Prostate Flashcards
Give 4 risk factors for developing prostate cancer
Increasing age Androgens (rare if castrated < 40yo) Black > White > Asian Genetics - BRCA1+2 Folic acid supplements
What type of cancer is most common in the prostate and where is it likely to be?
Adenocarcinoma in the peripheral zone
can be TCC or neuroendocrine
What grading system is used for Prostate Cancer?
Gleason grading - assesses aggressiveness according to differentiation
How is the overall grade for prostate cancer worked out?
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
Describe what is meant by each Gleeson grade between 1-5
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
What is the T staging on DRE?
T1/T2 - localised
T3 - locally advanced
T4 - advanced, hard
How does prostate cancer present?
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)
What investigations are done for a patient with LUTS where prostate cancer is suspected?
DRE
PSA
What would constitute an abnormal DRE and PSA and what is done next?
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)
Other than prostate cancer, what else can raise a PSA?
Prostatitis UTI BPH Retention Recent ejaculation Iatrogenic: following a DRE or cystoscopy
Where can prostate cancer metastasise?
Bone
Adjacent Structures
Lymph
How and where specifically does prostate cancer metastasise to bone? What is the appearance of these boney lesions?
Via the Batson venous plexus to vertebral bodies to form sclerotic lesions
What adjacent structures can prostate cancer metastasise to?
Seminal vesicles
Bladder
Rectum
What lymph nodes does prostate cancer metastasise to?
obturator
What are the management options for prostate cancer
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
Outline the hormone therapy options for prostate cancer
Surgical: bilateral orchidectomy
GnRH agonist (Goserelin)
Anti-androgen (cyproterone acetate)
What are the disadvantages of hormone therapy for prostate cancer?
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)
When does Testosterone flare happen and what symptoms do patients get?
When using GnRH agonists
bone pain +/- cord compression
bladder outlet obstruction can lead to AKI
fatal CVS events - hypercoagulable
What occurs in a radical prostatectomy?
Open or Laparoscopic removal of entire prostate and seminal vesicles and obturator nodes
What are the side effects of a prostatectomy?
Erectile dysfunction
Incontinence
What are the side effects/risks of radiotherapy for prostate cancer?
Cystitis
Urethritis
Proctitis
Impotence
Increased risk of bladder and colorectal cancer
What is brachytherapy?
Implant radioactive iodine seeds in the prostate using TRUS
What advantages does brachytherapy have over external beam radiotherapy?
No systemic effects
What is active surveillance with regards to prostate cancer?
Regular biopsies
Management option of choice for localised prostate cancers
What is watchful waiting with regards to prostate cancer?
Done in frail men with complicated co-morbidities who wont survive treatment.
Monitoring less regular and in GP setting
What are some complications of TRUS with core biopsy?
Haematospermia Prostatitis Urinary sepsis Urinary retention Rectal bleeding
Why is PSA not used in a national screening programme?
Not reliable
Doesn’t reduce deaths from cancer
Harm associated with over diagnosis
What is the pathophysiology of prostate cancer?
Adenocarcinomas
Much rarer can be transitional cell, squamous cell or neuroendocrine
Most in peripheral zone
Some in central or transitional
What are the clinical features of prostate cancer?
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
When should a DRE be considered for men?
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
What should men not have before PSA testing?
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
What is PSA?
Prostate specific antigen protein produced by prostate epithelial cells
Who should be referred on the urgent two week wait pathway?
All men with suspected prostate cancer
Abnormal prostate on DRE
PSA level elevated above age-specific range
What is the first line investigation in the diagnosis of prostate cancer?
Multiparametric MRI
Likert-score - 5 point score on impression of the scan:
- Clinically significant cancer highly unlikely to be present
- Clinically significant cancer is unlikely to be present
- Chance of clinically significant cancer is equivocal
- Clinically significant cancer is likely to be present
- Clinically significant cancer is highly likely to be present
When is a prostate biopsy then offered?
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
What is the staging of prostate cancer
TNM staging
Gleason score gives histological grade
What is the pathophysiology of androgen deprivation therapy and using GnRH agonists?
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
What treatment options are advised for the different risks?
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
What are some differentials for a prostate mass detectable by DRE?
Prostate cancer Normal benign asymmetry Benign prostatic hypertrophy Prostatitis Cyst Prior TURP/biopsy scar
What lab investigations are useful for prostate cancer workup?
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
What is the Gleason score grading?
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
What does a Gleason score indicate?
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
What are the patterns of spread of prostate cancer?
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
What are the advantages and disadvantages of external beam radiation therapy?
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
What are the advantages and disadvantages of brachytherapy?
Single session, if high risk may need only a few
Contraindicated if
Large prostate, unfit for anaesthesia, recent TURP procedure
What are some of the potential side effects of anti-androgen treatment?
Impotency Loss of libido Anaemia Nausea and vomiting CNS, neurological changes Galactorrhoea Muscle atrophy Osteoporosis Delayed testosterone recovery Increased AST/LDH Gynaecomastia
