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Renal > Prostate and Bladder Cancer > Flashcards

Prostate and Bladder Cancer Flashcards

1
Q

How much does the normal prostate weigh in a young adult?

A

20g

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2
Q

What are some parts of the prostate?

A 
Apex = inferior portion, continuous with striated sphincter
Base = superior portion, continuous with bladder neck
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3
Q

What cell type covers the prostatic urethra?

A

Transitional epithelium

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4
Q

Where is the verumontanum of the prostatic urethra located?

A

Just distal to the urethral angulation = ejaculatory ducts drain into either side

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5
Q

Where is the transition zone of the prostate located?

A

Surrounds prostatic urethra proximal to the verumontanum = only accounts for 10% of prostatic glandular tissue in young men

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6
Q

How common are cancers of the transition zone of the prostate?

A

Accounts for 20% of prostate cancers

Area gives rise to benign prostatic hyperplasia

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7
Q

Where is the central zone of the prostate located?

A

Cone shaped region that surrounds the ejaculatory ducts = 25% of glandular tissue in young men

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8
Q

How common are cancers of the central zone of the prostate?

A

Only accounts for 1-5% of prostate cancers

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9
Q

What are some features of the peripheral zone of the prostate?

A

Posteriolateral prostate = majority of prostatic glandular tissue, origin of up to 70% of prostate adenocarcinomas

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10
Q

What is the epidemiology of prostate cancer?

A

Most common malignancy in men in the UK

Second highest cancer mortality = 13% of all cancer related deaths in men in the UK

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11
Q

What is the course of prostate cancer?

A

Long natural history and indolent course = many patients die from other causes rather than causes directly attributable to the cancer

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12
Q

What is the aetiology of prostate cancer?

A

Precise cause unknown
Highest rate in Scandinavia and North America
Lowest rates in Asia

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13
Q

What age does prostate cancer tend to present at?

A

Peak age is 70-74
Rare < age 50
85% of cases are patients >65

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14
Q

What ethnicities are at higher risk of prostate cancer?

A

Black men at higher risk than Caucasians

Asians rarely develop it unless they move to the West

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15
Q

What are the genetic associations of prostate cancer?

A

Genetic abnormality on chromosome 1q, 8q, Xp and mutations in BRCA2

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16
Q

How does prostate cancer cluster in families?

A

Risk of CaP doubled with one first degree relative

Four fold increase with two first degree family members

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17
Q

How do most patients with prostate cancer present?

A

Most are asymptomatic and are picked up by PSA or abnormal DRE

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18
Q

What are some symptoms of prostate cancer?

A

Lower urinary symptoms, haematuria/haematospermia,

bone pain, anorexia, weight loss

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19
Q

Why are DREs important to do for patients with suspected prostate cancer?

A

75% of cancer are in the peripheral zone so can be palpated on rectal examination

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20
Q

What are some features of an abnormal prostate on DRE?

A

Asymmetry, nodule, fixed craggy mass

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21
Q

How good is DRE for identifying patients with prostate cancer?

A

50% of abnormal DREs are associated with CaP

30% with normal PSA and abnormal DRE will have CaP

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22
Q

What does an abnormal DRE mean for the stage of the prostate cancer?

A

Usually quite advanced = only 40% with abnormal DRE will have organ-confined disease

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23
Q

What is prostate specific antigen (PSA)?

A

Glycoprotein enzyme (kallikrein-like serine protease) = produced by the secretory epithelial cells of the prostate and involved in liquefaction of semen

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24
Q

What are PSA levels like normally?

A

In health semen levels of PSA are high and serum levels are low = prostate cancer increases serum levels

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25
Q

Is PSA a good prostate cancer tumour marker?

A

Not really = has 90% sensitivity but only 40% specificity

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26
Q

What are some other conditions that can cause PSA to rise?

A

Benign prostatic hyperplasia, prostatitis, UTI, retention, catheterisation, DRE

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27
Q

What must always be done before carrying out a PSA test on an asymptomatic individual?

A

PSA counselling

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28
Q

What areas should be included in PSA counselling?

A

Cancer identified in <5% of patients
TRUS biopsy = uncomfortable, 1% risk of significant sepsis and bleeding, may need repeat biopsy
Treatment may not be necessary or curative

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29
Q

What are the indications for a trans-rectal USS-guided biopsy (TRUS) to investigate prostate cancer?

A

Men with abnormal DRE/elevated PSA, previous biopsies showing PIN or ASAP, previous normal biopsies but rising PSA trend

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30
Q

How is a TRUS biopsy carried out?

A

USS probe passed through the rectum and prostate visualised in transverse and sagittal sections = 10 biopsies taken (5 from each lobe)

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31
Q

What are the complications of a TRUS biopsy?

A

0.5% risk of sepsis
0.5% risk of rectal bleeding
Vaso-vagal fainting
Haematuria/haematospermia for 2-3 weeks after

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32
Q

What are most prostate cancers?

A

> 95% are multifocal adenocarcinomas

33
Q

What is the pattern of growth of prostate cancer?

A

Starts with local extension through prostatic capsule, to urethra, bladder base and seminal vesicles and with perineural invasion along autonomic nerves

34
Q

Where are the most common sites for metastases from prostate cancer?

A

Pelvic lymph nodes and skeleton

35
Q

What are the characteristic lesions of prostate cancer?

A

Sclerotic lesions

36
Q

What is Gleason’s scoring for prostate cancer?

A

Gives score on the architectural appearance of the prostate glands rather than cytological features = good prognostic predictor

37
Q

How is prostate cancer graded microscopically?

A

Grade 1-5 = initial feature of CaP is loss of basement membrane

38
Q

What does the Gleason score increase with?

A

Microscopic loss of glandular structure and replacement by a disorganised malignant cell growth pattern

39
Q

How is the Gleason grade written?

A

Two most abundant cell patterns are assessed and the added together to give a score between 2 and 10

40
Q

What is T1-3 staging of prostate cancer?

A 
T1 = clinically inapparent tumour not palpable/visible by imaging 
T2 = tumour confined within the prostate
T3 = tumour extends through prostate capsule
41
Q

What is stage T4 of prostate cancer?

A

Tumour fixed or invades adjacent structures other than seminal vesicles = bladder neck, external sphincter, rectum, levator muscles, pelvic wall

42
Q

What is the N staging of prostate cancer?

A 
N0 = no regional lymph node metastases
N1 = regional lymph node metastases
43
Q

What is the M staging of prostate cancer?

A 
M0 = no distant metastases
M1 = distant metastases
44
Q

What imaging modalities can be used to stage prostate cancer?

A

Bone scan, MRI, CT scan

45
Q

What are some broad classifications of prostate tumours?

A

Organ confined disease = T1-2, N0, M0
Locally advanced disease = T3-4, N0, M0
Metastatic disease = N1, M1

46
Q

What are some factors that influence management of prostate cancer?

A

Category cancer belongs to, age, co-morbidities, life expectancy, patient preference, quality of life

47
Q

How is organ confined prostate cancer managed?

A

Conservative management until further development
Active monitoring
Radical surgery or radiotherapy

48
Q

What is done in active monitoring of prostate cancer?

A

Close surveillance of progression (short PSA doubling time and deteriorating histopathological factors)

49
Q

What are some radical surgeries that can be done for prostate cancer?

A

Radical prostatectomy = complications of erectile dysfunction, incontinence and bladder neck stenosis

50
Q

What are some radical radiotherapy options for prostate cancer?

A

EBRT or brachytherapy = complications are irritative LUTS, haematuria, GI symptoms, erectile dysfunction and incontinence

51
Q

How is locally advanced prostate cancer treated?

A

Radiotherapy with neo-adjuvant hormonal therapy
Watchful waiting
Hormonal therapy

52
Q

What prostate cancer patients are suitable to be managed with watchful waiting?

A

Asymptomatic patients with well and moderately differentiated tumours and <10 year life expectancy, patients who don’t accept treatment-related complications

53
Q

What prostate cancer patients are suitable for hormonal therapy?

A

Symptomatic patients who need palliation of symptoms, unfit for curative treatment

54
Q

How is metastatic prostate cancer treated?

A

Androgen dependent therapy
Diethylstilboestrol/steroids
Cytotoxic chemotherapy

55
Q

What are some different forms of androgen dependent therapy?

A

Hormonal therapy = anti-androgens, LHRH analogues
Bilateral subcapsular orchidectomy
Maximal androgen blockade

56
Q

What is the growth of prostate cancer cells under the influence of?

A

Testosterone and dihydrotestosterone

57
Q

What are some features of testosterone?

A

Produced by testes (90%) and adrenals
Secretion regulated by HPG axis
Exerts negative feedback control of hypothalamic LH secretion

58
Q

What happens to prostate cells if they are deprived of androgenic stimulation?

A

They undergo apoptosis

59
Q

What does chronic exposure to LHRH agonists lead to?

A

Down-regulation of LHRH receptors = subsequent suppression of pituitary LH and FSH secretion and testosterone production

60
Q

How do LHRH agonists cause a testosterone surge?

A

Initially stimulate pituitary LHRH receptors = induces a transient rise in LH and FSH release, and consequently elevates testosterone production

61
Q

How do patients with a testosterone surge caused by LHRH agonists present?

A

20% of patients present with catastrophic spinal cord compression

62
Q

How is a testosterone surge prevented when prescribing LHRH agonists?

A

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

63
Q

What are the side effects of LHRH agonists?

A

Loss of libido, erectile dysfunction, hot flushes and sweats, weight gain, gynaecomastia, anaemia, cognitive changes, osteoporosis

64
Q

How do anti-androgens work?

A

Compete with testosterone and DHT for binding sites on their receptors in the prostate cell nucleus = promotes apoptosis and inhibits cancer growth

65
Q

What is an example of a steroidal anti-androgen?

A

Cyproterone = side effects are loss of libido, erectile dysfunction, gynaecomastia (rare), cardiomegaly and hepatomegaly

66
Q

What are the two types of anti-androgens?

A

Steroidal and non-steroidal

67
Q

What are some examples of non-steroidal anti-androgens?

A

Nilutamide, flutamide and bicalutamide = sexual interest and libido are preserved, side effects of gynaecomastia, breast pain, hot flashes and hepatotoxicity

68
Q

What does urinary bladder cancer require?

A

Lifelong routine monitoring and treatment = highest cost of any cancer from diagnosis to death

69
Q

What is the most common urothelial cell tumour?

A

Transitional cell carcinoma = 90%

70
Q

What are some rarer urothelial cell tumours?

A

Squamous cell carcinoma = 9%

Other (1%) = sarcoma, adenocarcinoma, undifferentiated, benign mesodermal

71
Q

What are the types of transitional cell carcinomas?

A 
Papillary type (80%) = 50% are infiltrative malignancies
Non-papillary type (20%) = all malignant
72
Q

What can the classification of transitional cell carcinomas range from?

A

Well differentiated papilloma (grade 1) to malignancy (low grade and superficial to high grade and invasive)

73
Q

How are transitional cell carcinomas imaged?

A

Excretory urogram, sonography, retrograde pyelogram, computed tomography, angiography

74
Q

What are the usual features of transitional cell carcinomas?

A

Tend to be multicentric and bilateral = bilateral in up to 10% (synchronous or metachronous)

75
Q

How common is bladder carcinoma in patients with ureteric or pelvic cancer?

A

Occurs in up to 50%

76
Q

What are some features of urinary bladder carcinomas?

A

Four times more common in men, patients usually age >50, investigated using cystoscopy or excretory urography (insensitive for diagnosis)

77
Q

What is a radiological sign of urinary bladder cancer?

A

Halo sign

78
Q

What uroepithelial tumours undergo calcification?

A

Transitional cell, squamous cell and urachal carcinomas

Renal (36 decks)

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