Prostate Flashcards
epidemiology
most common malignancy in males in the UK
2nd largest death
incidence rates are high, ageing population, better diagnostic procedures
aetiology
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)
direct spread
prostate, SV, rectum and bladder
lymphatic spread
pre-sacral
para-aortics
common iliac
internal iliac
external iliac
obturator
haematological spread
mets in L spine
skull, ribs, T-spine
liver and lung are RARE
presentation
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
what is classed as locally advanced
T3/T4 with M0 N0
what is met spread
anything with M1
investigations
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
what staging is used
TNM
grade 1
well differentiated [looks like parent cell], uniform good pattern
grade 2
well differentiated, glands vary in size and shape
grade 3
moderately differentiated
a) irregular acine glands, widespread
b) well defined papillary/ crib form structures
grade 4
poorly differentiated, glands fused and invading stoma
grade 5
very poor differentiation, little or no gland formation
what does the gleason grade look at
the appearance of cells
what happens to the gleason grade
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
describe the scores
6< = low grade [slow]
7 = medium grade
8-10 = high grade
what are the OAR
rectum, bladder, bowel
what is the primary option for low risk localised disease
AS
continuous monitoring unless the treatment changes or the patient dues, if there was progression a more proactive scheme will be undertaken instead
does prostate have a high or low alpha beta ratio
LOW
what does the alpha beta ratio indicate
hypo fractionation, higher doses per fraction
treatment prep
2 cups for 30 minutes, enema
what happens at planning CT
visualise the target, OAR position, provide electron density information to calculate TPS, MRI guided mark up
what is low risk
only prostate gland
what is intermediate or high risk
microscopic spread estimated
what imaging is used
VMAT, IMRT rotating around the patient, as the gantry moves so does the MLC’s to shield the OARs
what is the treatment delivery
MR linac
linac
cyberknife
proton therapy
RT follow up includes:
PSA reading
urinary, bowel, erectile function
hormone therapy
concerns
GP updates and referrals
letter and follow up
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
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
what is prostate cancer dependent on
testosterone
what is the aim of hormone therapy
blocks/ lowers the amount of testosterone in the body, which lowers recurrence if combined with other treatments
what is hormone therapy in combo with
before RT, or a radical prostatectomy (3-6months intermediate) or (3 years for higher locally advanced disease)
how is it administered
injections, tablets or orchidectomy (removal of testicles)
the purpose of HT for met is….
to manage symptoms (bone pain), control growth BUT can’t cure
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
agonist examples
Zolodex
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
antagonist example
degarelix
antiandrogen receptor blocker
tablet: flutamide
how effective is an orchidectomy in treating symptoms
90%
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
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
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
what does LH stimulate
cells of Leydig to produce testosterone
anti-androgens
blocks actions of testosterone within prostate cells
target volume
total extent + 1-1.5cm margin
margin can be reduced to 0.75 posteriorly to spare the rectum
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
SE of BT treatment
perineal bruising
dysuria
proctitis
urethral stenosis
treatment bone mets
palliative EBRT
biophosphantes- pamidronate
radionuclides
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
prognosis
untreated localised: 80% 5 year survival
80% at 10 years - radical
mets: 18-24 months
5 year PSA relapse free
low = 95%
intermediate = 85%
high = 60%
