Prostate Flashcards
How common is prostate cancer?
second most common cancer in the UK and the most common in men
What is the location of the prostate?
between the bladder & external urethral sphincter, and anterior to the rectum. It surrounds the prostatic urethra below the urinary bladder and is palpable on digital rectal exam (DRE)
What is the function of the prostate?
fluid is secreted during ejaculation, and consists of proteolytic enzymes, including the prostate-specific antigen (PSA), and prostatic acid phosphatase
What are the zones of the prostate?
transitional - BPH
central
peripheral - 75% cancer
anterior
Where is prostate cancer commonly found?
commonly found in peripheral zone (75%) and then transitional and lowest central
What type is common?
- almost always adenocarcinoma
- acinar adenocarcinoma (most common)
- ductal adenocarcinoma (most aggressive)
- growth of cancer usually influenced by androgens
What are some risk factors for developing prostate cancer?
- family history - first degree relative increases risk by 2.5 times
- ethnicity - men of black ethnicity
- age
- potential link with obesity
What are the clinical features?
- can be asymptomatic if early
- local disease
- invasions of urethra: hesitancy, nocturia, frequency, haematuria
- invasion of ejaculatory ducts: haematospermia
- invasion of rectum: tenesmus
- metastatic spread: weight loss, lethargy, anorexia, bone pain etc
What features might you feel on DRE?
- asymmetry
- hard, irregular surface
- palpable mass
- signs of mets
How would you investigate suspected PC?
Bloods
Prostate specific antigen measurement
Digital rectal examination
Trans rectal USS (+/- biopsy)
MRI/ CT and bone scan for staging
bone scan
What is PSA?
💁🏽♂️ protein produced within prostate epithelial cells and secreted into prostatic fluid, small quantities detected in blood normally
- in cancer → abnormal architecture → higher levels in blood
Why might a PSA be indicated?
suspicious DRE, possible symptoms of prostate Ca, patient request over 50
Why might PSA be raised?
prostatitis, good DRE, BPH, UTI, catheterisation, prostate biopsy (upto 6w), vigorous exercise like cycling, ejaculation
Evaluate PSA as a screening tool.
Advantages as screening tool
- minimally invasive, earlier detection, earlier treatment, low cost, simple and reproducible
Disadvantages as screening tool
- false negatives, false positives, unnecessary investigations and treatment, over treatment
How is PC graded?
Graded using the Gleason grading system, two grades awarded 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5). The two added together give the Gleason score. Where 2 is best prognosis and 10 the worst
Where does PC spread to?
Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease
How might PC be managed?
conservative
radical prostatectomy
radiotherapy
hormonal therapy - testosterone deprivation
chemo
palliative
What is the difference between watch and wait and active surveillance?
- watchful waiting: regular primary care follow up to monitor disease progression by assessing symptoms, PSA testing with avoidance of invasive Ix like DRE or biopsy
- for older patient, multiple co-morbidities, more likely to die with rather than prostate Ca, in any risk group
- active surveillance: regular monitoring of progression with MRI at diagnosis, regular DRE, PSA and biopsies
- in low risk groups, only if patient is candidate for future radical treatment
What is offered in active surveillance?
have had at least 10 biopsy cores taken
have at least one re-biopsy
*If men on active surveillance show evidence of disease progression, offer radical treatment. Treatment decisions should be made with the man, taking into account co-morbidities and life expectancy
When might we opt for radical prostatectomy?
in intermediate or high risk localised cancer, failure of radical radiotherapy, locally advanced with adjunct, rarely in men over 70
How is radiotherapy used in PC mx?
- external beam radiotherapy: directed at tumour from outside body, for localised intermediate to high risk (with adjunctive for high), locally advanced (with brachy), relapse post surgery
- brachytherapy: low or high dose commonly adjunct with ERBT for localised and locally advanced, can be used as monotherapy in low risk with implanted radioactive seeds
What hormone therapies are utilised in PC?
testosterone dependent cancers, so reduce levels to reduce stimulation for cancer to grow
- testosterone antagonist cyproterone acetate
- GnRH agonist goserelin
How might you manage bone pain?
nalgesics, hormone therapy, radiotherapy, radiopharmaceuticals and chemotherapy for pain relief
osteoclast inhibitor (e.g. denosumab, zoledronic acid) to reduce the risk of skeletal complications
Why might there be problems with PC be managed as palliative?
- prostate sx: retention due to tumour mass, clot retention
- localised spread: lymphoedema
- bone: pain, #, spinal cord compression, BM failure
- psychosocial: altered body image, sexual dysfunction
