Prostate Flashcards
Prostate cancer is the most common cancer in men. It varies in how aggressive it is, and many prostate cancers are very slow-growing and do not cause death.
almost always androgen dependent meaning they reply on androgen hormones to grow.
where does advanced prostate cancer most commonly spread to?
- lymph nodes
- bones
what type of cancer are most prostate cancers and where do they most commonly grow?
adenocarcinoma
peripheral zone of prostate
which zone is commonly associated with bph?
BPH - transitional zone
what are some risk factors for prostate cancer?
- Increasing age
- Family history - 1st degree relative
- Black African or Caribbean origin
- Tall stature
- Anabolic steroids
1 1DR - 2.5 x increase
2 1DR - 4 x increase risk
how does prostate cancer present?
may be asymptomatic
may also present with lower urinary tract symptoms (LUTS), similar to benign prostate hyperplasia - include hesitancy, frequency, weak flow, terminal dribbling and nocturia.
Other symptoms include:
- Haematuria
- Erectile dysfunction
- Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)
what is prostate-specific antigen and how is it used?
PSA is a glycoprotein that is secreted in the semen, produced by epithelial cells of the prostate - small amount entering the blood
enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation
raised = maybe prostate cancer but raised in other prostate problems so not reliable to be used as a screening test for prostate cancer - high rate of false positive (75%) and false negatives (25%)
man >50 can request a PSA if they would like one
what are some common causes of raised PSA?
- Prostate cancer
- Benign prostatic hyperplasia
- Prostatitis
- Urinary tract infections
- Vigorous exercise (notably cycling)
- Recent ejaculation or prostate stimulation
problems with false positive PSA
may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary.
it may lead to the unnecessary diagnosis and treatment of prostate cancer that would never have caused problems (the patient would have died of other causes before experiencing any adverse effects of the prostate cancer)
problems with false negatives of PSA?
may lead to false reassurance.
progression of cancer
how is the prostate examined?
during a digital rectal examination
what does a benign prostate feel like on DRE?
A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus (the dip in the middle between the right and left lobe).
(There may be generalised enlargement in prostatic hyperplasia.)
how may an infected or inflamed prostate feel?
enlarged, tender, warm
what is the referral criteria for ?prostate cancer (how may a cancerous prostate feel on DRE?)
feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus.
There may be a hard nodule.
Any of these features can indicate prostate cancer and warrant further investigation.
In primary care, these findings require a two week wait urgent cancer referral to urology.
what initial ix can be done by gp
PSA
FBC
U&E
LFT
bone profile
not much else bc will get them through 2ww urgently
what is the first line investigation for prostate cancer and how are the results reported?
Multiparametric MRI of the prostate
reported on a Likert scale, scored as:
- 1 – very low suspicion
- 2 – low suspicion
- 3 – equivocal
- 4 – probable cancer
- 5 – definite cancer
radiologist can predict likelihood of cancer from this
what is done after the Multiparametric MRI of the prostate?
prostate biopsy
decision based on Likert ≥ 3 and clinical suspicion - exam and PSA
what is the most significant problem with prostate biopsy?
carries a risk of false-negative results if the biopsy misses the cancerous area.
Multiple needles are used to take samples from different areas of the prostate.
what are the 2 options for conducting a prostate biopsy?
- Transrectal ultrasound-guided biopsy (TRUS)
- Transperineal biopsy
what is a transrectal ultrasound-guided biopsy?
involves an ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate.
Guided biopsies are taken through the wall of the rectum, into the prostate.
usually take around 12 biopsies - 6 from each lobe
what is a transperineal biopsy?
involves needles inserted through the perineum. It is usually under local anaesthetic.
what are some risks associated with prostate biopsy?
- Pain (particularly lower abdominal, rectal or perineal pain)
- Bleeding (blood in the stools, urine or semen)
- Infection
- Urinary retention due to short term swelling of the prostate
- Erectile dysfunction (rare)
what is used to look for bony metastasis in prostate cancer?
An isotope bone scan (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.
A radioactive isotope is given by intravenous injection, followed by a short wait (2-3 hours) to allow the bones to take up the isotope.
A gamma camera is used to take pictures of the entire skeleton.
Metastatic bone lesions take up more of the isotope, making them stand out on the scan.
what is the gleason grading system?
based on the histology from the prostate biopsies.
specific to prostate cancer and helps to determine what treatment is most appropriate.
The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is.
The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).
The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):
- The first number is the grade of the most prevalent pattern in the biopsy
- The second number is the grade of the second most prevalent pattern in the biopsy
A Gleason score of:
- 6 is considered low risk
- 7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
- 8 or above is deemed to be high risk
describe the TNM staging for prostate cancer?
T for Tumour:
- TX – unable to assess size
- T1 – too small to be felt on examination or seen on scans
- T2 – contained within the prostate
- T3 – extends out of the prostate
- T4 – spread to nearby organs
N for Nodes:
- NX – unable to assess nodes
- N0 – no nodal spread
- N1 – spread to lymph nodes
M for Metastasis:
- M0 – no metastasis
- M1 – metastasis
what are the options for treating prostate cancer?
- Surveillance or watchful waiting in early prostate cancer
- External beam radiotherapy directed at the prostate
- Brachytherapy
- Hormone therapy
- Surgery
what is the main complication associated with external beam radiotherapy?
proctitis (inflammation in the rectum) caused by radiation affecting the rectum.
Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge.
Prednisolone suppositories can help reduce inflammation.
what is brachytherapy?
involves implanting radioactive metal “seeds” into the prostate.
This delivers continuous, targeted radiotherapy to the prostate.
The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis).
Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.
how is hormone therapy used to treat prostate cancer?
aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow.
They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible. The options are:
- Androgen-receptor blockers such as bicalutamide
- GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
- Bilateral orchidectomy to remove the testicles (rarely used)
what are the side effects of hormone therapy?
- Hot flushes
- Sexual dysfunction
- Gynaecomastia
- Fatigue
- Osteoporosis
what is a radical prostatectomy?
involves a surgical operation to remove the entire prostate.
The aim is to cure prostate cancer confined to the prostate.
Key complications are erectile dysfunction and urinary incontinence
