Prostate and bladder cancer Flashcards
What is the apex of the prostate?
Inferior pole (continuous with striated sphincter)
What is the base of the prostate?
Superior pole (continuous with bladder neck)
What type of epithelium composes the prostatic urethra?
Transitional
What is the vermontanum (seminal colliculus)?
Part of urethra distal to urethral angulation where the ejaculatory ducts drain
What are the ejaculatory ducts?
Joint vas deferans and seminal vesicles
What are the zones of the prostate?
Transitional
Central
Peripheral
Where is the transitional zone of the prostate
Surrounds prostatic distal to vermontanum
What common pathologies arise from the transitional zone of the prostate?
Prostate cancer (10-20%) Benign prostatic hyperplasia
Where is the central zone of the prostate?
Cone shaped region that surrounds the ejaculatory ducts
What pathology arises from the central zone of the prostate?
Prostate cancer (very rarely)
Where is the peripheral zone of the prostate?
Posterolateral
Which zone of the prostate is the biggest?
Peripheral zone (composes most of the tissue)
What pathology arises from the peripheral zone of the prostate?
Prostatic adenocarcinoma (majority)
The prostate has fibromuscular stroma which for some reason isn’t listed as one of the zones thank fuck for podcast lectures am i right. T/F
True - cannot be palpated on examination as it is anterior
What is the most common malignancy affecting males in the UK?
Prostate
Is mortality high in relation to prostate cancer?
Yes
Which screening test is used to detect prostate cancer?
Prostate specific antigen
What is the natural history of prostate cancer?
Long, indolent course
What are the risk factors associated with prostatic cancer?
Age (>50)
Western world
Black men
Family history
How does prostatic cancer present?
Majority asymptomatic Lower urinary tract symptoms Haematuria Haematospermia Bone pain (night) Anorexia Weight loss
How is asymptomatic prostate cancer picked up?
Prostate specific antigen
Digital rectal exam
How does prostate cancer present on rectal exam?
Asymmetry
Nodule
Fixed craggy mass
By the time prostate cancer is picked up most patients will have metastases. T/F
True
What is prostate specific antigen?
Glycoprotein enzyme
What produces prostate specific antigen?
Secretory epithelium of prostate
What does prostate specific antigen do?
`Help liquify semen
How will prostate specific antigen levels differ between normal and cancerous prostates?
Normal - high semen low serum
Cancerous - high semen high serum
What is the specificity and sensitivity of prostate specific antigen?
Specificity - low
Sensitivity - high
Which conditions elevate prostate specific antigen levels?
Benign prostatic hyperplasia Prostatitis UTI Retention Catheterisation Digital rectal exam
When is PSA testing indicated?
Symptomatic patients
Asymptomatic patients who’ve underwent counselling
Why is counselling mandatory prior to PSA in asymptomatic patients?
Cancer rates are very low and treatment/investigations can be associated with morbidity and lowered QoL
What is a TRUS biopsy? Is uncomfortable?
Trans rectal USS + biopsy
Honestly what do you think
What are the indications of a trans rectal US guided biopsy?
Abnormal rectal exam + raised PSA
Previous abnormal biopsy
Previous normal biopsy but with raised PSA
What are PIN and ASAP prostate biopsy results?
Prostatic intraepitherlial neoplasia
Atypical small acinar proliferation
How many biopsies are taken in a TRUS biopsy?
5 from each lobe of the prostate (i.e 10)
What are the complications of a TRUS biopsy?
Rectal bleeding
Haematuria/haemospermia for 2-3 week post procedure
Sepsis
Vaso-vagal fainting
The majority of prostate cancers are what?
Multifocal adenocarcinomas
How does adenocarcinoma tend to spread locally?
Prostate capsule Urethra Bladder base Seminal vesicles Autonomic nerves
Where does prostate cancer commonly metastasis to?
Bones
Pelvic lymph nodes
What type of bone metastases is present in prostatic cancer?
Osteosclerotic
How is prostatic cancer graded? Describe this system
Gleason’s score
Based on architectural appearance of prostate gland
- Initial feature of malignancy is loss of basement membrane –>
- Progressive loss of glandular structure and replacement by malignant growth –>
- Abundant cell patterns assessed then added to give score
Describe the TNM classification
T - 1 clinically inapparent - 2 confined to prostate - 3 extension through capsule - 4 local spread N - 0 no nodes - 1 regional nodes M - 0 no distant metastases - 1 distant metastases
How is prostatic cancer staged?
Bone scan
MRI
CT
What are the broad classifications of prostate cancer spread?
Organ confined
Local spread
Metastatic
Which factors influence management of prostate disease?
Category of disease Patient wishes/quality of life Life expectancy Co-morbidities Age
How is organ confined prostate cancer managed?
Watchful waiting/symptom guided (conservative > palliative)
Active monitoring
Radical surgery (prostatectomy)
Radical radiotherapy (EBRT, brachytherapy)
What are the complications of prostatectomy?
Erectile dysfunction
Incontinence
Bladder neck stenosis
What are the complications of radical radiotherapy?
Irritative lower urinary tract symptoms Haematuira GI symptoms Erectile dysfunction Incontinence
How is locally advanced prostate disease managed?
Radiotherapy with neo-adjuvant hormonal
Watchful waiting
Hormonal therapy
Where is watchful waiting indicated in locally advanced prostate cancer?
Patient refuses treatment
Asymptomatic and well differentiated tumour with
When is hormonal therapy indicated in locally advanced prostate cancer?
Symptomatic with need for palliation of symptoms but with no/low change of cure
How is metastatic prostate cancer managed?
Androgen deprivation therapy
Diethylstilbesterol/steroids
Cytotoxic chemotherapy
List the types of androgen deprivation therapy
Hormone therapy (LHRH analogues, anti-androgens)
Bilateral subcapsular orchidectomy
Maximal androgen blockade
Which hormones influence growth of prostate cancer?
Testosterone
Dihydrotestosterone
Where do hormones influencing the growth of prostate cancer come form?
Adrenal
Testis
Testosterone induces negative feedback how?
Reduces hypothalamic LH secretion (i.e reduces LHRH)
What happens if prostate cells are not stimulated by androgens?
Undergo apoptosis
How do LHRH agonists work?
Down regulation of LHRH receptors and thus reduced secretion of FSH and LH –> reduced testosterone
What is testosterone surge in relation to LHRH agonists?
Initially cause an increase in LHRH and thus FSH and LH hence increased testosterone
What is the major serious complication of LHRH agonists? How can this be prevented?
Catastrophic spinal cord compression
Anti-androgens give one week prior and two weeks post first dose of LHRH agonists
What are the side effects of LHRH agonists?
Erectile dysfuction +/- loss of libido Weight loss Gynecomastia Cognitive change Osteoporosis Anaemia Hot flushes/sweats
How do anti-androgens work?
Compete with testosterone and dyhydrotestosterone for their binding sites within to prostate cell nucleus –> promotes apoptosis and inhibits cancer growth
What are the two types of anti androgens?
Steroidal (cyproterone acetate)
Non-steroidal (nilutamide, flutamide, bicalutamide)
What are the side effects of steroidal anti-androgens?
Loss of libido Erectile dysfunction Gynecomastia (rare) CVS toxicity Hepatotoxicity
What are the side effects of non-steroidal anti-androgens?
Gynecomastia
Breast pain
Hot flashes
Hepatotoxicity
Do males or females more commonly get bladder cancer?
Males
Bladder cancer needs lifelong monitoring +/- treatment. T/F
True
Bladder cancer is highest in the western world. T/F
True
How might bladder cancer be diagnosed?
KUB x-ray (IV pyelogram) USS Retrograde pyelogram (if kidney damage) Cytoscopy (this) CT (this) Angiography
Are transitional cell or squamous cell carcinomas more common in the bladder?
Transitional cell (by a large margin)
How can transitional cell bladder cancer be categorised? Which is more common
Papillary (common)
Non-papillary
All transitional cell bladder cancers are infiltrative. T/F
False - some papillary cancers are not invasive malignancies but all non-papillary ones are
What are the type types of non-papillary bladder malignancy?
Flat non-invasive
Flat invasive
What is the gross appearance of transitional cell tumours on imaging?
Single lesion (small papillary vs bulky sessile)
Multiple discrete
Diffuse and confluent
Transitional cell carcinoma can present where?
Anywhere along the collecting urinary tract (i.e pelvis, ureters, bladder, urethra, etc)
How do papillary transitional cell carcinomas present grossly within the renal pelvis/ureters?
Stippled
Multi centric and bilateral (more commonly unilateral)
Synchronous vs metachronous
What percentage of patients with transitional cell carcinomas of the renal pelvis/ureters go on to develop bladder cancer?
50%
Over which age do most bladder cancers present?
60
Excretory urograms have been replaced by CT urography. T/F
True - excretory urograms are insensitive
What can sometimes be seen on imaging of urinary bladder cancer?
Halo sign
Which bladder tumours may calcify?
Transitional cell
Sqaumous cell
Urachal cell
What is cystica glandularis?
Metaplasia (chronic irritation of bladder mucosa)
