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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
Q

what is low risk

A

only prostate gland

26
Q

what is intermediate or high risk

A

microscopic spread estimated

27
Q

what imaging is used

A

VMAT, IMRT rotating around the patient, as the gantry moves so does the MLC’s to shield the OARs

28
Q

what is the treatment delivery

A

MR linac
linac
cyberknife
proton therapy

29
Q

RT follow up includes:

A

PSA reading
urinary, bowel, erectile function
hormone therapy
concerns
GP updates and referrals
letter and follow up

30
Q

acute SE

A

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
Q

management for se

A

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
Q

what is prostate cancer dependent on

A

testosterone

33
Q

what is the aim of hormone therapy

A

blocks/ lowers the amount of testosterone in the body, which lowers recurrence if combined with other treatments

34
Q

what is hormone therapy in combo with

A

before RT, or a radical prostatectomy (3-6months intermediate) or (3 years for higher locally advanced disease)

35
Q

how is it administered

A

injections, tablets or orchidectomy (removal of testicles)

36
Q

the purpose of HT for met is….

A

to manage symptoms (bone pain), control growth BUT can’t cure

37
Q

what is LHRH = GnRH AGONISTS

A

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
Q

agonist examples

A

Zolodex

39
Q

what are LHRH = GnRH ANTAGONISTS

A

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
Q

antagonist example

A

degarelix

41
Q

antiandrogen receptor blocker

A

tablet: flutamide

42
Q

how effective is an orchidectomy in treating symptoms

A

90%

43
Q

SE and management for HT

A

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
Q

what advances in RT are there

A

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
Q

describe brachytherapy

A

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
Q

what does LH stimulate

A

cells of Leydig to produce testosterone

47
Q

anti-androgens

A

blocks actions of testosterone within prostate cells

48
Q

target volume

A

total extent + 1-1.5cm margin
margin can be reduced to 0.75 posteriorly to spare the rectum

49
Q

Treatment: BT

A

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
Q

SE of BT treatment

A

perineal bruising
dysuria
proctitis
urethral stenosis

51
Q

treatment bone mets

A

palliative EBRT
biophosphantes- pamidronate
radionuclides

52
Q

wide spread met treatment

A

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
Q

prognosis

A

untreated localised: 80% 5 year survival
80% at 10 years - radical
mets: 18-24 months

54
Q

5 year PSA relapse free

A

low = 95%
intermediate = 85%
high = 60%

Pelvis and Abdomen: R&O (22 decks)

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