Prostate

Question 1

How common is prostate cancer?

Answer 1

second most common cancer in the UK and the most common in men

Question 2

What is the location of the prostate?

Answer 2

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)

Question 3

What is the function of the prostate?

Answer 3

fluid is secreted during ejaculation, and consists of proteolytic enzymes, including the prostate-specific antigen (PSA), and prostatic acid phosphatase

Question 4

What are the zones of the prostate?

Answer 4

transitional - BPH
central
peripheral - 75% cancer
anterior

Question 5

Where is prostate cancer commonly found?

Answer 5

commonly found in peripheral zone (75%) and then transitional and lowest central

Question 6

What type is common?

Answer 6

• almost always adenocarcinoma
  
  • acinar adenocarcinoma (most common)
  • ductal adenocarcinoma (most aggressive)
  • growth of cancer usually influenced by androgens

Question 7

What are some risk factors for developing prostate cancer?

Answer 7

• family history - first degree relative increases risk by 2.5 times
• ethnicity - men of black ethnicity
• age
• potential link with obesity

Question 8

What are the clinical features?

Answer 8

• 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

Question 9

What features might you feel on DRE?

Answer 9

• asymmetry
• hard, irregular surface
• palpable mass
• signs of mets

Question 10

How would you investigate suspected PC?

Answer 10

Bloods
Prostate specific antigen measurement
Digital rectal examination
Trans rectal USS (+/- biopsy)
MRI/ CT and bone scan for staging
bone scan

Question 11

What is PSA?

Answer 11

💁🏽‍♂️ 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

Question 12

Why might a PSA be indicated?

Answer 12

suspicious DRE, possible symptoms of prostate Ca, patient request over 50

Question 13

Why might PSA be raised?

Answer 13

prostatitis, good DRE, BPH, UTI, catheterisation, prostate biopsy (upto 6w), vigorous exercise like cycling, ejaculation

Question 14

Evaluate PSA as a screening tool.

Answer 14

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

Question 15

How is PC graded?

Answer 15

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

Question 16

Where does PC spread to?

Answer 16

Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease

Question 17

How might PC be managed?

Answer 17

conservative
radical prostatectomy
radiotherapy
hormonal therapy - testosterone deprivation
chemo
palliative

Question 18

What is the difference between watch and wait and active surveillance?

Answer 18

• 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

Question 19

What is offered in active surveillance?

Answer 19

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

Question 20

When might we opt for radical prostatectomy?

Answer 20

in intermediate or high risk localised cancer, failure of radical radiotherapy, locally advanced with adjunct, rarely in men over 70

Question 21

How is radiotherapy used in PC mx?

Answer 21

• 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

Question 22

What hormone therapies are utilised in PC?

Answer 22

testosterone dependent cancers, so reduce levels to reduce stimulation for cancer to grow
- testosterone antagonist cyproterone acetate
- GnRH agonist goserelin

Question 23

How might you manage bone pain?

Answer 23

nalgesics, hormone therapy, radiotherapy, radiopharmaceuticals and chemotherapy for pain relief

osteoclast inhibitor (e.g. denosumab, zoledronic acid) to reduce the risk of skeletal complications

Question 24

Why might there be problems with PC be managed as palliative?

Answer 24

• 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

Question 25

What are some complications for radical prostatectomy?

Answer 25

• immediate - infection, bleeding, VTE, anastomotic leak, urinary retention
• long term - incontinence, erectile dysfunction

Question 26

What are some complications in radiotherapy for PC?

Answer 26

• damage to mucosa of urinary tract: LUTS, haematuria, radiation cystitis
• damage to rectal mucosa: diarrhoea, rectal bleeding, rectal pain
• urinary retention: prostatic swelling or urethral stricture