Prostate and bladder cancer

Question 1

Describe the main zones of the prostate that we need to know

Answer 1

• You have the more central zones - the transitional and central zones
• You have the more peripheral zones - the peripheral zone

Question 2

Whats the most common malignancy affecting men in the UK ?

Answer 2

Prostate cancer

Question 3

Which zone of the prostate do most prostate cancers arise ?

Answer 3

The peripheral zone

Question 4

What are the common presenting symptoms of prostate cancer ?

Answer 4

​Localised prostate cancer is often asymptomatic but features of prostate cancer may include:

• Bladder outlet obstruction: hesitancy, urinary retention, terminal dribbling & poor flow, increased frequency, incomplete emptying, nocturia
• Haematuria, haematospermia
• Pain: back, perineal or testicular
• On DRE - asymmetrical, hard, nodular enlargement with loss of median sulcus

Question 5

What investigations would you do for someone with suspected prostate cancer or BPH?

Answer 5

• 1st line = ​FBC, U&E’s, CRP, LFTs, PSA, Ca & Phosphate + PSA + dipstick urine + post-void residual scan + PR exam
• 2nd line = MRI pelvis
• 3rd line to confirm Ca diagnosis if anything seen on MRI = TRUS biopsy of prostate

Question 6

What are the normal levels of PSA in men & there above which would warrant investigation for prostate cancer?

Answer 6

Question 7

Other than prostate cancer what are the other causes to be aware of which can cause a raised PSA?

Answer 7

• Benign prostatic hyperplasia (BPH)
• Prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
• Ejaculation (ideally not in the previous 48 hours)
• Vigorous exercise (ideally not in the previous 48 hours)
• Urinary retention
• Instrumentation of the urinary tract

Question 8

What type of cancer is the majority of prostate cancers?

Answer 8

Adenocarcinomas

Question 9

What are the common sites for metastasis of the prostate cancer ?

Answer 9

Lymph nodes and skeleton (sclerotic lesions)

Question 10

How is prostate cancer staged ?

Answer 10

TNM staging

T-Primary Tumour:

• T1 Clinically in-apparent tumour not palpable or visible by imaging
• T2 Tumour confined within the prostate
• T3 Tumour extends through the prostatic capsule
• T4 Tumour fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles or pelvic wall

N – Regional Lymph Nodes:

• N0 No regional lymph nodes metastasis
• N1 Regional lymph nodes metastasis

M – Distant Metastasis:

• M0 N0 Distant Metastasis
• M1 Distant Metastasis

Question 11

What is the treatment of prostate cancers confined just to the prostate ?

Answer 11

• Radial prostectomy (better but major surgery) so some may have radical radiotherapy instead
• Can also do active surveillance in very low risk patients

Question 12

What is the management of locally advanced prostate cancer i.e. when the cancer has spread into the capsule of the prostate or surrounding tissues ?

Answer 12

Radiotherapy + hormonal therapy

Examples of the hormone therapy -

Question 13

What hormone controls the growth of prostate cancer cells ?

Answer 13

Testosterone

Question 14

What is the 2 main types of hormone therapy in treatment of prostate cancers ?

Answer 14

• LHRH AGONISTS
• ANTI-ANDROGENS

Question 15

What are the 2 main classes of transitional cell carcinomas of the bladder ?

Answer 15

Papillary and non-papillary

Question 16

Describe the mechanism of action of LHRH agonsits and how they decrease testosterone production to treat prostate cancers

Answer 16

1. LHRH analogues initially stimulate pituitary LHRH receptors, inducing a transient rise in LH and FSH release, and consequently elevate testosterone production
2. Chronic exposure to LHRH agonists eventually results in down-regulation of LHRH-receptors, with subsequent suppression of pituitary LH and FSH secretion and testosterone production

Question 17

Describe the mechanism of action of anti-androgen

Answer 17

Anti-androgens compete with testosterone and DHT for binding sites on their receptors in the prostate cell nucleus, thus promoting apoptosis and inhibiting growth

Question 18

Give some examples of anti-androgens and LHRH agonists

Answer 18

• Anti-androgens =cyproterone acetate or nilutamide, flutamide
• LHRH agonists = groserelin, leuprorelin

Question 19

What is the treatment for metastatic prostate cancer ?

Answer 19

Hormone therapy:

• LHRH analogues
• Anti-androgens

Bilateral Orchidectomy - as removal of the testis will mean no more testosterone produced (they are the site of testosterone production)

Question 20

What is the key presenting feature of bladder cancer?

Answer 20

Macroscopic (frank) haematuria is the key presenting feature

Question 21

What are the main types of bladder cancer ?

Answer 21

• 90% TRANSITIONAL CELL
• 9% SQUAMOUS CELL

Question 22

How are bladder cancers diagnosed?

Answer 22

CT urogram + cystoscopy

Question 23

What is the characteristic appearance of papillary type of transitional cell carcinomas ?

Answer 23

Stippled appearance

Question 24

What is the treatment for bladder cancers which have not invaded into the muscle of the bladder ?

Answer 24

1st line = transurethral resection of the bladder (TURBT) + immediate post-operative intravesical chemo

Question 25

What is the treatment of locally invasive bladder tumours ?

Answer 25

1st line = Radical or partial cystectomy with pelvic lymph node dissection

Question 26

What is the treatment of metastatic bladder cancers?

Answer 26

• 1st line = systemic chemotherapy
• adjunct - surgery or radiotherapy