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Year 2 Clinical > Prostate and Bladder Cancer > Flashcards

Prostate and Bladder Cancer Flashcards

1
Q

What is the veromontanum?

A

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

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2
Q

Zones of the prostate?

A

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

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3
Q

Which zones give rise to prostate cancer?

A

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

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4
Q

Which zone gives rise to BPH?

A

TZ

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5
Q

Deaths due to prostate cancer?

A

Has a very long and indolent course (typically, it is not very aggressive); most people die from other causes

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6
Q

Occurrence of prostate cancer?

A

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

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7
Q

FH with relation to prostate cancer?

A

Risk is doubled if one 1st-degree relative is affected

Genetic abnormalities can be present on certain chromosomes

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8
Q

Clinical presentation of prostate cancer?

A

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

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9
Q

Findings with prostate cancer on PR exam?

A

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

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10
Q

What is PSA?

A

Prostate Specific Antigen - glycoprotein enzyme produced by the secretory epithelial cells of the prostate gland

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11
Q

Other conditions which elevate PSA?

A 
BPH
Prostatitis/UTIs
Retention
Catheterisation
PR exam/DRE
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12
Q

Indications for PSA testing?

A

Symptomatic patients

In asymptomatic patient, counselling for PSA testing prior to testing is mandatory

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13
Q

Follow-up Ix after PSA?

A

TRUS biopsy (AKA trans-rectal USS guided prostate biopsy); 10 biopsies are taken from the prostate (5 from each lobe)

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14
Q

Indications for a TRUS?

A

Men with an abnormal DRE or an elevated PSA

Previously normal biopsies but rising PSA trends

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15
Q

Complications of TRUS biopsy?

A

Sepsis, risk of rectal bleeding

Vaso-vagal fainting

Haematospermia and haematuria for 2-3 weeks following the procedure

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16
Q

Pathology and spread of most prostate cancer?

A

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

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17
Q

Common sites to which prostate cancer spreads?

A

Pelvic lymph nodes and the skeleton

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18
Q

Characteristic appearance of bone metastases from a prostate cancer?

A

Sclerotic lesions

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19
Q

Grading of prostate cancers?

A

Gleason’s scoring system - based on the architectural appearance of the prostate cancer, rather than on the cytological features

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20
Q

Grades in Gleason’s scoring system?

A

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

21
Q

T part of the TNM staging of prostate cancer?

A

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

22
Q

N part of the TNM staging of prostate cancer?

A

N0 - no regional lymph node metastasis

N1 - regional lymph node metastasis

23
Q

M part of the TNM staging of prostate cancer?

A

M0 - no distant metastasis

M1 - distant metastasis

24
Q

Imaging modalities available to stage a prostate cancer?

A

Bone scan, MRI and CT scan

25
Q

Broad classifications of prostate cancer with TNM staging?

A

Organ-confined disease:
• T1-2, N0, M0

Locally-advanced disease:
• T3-4, N0, M0

Metastatic disease:
• N1, M1

26
Q

Management of organ-confined prostate cancer?

A

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

27
Q

Complications of radial prostatectomy?

A
  • Erectile dysfunction
  • Incontinence
  • Bladder neck stenosis
28
Q

Complications of radical radiotherapy?

A
  • Irritative LUTS
  • Haematuria
  • GI symptoms
  • Erectile dysfunction
  • Incontinence
29
Q

Management of locally advanced prostate cancer?

A

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

30
Q

Management of metastatic prostate cancer?

A

Androgen deprivation therapy:
• Hormonal therapy - LHRH analogues, anti-androgens
• Bilateral subcapsular orchidectomy
• Maximal androgen blockade

Diethylstilbestrol/steroids

Cytotoxic chemotherapy

31
Q

Hormonal control of prostate gland?

A

Growth of prostate cancer cells is under the influence of testosterone and dihydrotestosterone

If prostate cells are deprived of androgenic stimulation, they undergo apoptosis

32
Q

Mechanism of action of LHRH agonists?

A

Chronic exposure results in down-regulation of LHRH-receptors; there is subsequent suppression of LH, FSH and testosterone secretion

33
Q

Describe the testosterone surge/flare up phenomenon

A

LHRH analogues initially stimulate pituitary LHRH receptors, inducing a transient rise in LH, FSH and testosterone secretion

34
Q

How is the testosterone surge prevented?

A

Anti-androgen cover is given for 1 week and 2 weeks after the 1st dose of LHRH injection

35
Q

Side effects of LHRH agonists?

A

Loss of libido and erectile dysfunction
Hot flushes and sweats

Weight gain

Gynaecomastia

Anaemia and osteoporosis

Cognitive changes

36
Q

Mechanism of action of anti-androgens?

A

Compete with testosterone and DHT for receptors in the prostate cell nucleus; this promotes apoptosis and inhibits prostate cancer growth

37
Q

Types of anti-androgen therapy?

A

Steroidal

Non-steroidal - libido and sexual interest maintained

38
Q

Side effects of steroidal and non-steroidal anti-androgen therapy?

A

Steroidal - loss of libido and ED, CV and hepatotoxicity; rarely, gynaecomastia can occur

Non-steroidal - gynaecomastia, breast pain, hot flashes and hepatotoxicity

39
Q

Types of urothelial tumours?

A

90% are transitional cell

9% are squamous cell

1% are:
• Adenocarcinoma
• Sarcoma
• Undifferentiated
• Benign mesodermal
40
Q

Classifications of transitional cell carcinoma?

A

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

41
Q

Pathological transitional cell tumours?

A

Well-differentiated papilloma (grade 1)

Malignancy - ranges from low-grade and superficial TO high-grade and invasive

42
Q

Imaging modalities for uroepithelial tumours?

A

Excretory urogram

Sonography

Retrograde pyelogram

CT angiography

43
Q

Gross appearance of transitional cell tumours on imaging studies?

A

Single lesion

Multiple discrete lesions

Diffuse and confluent lesions

44
Q

Appearance of papillary type uroepithelial tumours?

A

Stippled appearance (looks like a tree)

45
Q

Typical appearance of transitional cell carcinoma?

A

Tend to be multicentric and bilateral

Bilateral in ~10% of patients

46
Q

Occurrence of transitional cell carcinoma?

A

More common in males (4:1) and usually >50 years old

~1/2 of patients with CA ureter or pelvis will develop bladder carcinoma

47
Q

Ix for urinary bladder carcinoma?

A

Excretory urography is INSENSITIVE (replaced by CT urography)

Cystoscopy

48
Q

Typical appearance of transitional cell carcinoma (urinary bladder)?

A

HALO SIGN (due to the formation of a pseudoureterocele)

49
Q

Calcification of uroepithelial tumours?

A
  1. Transitional cell carcinoma
  2. Squamous carcinoma
  3. Urachal carcinoma

Year 2 Clinical (119 decks)

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