Prostate Flashcards
List some DDx for a presentation of:
- 65 yo male
- urinary retention 6hrs
- interscapular pain
- mild bilat leg weakness
- unwell 6 weeks
- weight loss
PDx. Prostate ca with secondary spinal cord compression
DDx.
• Genitourinary
o Prostate- BPH, prostate ca
o Penile- tumour
o Ureter- UTI, ureteritis, ureter ca
o Bladder- UTI, bladder ca
• CNS
o Disc herniation/prolapse
o Spinal trauma
o Spondylolisthesis and facet joint degeneration
o Spinal stenosis (age, RA, SA, Paget’s disease)
o Vertebral fracture- osteoporosis, trauma, osteolytic lesion (e.g. MM, mets)
o Stroke
o Psychogenic
o Multiple sclerosis
o Infective- epidural abscess, vertebral osteomyelitis
• Respiratory- lung ca, PE, metastases, TB, pneumonia
What is PSA?
PSA
• Glycoprotein, enzyme produced by prostate gland epithelial cells
• Function: lysing seminal coagulum -> prevent seminal fluid clotting -> allow navigation of cervix
• Elevation due to increased prostate volume (of ANY cause), thus specific for prostate disease (not prostate ca)
• Elevation causes: BPH, prostatitis, prostate ca, 24hrs post ejaculation, 7 days post urinary catheter, bicycle riding, aggressive PR, transurethral resection of the prostate (TURP)
• Should use age-specific ranges to contextualize readings
Results:
• Normal level <4ng/ml
• Grey zone 4-10
• Likely prostate ca >10
Describe the risks and benefits of PSA screening?
• Screening aim: detect disease, exclude those without
• Recommendation: RACGP considers PSA unsuitable
-> due to low PPV and risk of adverse events if positive
• Follow up biopsy if PSA doubles in 1 year or continues on upward trend
• Benefits: detect earlier, better prognosis with early Dx
• Risks: false positive, invasive biopsies, unnecessary treatment and SE (impotence, incontinence), detection of untreatable prostate ca
Describe the spread of prostate cancer?
1) Local invasion
o Most start in peripheral zone (most asymptomatic) -> advance on urethra -> urinary retention
2) Haematological spread via Batson’s venous plexus (between false and true prostate capsules)
- Location and lack of valves -> vertebral column metastases and infection (UTI -> osteomyelitis)
3) Lymphatic spread
o Internal iliac nodes -> common iliac nodes -> para-aortic nodes
How does the Gleason scoring system work?
Evaluated prognosis by examining the 2 of the worst differentiation patterns (graded 1-5) and adding them to get a score out of 10
• Scoring
o 1- small, uniform glands
o 5- irregular masses of neoplastic glands
Describe histological features of prostate adenocarcinoma?
o Loss of basal cell layer (glandular structures usually have basal cuboidal layer and superficial pseudoglandular layer)
o Abundant cytoplasm in cells
o Basophilic cytoplasm (i.e. tinged blue)
Describe the 5 surfaces of the prostate?
1) superior: bladder neck, pierced by urethra
2) inferior: blunt apex above external sphincter
3) anterior: retropubic space
4) inferolateral: levator ani
5) posterior: lower rectum
Describe the prostatic capsules?
1) False capsule- thin layer or thin CT surrounding prostate
2) True capsule- external, consists of pelvic fascia
Note: space between the two capsules contains prostatic venous plexus
Describe the zones of the prostate?
Microscopic: glandular tissue (70%) and fibromuscular tissue (30%)
4 zones:
1. Central zone
- 20% glandular tissue, surrounds ejaculatory duct
- accounts of 2.5% prostate ca (more aggressive, likely to invade seminal vesicles)
- furthest from rectum, NOT not palpable on PR
2. Transitional zone
- 10% glandular tissue
- Anterior and superior to central zone, surrounds middle of prostatic urethra
- Responsible for BPH, <20% prostate ca originates in this zone
3. Peripheral zone
- 70% glandular tissue
- Subscapsular portion of posterior aspect of prostatic gland, surrounds distal urethra
- Accounts for 70-80% prostatic ca
- Closest to rectum, palpable on PR
4. Anterior fibromuscular zone
Describe the arterial supply of the prostate?
Internal iliac artery -> inferior vesical artery
-> base of bladder, distal ureters, prostate
o 1st branch inferior vesical artery -> urethral a (transitional zones)
o 2nd branch inferior vesical artery -> capsular a (glandular tissue)
Describe the venous drainage of the prostate?
Prostatic venous plexus
- > pudendal venous plexus
- > vesical plexus
- > internal iliac vein
Describe the innervation of the prostate?
• Parasympathetic innervation of acini: sacral and pelvic splanchnic (S2-4)
- > inferior hypogastric plexus
- > pelvic splanchnic nerves
• Sympathetic innervation of stroma muscle fibers: sacral and pelvic splanchnic (S2-4)
-> inferior hypogastric
Describe the lymphatic drainage of the prostate?
Internal iliac nodes
- > common iliac nodes
- > para-aortic nodes
What is benign prostatic hyperplasia?
BPH
Path: hyperplasia of prostatic stroma and glands, NO increased cancer risk
-> testosterone converts DHT -> acts on stroma and epithelial cells -> make hyperplastic nodules in periurethral zone -> urethra compression
• Clinical: starting, hesitancy, dribbling, incontinence, impaired bladder emptying
• Ix: microscopic haematuria, PSA slightly elvated, hydronephrosis
• Rx: Tansulosin (alpha 1 antagonist) -> relax smooth muscle -> relieve obstruction
How would you treat prostatic carcinoma?
Treatment dependent on staging:
• Stage 1-2: localised within prostate
- Watch and wait- for low grade (low Gleeson score), PSA monitored 3/12, biopsy every 12-24 months
- Radical prostatectomy- for more aggressive carcinomas
• Stage 3: locally advanced
- Radiation therapy and/or androgen deprivation therapy
• Stage 4: androgen deprivation therapy and palliative care
