Prostate and UT Cancers Flashcards
What are the 3 Zones of the Prostate Gland?
Transitional
Central
Peripheral
Why are the prostate gland zones important?
The Prostate Gland Zones are important as they have implications of the disease pathway and different propensities to disease
The reason being that each zone is derived from different embryological layers i.e. Transitional Zone is derived from Mesoderm and Peripheral Zone is derived from the Endoderm.
What disease pathways affect which zones of the prostate gland?
The transitional zone tends to be more prone to benign prostate enlargement/hyperplasia (BPE/BPH) which causes an inability to pee (retention).
The peripheral zone tends to be more prone to cancers
Can prostate hyperplasia be normal?
Yes.
As the male increases in age, the prostate gland tends to increase in size due to the influence of the androgen hormones, which affect predominantly the transitional and central zones of the prostate.
What is the issue with BPH?
Affected zones border the urethra and so, can obstruct urinary flow, causing the LUT symptoms associated with it.
Generally, the Central Zone is more affected and obstructions can be fixed via Trans-Urethral Resection.
What are symptoms of prostate cancer?
THE MAJORITY OF PATIENTS ARE ASYMPTOMATIC ON PRESENTATION.
LUT Symptoms (if the Transitional Zone affected)
Haematuria/Haematospermia
Bone pain (consider mets)
Anorexia
Weight loss
On DRE; a hard, firm prostate with an asymmetry, singular nodules, fixed craggy mass which indicates abnormality (one possibility is abnormal prostate due to tumour growth in cancer)
What are investigations for prostate cancer?
PSA
DRE
What is important to remember with PSA?
Note that PSA is not a prostate cancer specific antigen but is prostate specific. Therefore, it highlights anything that is wrong with prostate as any prostate abnormality can cause PSA increase e.g. infection, enlargement, prostatitis, retention, catheterisation, abnormal DRE
Why is there no screening for prostate cancer in the UK?
It is extremely slow growing
What is PSA?
A protein that causes liquefication of semen
ALL PATIENTS WITH HIGH PSA WARRANT FURTHER INVESTIGATION
Generally, patients with PSA in their 1000s tend to have cancer
.
What is important to remember when it comes to measuring PSA levels?
The extremely high-grade (nasty) cancers do NOT produce PSA as the higher the grade of cancer, the more abnormal the cell is and therefore, the less likely they are to behave like normal cells.
NEVER DO A PSA SCREEN AFTER A DRE/PR EXAM AS RUBBING THE PROSTATE DURING THE EXAM CAUSES A PSA INCREASE.
Increasing PSA during/after treatment can indicate Recurrence of Cancer
When is trans-rectal biopsy for prostate cancer indicated?
Men with abnormal DRE
Previous biopsies with Prostatic Intraepithelial Neoplasia
Normal biopsy but rising PSA
How many biopsies are taken from the prostate gland and why?
10 biopsies are taken from the prostate (5 from each lobe) or sometimes, more
The majority of prostate cancers are multifocal adenocarcinomas
What grading is used for prostate cancer and how does it work?
Gleason’s Scoring
2 most abundant cell features are assessed and added together to make a combined score i.e. The Gleason’s Score.
1-5 is Microscopic
6 = Low Grade
7 = Immediate Risk
>7 = High Risk
How is staging for prostate cancer done?
TMN Staging
What is the management of organ-confined prostate cancer?
- Watchful waiting/deferred treatment
- Active surveillance/monitoring
- Radical surgery
- Radical radiotherapy for high/intermediate risk
What is management of locally advanced prostate cancer?
- Radiotherapy with neo-adjuvant hormonal (testosterone cutting) therapy
- Watchful waiting
- Hormonal therapy
What is management of metastatic prostate cancer?
- Androgen deprivation therapy
- Diethylstilboestrol/ Steroids
- Cytotoxic chemo
What are the 2 major types of urinary tract (UT) cancer?
- Non-Muscle Invasive Cancer, which requires lifelong monitoring
- Muscle Invasive Cancer, which requires the bladder to be taken out (Cystectomy)
Describe the progression of UT cancer?
The cancer starts from the transitional epithelium and moves into the submucosa.
If muscle invasive, it then moves into the muscles and finally, into the fat
What are the 3 subtypes of UT cancer (cell type)?
Transitional cell cancer (Most common)
Squamous cell
Adenocarcinoma etc. (Least common)
Which of the 3 cell type UT cancers is most associated with calcification?
TCC
How are UT cancers categorised according to morphology?
- Papillary (50% are infiltrative and a stippled appearance)
- Non-Papillary (Flat) are the Worst of the 2 types as they tend to Grow into the Bladder Wall and are ALL MALIGNANT
Describe features of TCC
Multicentric
Bilateral in up to 10% of Patients (Synchronous or Metachronous)
Up to 50% of Patients with a cancerous ureter/pelvis will develop carcinoma
Papillary Transitional Cell Carcinomas tend to be more common than their ‘Carcinoma In-Situ’ Flat counterparts.
Have Fibrovascular Cores
Why is biopsy needed in flat TCC?
Flat TCCs tend to present as a Bright Red Patch on pathology and so, a Biopsy is needed to differentiated between possible inflammation and cancer.
Biopsy is done, even in the most obvious patient histories for inflammation/infection to be able to 100% exclude the possibility of Flat TCC.
What are TCC risk factors?
Cyclophosphamide
Smoking
What is important to remember with UT cancer potential?
THE ENTIRE URINARY TRACT IS EXPOSED TO THE SAME RISK FACTORS.
Therefore, if the patient’s urine indicates cancer but the bladder is fine, the cancer must be higher up in the urinary tract.
What makes adenocarcinoma difficult to diagnose?
Adenocarcinoma can occur on a background of metaplasia and also, can be difficult to distinguish from colon cancer that has invaded through the bladder.
Radiology is often needed to distinguish the origin of the adenocarcinoma.
What particular structure can adenocarcinomas arise from?
Urechus
What are symptoms of UT Cancer?
Haematuria, which presents in 75-85% of patients
Retention of Urine
Urinary Irritative Symptoms
Loin Pain
PATIENTS >40 WITH HAEMATURIA HAVE TO BE INVESTIGATED
What are investigations for UT cancer?
Flexible Cystoscopy
CT Scan (MRI in those allergic to contrast)
USS
Halo Sign (imaging characteristic sign) is a filling defect of bladder due to the tumour being close to the wall.
What is the management of UT cancer?
If tumours are Superficial, then treatment is via Endoscopy.
Otherwise, treatment is Cystectomy with a Piece of the Bowel and Stoma used to create a New Bladder with the Ureters attached i.e. Radical Cystectomy Bladder Reconstruction
As the most common region of urinary bladder cancer metastases is the Lymph Nodes, do a Lymph Node Dissection to reduce Recurrence chances
