Prostate and Bladder Cancer Flashcards
how much does the prostate weight in a young adult?
20g
what are the 2 areas of the prostate?
apex - inferior portion of prostate, continuous with striated sphincter
base - superior portion and continuous with bladder neck
describe the prostatic urethra
covered by transitional epithelium contains verumontanum (landmark near the entrance of the ejaculatory ducts (on both sides, corresponding vas deferens and seminal vesicle feed into corresponding ejaculatory duct).)
what are the 3 zones of the prostate?
transitional zone
central zone
peripheral zone
describe transitional zone
surrounds prostatic urethra proximal to the veru
gives rise to BPH
only 20% of cancers arise here
describe central zone
cone shaped region that surrounds the ejaculatory duct
very rare site of cancer
describe peripheral zone
posteriolateral prostate
majority of prostatic glandular tissue
70% of prostate cancers arise here
most common cancer in males?
prostate
what screening tool is used in prostate cancer/enlargement?
PSA (prostate specific antigen)
- not cancer specific, only shows prostate disease/enlargement
risk factors for prostate cancer?
peak age = 70-74 (rare under 50) more common in the west (rarer in asia) more common in black males rare in Asians family history
presentation of prostate cancer?
arises from peripheral zone so usually has no symptoms and is picked up by PSA tests and abnormal PR exam
how might late stage prostate cancer present?
lower urinary tract symptoms
haematuria/hematospermia
bone pain, anorexia, weight loss
urinary retention indicates BPH or prostate cancer, why?
BPH
BPH arises in transitional zone so causes urinary symptoms
cancer arises in peripheral zone so doesn’t really affect urinary tract
what is PSA?
prostatic specific antigen
glycoprotein enzyme produced by secretory epithelial cells of prostate gland
involved with liquefaction of semen
describe PSA levels in health
high semen levels
low serum levels
- serum levels increase in cancer
what is done if raised PSA is found?
trans rectal US guised prostate biopsy (TRUS biopsy)
US probe passed through rectum and prostate visualised in transverse and sagittal section
10 biopsies taken (5 from each lobe - as prostate cancer is multifocal)
risks of TRUS biopsy?
infection
bleeding
fainting
haematospermia and haematuria for 2-3 weeks
describe features of most prostate cancers
most are multifocal adenocarcinomas
growth starts with local extension through capsule, into urethra, bladder, seminal vesicles etc and then perineural invasion along autonomic nerves
sclerotic lesions are characteristic
common sites for metastases in prostate cancer?
pelvic lymph nodes
skeleton
how is prostate cancer graded?
gleasons system (based on architectural appearance) stages 1-5 score increases with loss of glandular structure and replacement by a disorganised malignant growth pattern
how is prostate cancer staged?
TNM T = primary tumour - T1 = not palpable or visible by imaging T2 = tumour confined within prostate T3 = tumour extends through prostate capsule T4 = tumour fixed or invades adjacent structures other than seminal vesicle, bladder neck, external sphincter, rectum, levator muscles or pelvic wall N = regional lymph nodes N0 = no regional lymph nodes metastasis N1 = regional lymph node metastases M = distant metastases M0 = no distant metastasis M1 = distant metastasis
how is prostate cancer imaged?
bone scan
MRI
CT scan
3 broad categories of prostate cancer?
organ confined - T1-2, N0, M0 locally advanced - T3-4, N0, M0 metastatic disease - N+, M+
how is organ defined disease managed?
watch and wait/deferred treatment/symptoms management
active surveillance/monitoring (treat at pre-defined thresholds that classify progression, curative intent)
radical surgery
radical radiotherapy
management of locally advanced disease?
radiotherapy with neo-adjuvant therapy watchful waiting (in asymptomatic palliative patients) hormonal therapy (for symptom management in palliative patients)
how is metastatic disease managed?
androgen deprivation - hormonal therapy (LHRH analogues, anti-androgens) - orchidectomy - max androgen blockade diethylstilbesterol/steroids cytotoxic chemotherapy
growth of prostate cancer cells is under control of what 2 hormones?
testosterone
dihydrotestosterone
testosterone exerts a negative feedback control on hypothalamic LH secretion, if prostate cells are deprived of androgenic stimulation, they undergo apoptosis
where does testosterone come from and what regulates its secretion?
90% from testes
10% from adrenals
regulated by hypothalamic-pituitary-gonadal axis
how can androgen agonist therapy be used in control of prostate?
chronic exposure to LHRH agonists results in f=down-regulation of LHRH receptors, with subsequent suppression of pituitary LH and FAH secretion and testosterone production
side effects of LHRH agonists?
initially causes a surge in LH and FSH and therefore testosterone as the initially stimulate LHRH receptors - can cause spinal cord compression - prevented with use of anti-androgens loss of libido ED hot flushes/sweats weight gain gynaecomastia anaemia cognitive changes osteoporosis
how can anti-androgens be used to control prostate?
they compete with testosterone and DHT for binding sites on their receptors in prostate cell nucleus, promoting apoptosis
what are the types of anti-androgens?
steroidal (cyproterone acetate)
- causes loss of libido, ED, gynaecomastia, cardio toxicity and hepatotoxicity
non-steroidal
- sexual intrest/libido maintained
- causes gynaecomastia, breast pain and hot flashes, hepatotoxicity
how is bladder cancer diagnosed?
clinical symptoms
CT contrast scan
- MRI if contrast allergic
urethroscope (cystoscopy)
types of cancers in bladder?
90% are transitional cell
9% are squamous cell
1% (adeno, sarcoma etc)
classification of transitional cell carcinoma?
papillary (80% - only 50% are infiltrative malignancies)
non-papillary (20% - all are considered malignant)
2 types of papillary carcinoma?
papilloma (growing outwards, pedunculated)
invasive = growing deep into structure
2 types of flat carcinoma?
invasive
non-invasive
how are uroepithelial tumours imaged?
excretory urogram sonography retrograde pyelogram computed tomography angiography
how may a transitional cell tumour appear on imaging?
single lesion (can be small and papillary or bulky and sessile)
multiple discrete lesions
diffuse and confluent lesions
describe transitional cell carcinoma
tend to be multicenteric and bilateral
who is bladder cancer more common in?
males
after 5th decade of life
main diagnostic tool for bladder carcinoma?
CT urography
cystography
common metastases for bladder cancer?
lymph nodes
