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Cancer Care > Prostate > Flashcards

Prostate Flashcards

1
Q

Give 4 risk factors for developing prostate cancer

A 
Increasing age
Androgens (rare if castrated < 40yo)
Black > White > Asian
Genetics - BRCA1+2
Folic acid supplements
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2
Q

What type of cancer is most common in the prostate and where is it likely to be?

A

Adenocarcinoma in the peripheral zone

can be TCC or neuroendocrine

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3
Q

What grading system is used for Prostate Cancer?

A

Gleason grading - assesses aggressiveness according to differentiation

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4
Q

How is the overall grade for prostate cancer worked out?

A

Primary grade - cells make up largest area
Secondary grade - cells make up 2nd largest area of tumour

Each grade 1-5

Add primary and secondary grade

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5
Q

Describe what is meant by each Gleeson grade between 1-5

A

1 - small uniform glands
2 - Increased stroma (space) between glands
3 - Infiltration of cells from glands at margins
4 - Irregular masses of neoplastic cells with few glands
5 - Lack of glands, sheets of cells

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6
Q

What is the T staging on DRE?

A

T1/T2 - localised
T3 - locally advanced
T4 - advanced, hard

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7
Q

How does prostate cancer present?

A

normally asymptomatic as peripheral zone wont cause LUTS

LUTS - frequency, nocturia, poor stream, haematuria, retention

Invasive symptoms - UTI, impotence, haemospermia, AKI/CKD from obstruction, bone pain (mets)

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8
Q

What investigations are done for a patient with LUTS where prostate cancer is suspected?

A

DRE

PSA

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9
Q

What would constitute an abnormal DRE and PSA and what is done next?

A

DRE: hard, irregular, asymmetrical with loss of median sulcus
PSA: Generally >4 but some sources say >3

MRI is now first line (not TRUS with core biopsy)

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10
Q

Other than prostate cancer, what else can raise a PSA?

A 
Prostatitis
UTI
BPH
Retention 
Recent ejaculation
Iatrogenic: following a DRE or cystoscopy
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11
Q

Where can prostate cancer metastasise?

A

Bone
Adjacent Structures
Lymph

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12
Q

How and where specifically does prostate cancer metastasise to bone? What is the appearance of these boney lesions?

A

Via the Batson venous plexus to vertebral bodies to form sclerotic lesions

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13
Q

What adjacent structures can prostate cancer metastasise to?

A

Seminal vesicles
Bladder
Rectum

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14
Q

What lymph nodes does prostate cancer metastasise to?

A

obturator

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15
Q

What are the management options for prostate cancer

A

Active surveillance - regular PSA, DREs, MRIs

Radical prostatectomy - removal of entire prostate and tissues; open, laparoscopic, robotic

Radical radiotherapy - external beam targeting prostate, or brachytherapy implanting radioactive seeds directly into the prostate

Androgen deprivation therapy
Lowers androgen levels to intermediate or high risk localised disease if also receiving radiotherapy:
Use of GnRH agonists
Bicalutamide - anti-androgen
Bilateral orchidectomy - castration

Docetaxel chemo - inhibits micro tubular depolymerisation

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16
Q

Outline the hormone therapy options for prostate cancer

A

Surgical: bilateral orchidectomy
GnRH agonist (Goserelin)
Anti-androgen (cyproterone acetate)

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17
Q

What are the disadvantages of hormone therapy for prostate cancer?

A 
Hormone refractory disease eventually develop
Impotence
Decreased sexual desire
Hot flushes and sweats
Gynaecomastia
Loss of muscle mass

Testosterone flare (GnRH agonist - flare before fall)

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18
Q

When does Testosterone flare happen and what symptoms do patients get?

A

When using GnRH agonists

bone pain +/- cord compression
bladder outlet obstruction can lead to AKI
fatal CVS events - hypercoagulable

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19
Q

What occurs in a radical prostatectomy?

A

Open or Laparoscopic removal of entire prostate and seminal vesicles and obturator nodes

20
Q

What are the side effects of a prostatectomy?

A

Erectile dysfunction

Incontinence

21
Q

What are the side effects/risks of radiotherapy for prostate cancer?

A

Cystitis
Urethritis
Proctitis
Impotence

Increased risk of bladder and colorectal cancer

22
Q

What is brachytherapy?

A

Implant radioactive iodine seeds in the prostate using TRUS

23
Q

What advantages does brachytherapy have over external beam radiotherapy?

A

No systemic effects

24
Q

What is active surveillance with regards to prostate cancer?

A

Regular biopsies

Management option of choice for localised prostate cancers

25
Q

What is watchful waiting with regards to prostate cancer?

A

Done in frail men with complicated co-morbidities who wont survive treatment.

Monitoring less regular and in GP setting

26
Q

What are some complications of TRUS with core biopsy?

A 
Haematospermia
Prostatitis
Urinary sepsis
Urinary retention
Rectal bleeding
27
Q

Why is PSA not used in a national screening programme?

A

Not reliable
Doesn’t reduce deaths from cancer
Harm associated with over diagnosis

28
Q

What is the pathophysiology of prostate cancer?

A

Adenocarcinomas
Much rarer can be transitional cell, squamous cell or neuroendocrine

Most in peripheral zone
Some in central or transitional

29
Q

What are the clinical features of prostate cancer?

A

LUTS:
Nocturia, freq, hesitancy, urgency, dribbling, overactive bladder, retention

Visible haematuria
Abnormal DRE - hard, nodular, enlarged, asymmetrical
Symptoms of advanced disease e.g. haematuria, blood in semen, lower back pain, bone pain, weight loss

30
Q

When should a DRE be considered for men?

A

Lower urinary tract symptoms
Haematuria
Unexplained symptoms which may be due to advanced prostate cancer e.g. back pain, bone pain, weight loss
Erectile dysfunction
Other reasons to be concerned e.g. elevated PSA

31
Q

What should men not have before PSA testing?

A

Active or recent UTI - last 6 weeks
Recent ejaculation, anal sex or prostate stimulation
Vigorous exercise for 48 hrs
Urological intervention in past 6 weeks

32
Q

What is PSA?

A

Prostate specific antigen protein produced by prostate epithelial cells

33
Q

Who should be referred on the urgent two week wait pathway?

A

All men with suspected prostate cancer
Abnormal prostate on DRE
PSA level elevated above age-specific range

34
Q

What is the first line investigation in the diagnosis of prostate cancer?

A

Multiparametric MRI
Likert-score - 5 point score on impression of the scan:

  1. Clinically significant cancer highly unlikely to be present
  2. Clinically significant cancer is unlikely to be present
  3. Chance of clinically significant cancer is equivocal
  4. Clinically significant cancer is likely to be present
  5. Clinically significant cancer is highly likely to be present
35
Q

When is a prostate biopsy then offered?

A

To those with a Likert score of 3 or greater
Biopsy guided by MRI images and use of USS

Those who do not have biopsy with Likert score of 1/2 and raised PSA - ongoing active surveillance

36
Q

What is the staging of prostate cancer

A

TNM staging

Gleason score gives histological grade

37
Q

What is the pathophysiology of androgen deprivation therapy and using GnRH agonists?

A

Chemical castration
Initially causes increase in LH/FSH release from anterior pituitary
Persistence then causes downregulation of receptors on pituitary leading to reduced LH/FSH
e.g. Goserelin/Zoladex

38
Q

What treatment options are advised for the different risks?

A

Low risk - active surveillance, radical prostatectomy, radical radiotherapy

Intermediate risk disease - radical prostatectomy or radiotherapy, active surveillance in those that decline this

High risk - radical prostatectomy, or radical radiotherapy, do not advise active surveillance

39
Q

What are some differentials for a prostate mass detectable by DRE?

A 
Prostate cancer
Normal benign asymmetry
Benign prostatic hypertrophy
Prostatitis
Cyst
Prior TURP/biopsy scar
40
Q

What lab investigations are useful for prostate cancer workup?

A

FBC - anaemia, pancytopenia due to bone marrow involvement or chronic disease
PSA
ALP, Ca - bone mets
U&Es - kidney function, bladder obstruction
LFTs, albumin - ability to treat with anti-androgen medication
LDH - metastatic disease

41
Q

What is the Gleason score grading?

A

1 - normal prostate, uniform glands, little stroma
2 - well formed glands
3 - variable sized glands
4 - incomplete gland formation, cell nests
5 - grossly abnormal, no gland formation

42
Q

What does a Gleason score indicate?

A

6 or less - low grade, slow growth, may not need tx

7 - intermediate grade, growth and spread at mod pace

8, 9, 10 - high grade, fast growth, tx needed

43
Q

What are the patterns of spread of prostate cancer?

A

Local - via thinner weaker capsular walls, to bladder neck, seminal vesicles T3

Lymphatic via obturator, hypogastric, presacral and external iliac nodes

Haematogenous - distant mets to the bone, sometimes rarely liver or lungs

44
Q

What are the advantages and disadvantages of external beam radiation therapy?

A

Curative, may be as efficacious as surgery, no surgery necessary

whereas no pathological staging available
longer treatment course
SEs - fatigue, nausea, anorexia, irritative bowel and bladder symptoms

45
Q

What are the advantages and disadvantages of brachytherapy?

A

Single session, if high risk may need only a few

Contraindicated if
Large prostate, unfit for anaesthesia, recent TURP procedure

46
Q

What are some of the potential side effects of anti-androgen treatment?

A 
Impotency
Loss of libido
Anaemia
Nausea and vomiting
CNS, neurological changes
Galactorrhoea
Muscle atrophy
Osteoporosis
Delayed testosterone recovery 
Increased AST/LDH
Gynaecomastia

Cancer Care (15 decks)

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