Prostate and Testicular Cancer Flashcards
What is the epidemiology of prostate cancer?
Commonest cancer diagnosed in men
45% of new cases are >70 yrs
14% of cancer deaths in men - 2nd commonest
Economic burden - £800million/ year
Describe prostate mortality in the UK
> 12000 deaths a year
Highest in men aged over 90 years
75% of deaths occur in men over 75 years
What are some risk factors for prostate cancer?
Age, race/ ethnicity - African or afro-Caribbean highest risk, geography, FH - first degree relative, HPC1, BRCA1+2 and lynch syndrome, obesity, and diet
Describe presentation and diagnosis with prostate cancer
80% are localised
Mostly asymptomatic and diagnosed through opportunistic PSA testing (prostate specific not cancer specific)
What are some of the presenting symptoms of localised prostate cancer?
Weak stream, hesitancy, sensation of incomplete emptying, frequency, urgency, urge incontinence and UTI
What are some of presenting symptoms in locally invasive prostate cancer?
Haematuria, perineal and suprapubic pain, impotence, incontinence, loin pain or anuria, renal failure, haemospermia, and rectal symptoms
What are some symptoms for metastatic prostate cancer?
Bone pain or sciatica, paraplegia secondary to spinal cord compression, lymph node enlargement, lymphoedema and loin pain or anuria
What is the commonest mode of presentation for prostate cancer?
Asymptomatic - incidentally noted
What is PSA?
Kallikrein serine protease - liquifies semen
Produced by glands of prostate - may leak into serum
Levels increase with age
What is the normal level of PSA?
0-4ug/ml
What are age specific ranges for PSA?
> 50 years - 2.5 upper limit
50-60 years - 3.5 upper limit
60-70 years - 4.5 upper limit
70 years - 6.5 upper limit
What causes a transient rise in PSA levels?
UTI, chronic prostatitis, instrumentation (catheterisation), physiological (ejaculation) and recent urological procedure
What causes a persistent rise in PSA levels?
BPH and prostate cancer
How can transient vs persistent rise in PSA be differentiated?
Recheck PSA at least in 3 weeks
Half life of PSA is 2.2 days
Describe the probability of cancer based on PSA
0-1 - 5%
1-2.5 - 15%
2.5-4 - 25%
4-10 - 40%
>10 - 70%
What is a summary of diagnostic work-up?
Serum PSA estimation
Digital rectal exam
Pre-biopsy prostate mpMRI
Biopsy - TRUS guided or MRI fusion targeted
Additional staging
What is the screening for prostate cancer?
Do not need national screening programme but have Ad-hoc PSA testing
What is grading an assessment of?
Aggressiveness, based on histological differentiation - biopsy samples are needed
What is staging an assessment of?
Spread, based on clinical (PSA and DRE) and radiological assessment
What is grading for prostate cancer based on?
Gleason sum score
What can staging for prostate cancer be classified into?
Clinical staging system
TNM staging
Describe Gleason grading for prostate cancer
Pathologist classifies grade of prostate cancer
Score 3-5 well to poor differentiated
Summated to give SUM score
Most common + second most common
What is the prognostic value of Gleason score?
6 - 4-30% risk of death
7 - 42-70%
8-10 - 60-87%
How is localised prostate cancer staged?
Digital rectal examination
PSA
MRI
CT
Bone scan - distant staging
What does T1 and T2c mean in staging by DRE?
T1 - impalpable disease
T2c - both lobes
What are the 4 clinical stages of prostate cancer?
Localised stage
Locally advanced stage
Metastatic stage
Castrate-resistant/ Hormone refractory stage
What is included in the D’Aminco risk classification for localised disease stage?
PSA
Gleason sum score
Clinical T stage
10 year risk of biochemical recurrence
What is the treatment for low risk localised prostate cancer?
Active surveillance
Surgery - lap, robotic or open
EBRT
Brachytherapy
What is the treatment for intermediate and high risk localised prostate cancer?
Surgery for intermediate
Then EBRT and brachytherapy
HT - hormone therapy
What is the treatment for locally advanced prostate cancer?
Watchful waiting
Hormone therapy followed by surgery or radiation
Hormone therapy alone
Intermitted HT
What are the types of hormonal therapy for prostate cancer?
Surgical castration
Chemical castration
Anti-androgens
Oestrogens
Explain chemical castration in treatment for prostate cancer
LHRH analogues eventually downregulates androgen receptors by negative feedback
Tumour flare in first week so need anti-androgens
LHRH antagonists do not cause flare
Explain anti-androgens in treatment for prostate cancer
Inhibits androgen receptors
Not effective on its own - used with LHRH analogue
Explain oestrogen in treatment for prostate cancer
Inhibits LHRH and testosterone secretion, inactivates androgens and has cytotoxic effects on prostate epithelial cells
What is the complications with hormone therapy for prostate cancer?
Bone - pain, fractures, anaemia and spinal cord compression
Rectal - constipation and bowel obstruction
Ureteric - obstruction
Pelvic lymphatic obstruction
Lower urinary tract dysfunction
What is standard treatment for metastatic prostate cancer?
Immediate hormonal therapy
Plus docetaxel in fit patients
Abiraterone and Enzalutamide combined as alternate with HT and steroids
Describe the hormone refractory phase
Reached in 18-24 months of HT
Management continues with HT and Docetaxel, Abiraterone or Enzalutamide
Alternative is chemo
What is the presentation of testicular cancer?
Usually - painless lump
Less often - tender inflamed swelling, history of trauma, para-aortic lymph nodes, bone and chest
What are the risk factors of testicular cancer?
Undescended testis, infertility, atrophic testis, genetic abnormalities, chromosomal abnormalities, race (Caucasian) and previous cancer in contralateral testis
What is a precursor lesion of of testicular cancer?
Testicular germ cell neoplasia in-situ (TGCNIS)
When is peak incidence of testicular cancer?
In 3rd decade
How is testicular cancer diagnosed?
Lump in testis - can be infection, epidydimal cyst and missed testicular torsion
MSSU
Testicular US
Tumour markers
What are the types of tumour markers in testicular cancer?
AFP - teratoma
BHCG - seminoma
LDH - non specific biomarker of tumour burden
Up to 70& of patients have abnormal tumour markers
For testicular cancer, the main lymphatic spread to regional lymph nodes occurs in which group of lymph nodes?
Para-aortic lymph nodes
What is used for treatment in testicular cancer?
Radical orchidectomy using inguinal incision centred over inguinal canal
Is biopsy done in testicular cancer?
Biopsy not performed as risk to tumour seedling along biopsy track
May need biopsy of normal contralateral testis if high risk germ cell neoplasia in situ
What are the types of germ cell tumour?
Seminomatous GCT - mainly 30-40 yrs old
Non-seminomatous GCT - mainly 20-30 yrs old and often mixed
What are the types of non-germ cell tumour?
(sex cord/ stromal cells)
Leydig
Sertoli
Lymphoma - rare
How is testicular cancer graded?
Based on histological assessment of differentiation
Low grade - well differentiated
High grade - poorly differentiated
How is testicular cancer staged?
Local staging
Nodal staging - CT scan of para-aortic lymph nodes
Distant staging - CT scan
Tumour markers
TNM staging
What are the stages of testicular cancer?
Stage 1 - confined to testis
Stage 2 - infra-diaphragmatic para-aortic lymph nodes involved
Stage 3 - supra-diaphragmatic para-aortic lymph nodes
Stage 4 - extra-lymphatic disease (lungs, liver and bone)
What does further treatment after orchidectomy depend on?
Tumour type, TNM staging and grade
What is the treatment for low stage and negative markers in testicular cancer?
Orchidectomy followed by surveillance or adjuvant RT or prophylactic chemo
What is the treatment for nodal disease, persistent tumour markers or relapse in testicular cancer?
Combination chemo or lymph node dissection
What is the treatment for metastases in testicular cancer?
First line chemo
Second line chemo
Describe the prognosis of testicular cancer
Overall UK 10 year survival is 98%
