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Pelvis and Abdomen: R&O > Prostate > Flashcards

Prostate Flashcards

1
Q

epidemiology

A

most common malignancy in males in the UK
2nd largest death
incidence rates are high, ageing population, better diagnostic procedures

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2
Q

aetiology

A

rare in below 45
found in post mortem in over 80
black American twice more likely
diet: high fatty foods
family history
more common is cities
androgen production: nor seen in castrated males
radiation and cadmium exposure (not direct link)

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3
Q

direct spread

A

prostate, SV, rectum and bladder

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4
Q

lymphatic spread

A

pre-sacral
para-aortics
common iliac
internal iliac
external iliac
obturator

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5
Q

haematological spread

A

mets in L spine
skull, ribs, T-spine
liver and lung are RARE

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6
Q

presentation

A

asymptomatic
urinary dysfunctio: nocturne, urgency, frequency, hesitancy, poor stream, terminal dribble
haematuria
obstruction: enlarged prostate will compress on the urethra, which could cause a back-flow of urine into the kidney cause acute renal failure
renal impairment
hypercalcemia: high ca in the blood, bone mets in L spine causes bone to be broken down releasing calcium
nerve pain associated with L-spine mets due to sacral nerves
met symptoms: pathological fracture

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7
Q

what is classed as locally advanced

A

T3/T4 with M0 N0

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8
Q

what is met spread

A

anything with M1

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9
Q

investigations

A

haematological: RBC, WBC, platlets, bone mets can destroy the blood pattern. U&E: renal failure, looks at ca levels
PSA
full medical history: family history, diet, lifestyle, symptom duration
physical exam: digital rectal exam, fingers places into the rectum, to feel for anything abnormal in the prostate if hard or irregular it would be due to disease
biopsy: TURP (transurethral prostate): US guided
radiography: CT: soft tissue and nodal involvement, US, MRI: extra capsular involvement. Isotope bone scan always performed to make sure it hasn’t spread to the bone and if PSA> 10
PSMA PET; prostate specific membrane antigen, very sensitive to PSA

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10
Q

what staging is used

A

TNM

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11
Q

grade 1

A

well differentiated [looks like parent cell], uniform good pattern

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12
Q

grade 2

A

well differentiated, glands vary in size and shape

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13
Q

grade 3

A

moderately differentiated
a) irregular acine glands, widespread
b) well defined papillary/ crib form structures

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14
Q

grade 4

A

poorly differentiated, glands fused and invading stoma

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15
Q

grade 5

A

very poor differentiation, little or no gland formation

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16
Q

what does the gleason grade look at

A

the appearance of cells

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17
Q

what happens to the gleason grade

A

it becomes a score, six biopsies are taken, three at each lobe, each biopsy is graded to the most common cellular pattern, the two most common are added together to give the score

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18
Q

describe the scores

A

6< = low grade [slow]
7 = medium grade
8-10 = high grade

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19
Q

what are the OAR

A

rectum, bladder, bowel

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20
Q

what is the primary option for low risk localised disease

A

AS
continuous monitoring unless the treatment changes or the patient dues, if there was progression a more proactive scheme will be undertaken instead

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21
Q

does prostate have a high or low alpha beta ratio

A

LOW

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22
Q

what does the alpha beta ratio indicate

A

hypo fractionation, higher doses per fraction

23
Q

treatment prep

A

2 cups for 30 minutes, enema

24
Q

what happens at planning CT

A

visualise the target, OAR position, provide electron density information to calculate TPS, MRI guided mark up

25
what is low risk
only prostate gland
26
what is intermediate or high risk
microscopic spread estimated
27
what imaging is used
VMAT, IMRT rotating around the patient, as the gantry moves so does the MLC's to shield the OARs
28
what is the treatment delivery
MR linac linac cyberknife proton therapy
29
RT follow up includes:
PSA reading urinary, bowel, erectile function hormone therapy concerns GP updates and referrals letter and follow up
30
acute SE
irritation + inflammation of bladder and urethra radiation induced cystitis - increase fluid, avoid caffeine and alcohol diarrhoea: decrease fibre urinary tract problems: frequency and urgency haematuria hesitancy most start a week or two into treatment SE settle about 3-6 months
31
management for se
may need to provide urine sample advice of analgesia or anti-inflammatory medication, alpha blocker, relaxes the muscles in the prostate and urethra making it easier to urinate medication for bladder spasms which reduce urgency may need a catheter
32
what is prostate cancer dependent on
testosterone
33
what is the aim of hormone therapy
blocks/ lowers the amount of testosterone in the body, which lowers recurrence if combined with other treatments
34
what is hormone therapy in combo with
before RT, or a radical prostatectomy (3-6months intermediate) or (3 years for higher locally advanced disease)
35
how is it administered
injections, tablets or orchidectomy (removal of testicles)
36
the purpose of HT for met is....
to manage symptoms (bone pain), control growth BUT can't cure
37
what is LHRH = GnRH AGONISTS
act in a similar way to GnRH, which acts on the pituitary gland which causes a testosterone flare (increase in testosterone), as treatment continues it cause deteriates the pituitary gland, stopping production in men. you never want a surge so an anti-androgen tablet can be given to manage this for 28 days
38
agonist examples
Zolodex
39
what are LHRH = GnRH ANTAGONISTS
binds to the GnRH receptors blocking their interaction with GnRH, this induces fast, reducing LH and FSH, therefore suppressing testosterone given as an injection, acts on the pituitary, supresses LH secretion
40
antagonist example
degarelix
41
antiandrogen receptor blocker
tablet: flutamide
42
how effective is an orchidectomy in treating symptoms
90%
43
SE and management for HT
hot flushes: herbal remedies, acupuncture, drugs- medroxyprogesterone 20mg \ fatigue: standard loss of sex drive + impotence: vacuum pump, oral PDE5 inhibitors increase blood flow, viagra [1st line treatments] creams, pellets, intraurethral preparation or prostaglandin or intracavernosal injections [second line treatments] gynecomastia: breast swelling, nipple tenderness, RT to breast buds or tamoxifen ADH can alter body composition, increasing fat mass and decreasing muscle mass, increase strength training and heathy eating bone density decreases due to no testosterone, increasing risk of osteoporosis increase in cardiovascular disease and diabetes
44
what advances in RT are there
fiducial markers EHRT - extreme hypo fractionation RT: 5 fractions instead of 20 space OAR: hydrogel placed between rectum and prostate decreases dose to rectum
45
describe brachytherapy
HDR thin tubes inserted into prostate gland radiation passed through the tubes into the prostate for a few minutes radiation is then removed so none is remaining in the body monotherapy or with EBRT
46
what does LH stimulate
cells of Leydig to produce testosterone
47
anti-androgens
blocks actions of testosterone within prostate cells
48
target volume
total extent + 1-1.5cm margin margin can be reduced to 0.75 posteriorly to spare the rectum
49
Treatment: BT
permanent seed implant iodine- 125 PTV: whole prostate + 2-3 mm margin TRUS required for volumetric planning 80-100 seeds 145Gy peripheral dose 110Gy if previous EBRT SE: urinary, bowel and sexual function symptoms
50
SE of BT treatment
perineal bruising dysuria proctitis urethral stenosis
51
treatment bone mets
palliative EBRT biophosphantes- pamidronate radionuclides
52
wide spread met treatment
hemibody irradiation alleviates widespread painful mets upper hemibody fields extend from chin to umbilicus lower hemibody from umbilicus to knees POP, supine, extended FSD IV fluids before and antiemetic cover before and after treatment 8Gy in 1 fractions 10 MV
53
prognosis
untreated localised: 80% 5 year survival 80% at 10 years - radical mets: 18-24 months
54
5 year PSA relapse free
low = 95% intermediate = 85% high = 60%

Pelvis and Abdomen: R&O (22 decks)

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