Prostate and Bladder Cancer Flashcards
What is the veromontanum?
Just distal to the urethral angulation
It is where the ejaculatory ducts (from the union of the seminal vesicles and each vas deferens) drain to each side of the prostatic urethra
Zones of the prostate?
Transitional zone (TZ) - surrounds the prostatic urethra proximal to the veromontanum; in young men, it only accounts for 10% of prostatic glandular tissue
Central zone (CZ) - cone-shaped region surrounding the ejaculatory ducts; in young adults, 25%of glandular tissue
Peripheral zone (PZ) - posteriolateral prostate; it is the majority of prostatic glandular tissue
Which zones give rise to prostate cancer?
TZ - only 20% of prostate cancers arise from here
CZ - only 1-5% of prostate cancers arise from here
PZ - origin of up to 70% of prostate adenocarcinoma
Which zone gives rise to BPH?
TZ
Deaths due to prostate cancer?
Has a very long and indolent course (typically, it is not very aggressive); most people die from other causes
Occurrence of prostate cancer?
Peak age - 70-74 years; it is rare <50 years
Incidence is higher in the West and Black men are at higher risk than Caucasians
Asians rarely develop prostate cancer unless they migrate to the West
FH with relation to prostate cancer?
Risk is doubled if one 1st-degree relative is affected
Genetic abnormalities can be present on certain chromosomes
Clinical presentation of prostate cancer?
Most are asymptomatic and it is an incidental finding with PSA and abnormal DRE findings
Some can have lower urinary tract symptoms, haematuria/haematospermia
Rarely, bone pain, anorexia, and weight loss can occur
Findings with prostate cancer on PR exam?
75% arise in the peripheral zone and so there is abnormal DRE:
• Asymmetry
• Nodule
• Fixed craggy mass
50% of abnormal DRE/PR exams are assoc. with prostate cancer
What is PSA?
Prostate Specific Antigen - glycoprotein enzyme produced by the secretory epithelial cells of the prostate gland
Other conditions which elevate PSA?
BPH Prostatitis/UTIs Retention Catheterisation PR exam/DRE
Indications for PSA testing?
Symptomatic patients
In asymptomatic patient, counselling for PSA testing prior to testing is mandatory
Follow-up Ix after PSA?
TRUS biopsy (AKA trans-rectal USS guided prostate biopsy); 10 biopsies are taken from the prostate (5 from each lobe)
Indications for a TRUS?
Men with an abnormal DRE or an elevated PSA
Previously normal biopsies but rising PSA trends
Complications of TRUS biopsy?
Sepsis, risk of rectal bleeding
Vaso-vagal fainting
Haematospermia and haematuria for 2-3 weeks following the procedure
Pathology and spread of most prostate cancer?
Most are multifocal adenocarcinomas
Pattern of tumour growth tends to start with local extension through the prostatic capsule to the urethra, bladder base and seminal vesicles and with perineural invasion along autonomic nerves
Common sites to which prostate cancer spreads?
Pelvic lymph nodes and the skeleton
Characteristic appearance of bone metastases from a prostate cancer?
Sclerotic lesions
Grading of prostate cancers?
Gleason’s scoring system - based on the architectural appearance of the prostate cancer, rather than on the cytological features
Grades in Gleason’s scoring system?
Graded from 1-5
Initial feature is loss of the basement membrane and the score increases with loss of the glandular structure and replacement by a disorganised malignant cell growth pattern
2 most abundant cell patterns are assessed and then added together to produce a score between 2 and 10
T part of the TNM staging of prostate cancer?
T1 - clinically apparent tumour that is not palpable or visible by imaging
T2 - tumour confined within prostate
T3 - tumour extends through the prostate capsule
T4 - tumour fixed or invades adjacent structure other than the seminal vesicles, bladder neck, external sphincter, rectum, levator muscles or pelvic wall
N part of the TNM staging of prostate cancer?
N0 - no regional lymph node metastasis
N1 - regional lymph node metastasis
M part of the TNM staging of prostate cancer?
M0 - no distant metastasis
M1 - distant metastasis
Imaging modalities available to stage a prostate cancer?
Bone scan, MRI and CT scan
Broad classifications of prostate cancer with TNM staging?
Organ-confined disease:
• T1-2, N0, M0
Locally-advanced disease:
• T3-4, N0, M0
Metastatic disease:
• N1, M1
Management of organ-confined prostate cancer?
Watchful waiting/deferred treatment/symptom-guided treatment:
• Conservative Mx until the development of local/systemic progression, at which point the patient is treated palliatively
Active surveillance:
• Treat at pre-defined thresholds that classify progression; in these cases, treatment options are intended to be curative
Radical surgery, i.e: radical prostatectomy
Radical radiotherapy
Complications of radial prostatectomy?
- Erectile dysfunction
- Incontinence
- Bladder neck stenosis
Complications of radical radiotherapy?
- Irritative LUTS
- Haematuria
- GI symptoms
- Erectile dysfunction
- Incontinence
Management of locally advanced prostate cancer?
Radiotherapy with neo-adjuvant hormonal therapy
Watchful waiting - asymptomatic patients with well and moderately differentiated tumour and a life expectancy <10 years
Hormonal therapy - for symptomatic patient requiring palliation of symptoms but are unfit for curative treatment
Management of metastatic prostate cancer?
Androgen deprivation therapy:
• Hormonal therapy - LHRH analogues, anti-androgens
• Bilateral subcapsular orchidectomy
• Maximal androgen blockade
Diethylstilbestrol/steroids
Cytotoxic chemotherapy
Hormonal control of prostate gland?
Growth of prostate cancer cells is under the influence of testosterone and dihydrotestosterone
If prostate cells are deprived of androgenic stimulation, they undergo apoptosis
Mechanism of action of LHRH agonists?
Chronic exposure results in down-regulation of LHRH-receptors; there is subsequent suppression of LH, FSH and testosterone secretion
Describe the testosterone surge/flare up phenomenon
LHRH analogues initially stimulate pituitary LHRH receptors, inducing a transient rise in LH, FSH and testosterone secretion
How is the testosterone surge prevented?
Anti-androgen cover is given for 1 week and 2 weeks after the 1st dose of LHRH injection
Side effects of LHRH agonists?
Loss of libido and erectile dysfunction
Hot flushes and sweats
Weight gain
Gynaecomastia
Anaemia and osteoporosis
Cognitive changes
Mechanism of action of anti-androgens?
Compete with testosterone and DHT for receptors in the prostate cell nucleus; this promotes apoptosis and inhibits prostate cancer growth
Types of anti-androgen therapy?
Steroidal
Non-steroidal - libido and sexual interest maintained
Side effects of steroidal and non-steroidal anti-androgen therapy?
Steroidal - loss of libido and ED, CV and hepatotoxicity; rarely, gynaecomastia can occur
Non-steroidal - gynaecomastia, breast pain, hot flashes and hepatotoxicity
Types of urothelial tumours?
90% are transitional cell
9% are squamous cell
1% are: • Adenocarcinoma • Sarcoma • Undifferentiated • Benign mesodermal
Classifications of transitional cell carcinoma?
Papillary (80%) - 1/2 of these are infiltrative malignancies:
• Papilloma???
• Invasive paillary carcinoma
Non-papillary (flat)
(20%) - these are all considered malignant:
• Flat non-invasive carcinoma
• Flat invasive carcinoma
Pathological transitional cell tumours?
Well-differentiated papilloma (grade 1)
Malignancy - ranges from low-grade and superficial TO high-grade and invasive
Imaging modalities for uroepithelial tumours?
Excretory urogram
Sonography
Retrograde pyelogram
CT angiography
Gross appearance of transitional cell tumours on imaging studies?
Single lesion
Multiple discrete lesions
Diffuse and confluent lesions
Appearance of papillary type uroepithelial tumours?
Stippled appearance (looks like a tree)
Typical appearance of transitional cell carcinoma?
Tend to be multicentric and bilateral
Bilateral in ~10% of patients
Occurrence of transitional cell carcinoma?
More common in males (4:1) and usually >50 years old
~1/2 of patients with CA ureter or pelvis will develop bladder carcinoma
Ix for urinary bladder carcinoma?
Excretory urography is INSENSITIVE (replaced by CT urography)
Cystoscopy
Typical appearance of transitional cell carcinoma (urinary bladder)?
HALO SIGN (due to the formation of a pseudoureterocele)
Calcification of uroepithelial tumours?
- Transitional cell carcinoma
- Squamous carcinoma
- Urachal carcinoma
