentiate between rectum and prostate cells in a needle biopsy?

-Using immunohistochemical marker (alpha-methylacyl-coenzyme A-racemase) (AMACR) -CEA ( in rectal cells)

What are the gene mutations involved in the pathogenesis of prostate cancer?

-mutations or deletions that activate the PI3K/AKT pathway

How can you judge the success of a radical prostatectomy?

-Fall in level of PSA below detectable levels within 4-6 weeks -High PSA after prostatectomy--> consider recurrence

Why is PSA not reliable?

-PSA is organ specific, not cancer specific -Although serum levels of PSA are elevated to a lesser extent in BPH than prostate Ca there is considerable overlap -Other factors e.g. prostatitis, instrumentation of the prostate and ejaculation elevate PSA

What test could be used to exclude bony metastasis?

ALP

What type of bony metastasis occurs in prostate cancer? And why?

Sclerotic Due to increased bone deposition due to increased osteoblastic activity

What are the types of bone metastases?

Characterised based on radiographic and/or pathologic appearance of the lesions as: --> lytic --> sclerotic --> mixed

What is the rational in treating prostate cancer by bilateral orchidectomy?

-Androgen deprivation -The growth and survival of prostate cancer cells depends on androgens, which bind to the androgen receptor (AR) and induce the expression of pro-growth and pro-survival genes

What cells produce testosterone?

Leydig cells

What are the lobes of the prostate?

-Anterior lobe -Median love -Posterior lobe -Lateral lobes