Prostate Cancer Flashcards
Epidemiology
- second greatest cause of male cancer mortality
- highest rates are in Scandinavia, lowest in Asia
- higher incidence in African American men
Etiology
- increasing age
- diets high in fat
- race
- family history
- geographic location
Natural history of prostate ca
- found in peripheral zone of gland
- multifocal disease
- tend to extend into and through capsule of the gland, invade bladder neck, peri prostatic tissues and seminal vesicles
- have late local spread to the rectum and bladder
- slow growing
Screening process
- age 50-70 years annually (asymptomatic)
- DRE + PSA blood test
- only 25-50% with abnormal DRE have prostate ca on biopsy
Why is PSA screening currently debated?
does not reduce mortality from disease which is the whole rationale for screening programs!
Clinical presentation
-typically asymptomatic at presentation
Local disease: urinary hesitancy, nocturne, decreased stream, increased frequency, urinary obstruction, renal failure
Metastatic disease: bone pain, bone marrow failure, lymphedema
What are normal PSA levels by age
40-49: 0-2.5
50-59: 0-3.5
60-69: 0-4.5
70+: 0-6.5
Diagnosis
- Patient hx and physical exam
- DRE (can only detect posterior tutors through rectal wall)
- PSA test (>4/ng/mL requires referral to urology)
- TRUS (transracial ultrasound)
- Confirm malignancy via biopsy
- CBC, urinalysis, renal function test, calcium
- CT/MR pelvis (LN involvement)
- Bone scan is metastatic disease suspected
What percentage of lesions on the prostate are benign?
50%
What is a six quadrant TRUS guided bx?
Biopsy that takes samples from four zones of the prostate: base, apex, two sides and mid-gland
Has the highest diagnostic accuracy
What is done in the place of pelvic LN biopsies?
-LN dissection during radical prostatectomy is nodal involvement suspected (not routine for low risk pts)
Pathology of prostate ca?
-95% are adenocarcinomas and are located peripherally
What is BPH?
- Benign prostate hyperplasia
- enlargement of prostate due to overgrowth of cells
- not cancerous
- found in transition zone, surrounding urethra
- does NOT increase risk of having prostate ca
- typically asymptomatic
BPH tx
Alpha blockers to relax muscles near the prostate and lifestyle changes (examples: dec night time fluid intake, inc pelvic floor exercise)
Routes of spread of prostate ca?
- bone (90%)
- lung (46%)
- liver (25%)
Gleason system
-higher score=worse prognosis
G1: low grade, well differentiated (2-6)
G2: intermediate, moderately differentiated (7)
G3: high, poorly differentiated (8-10)
Grade groups
- group Gleason scores
- group 1 is most likely to spread slowly
- group 5 is most likely to grow and spread quickly
Staging
Localized=disease confined to prostate (Stages 1 and 2)
Locally advanced=spread through prostate capsule to surrounding tissue (Stages 3 and 4)
Metastatic disease=spread to other parts of the body
Risk levels
- Guide tx options and prognosis
- higher risk pts will be offered more aggressive tx than lower risk pts
Tx options-low risk patients
- active surveillance
- surgery (radical prostatectomy; T1 or T2)
- EBRT or brachy
RT doses for low risk patients
Proton: 76-82 Gy
EBRT: >10 MV, 4 field, IMRT, VMAT, fields include seminal vesicles and prostate gland (regional LN if advanced); 60Gy/ 20 fr or 78Gy/ 39
Brachy: Iridium 192, 45.5 Gy/7 fr/ 3.5 days
Organs at risk and their TD 5/5s
- bladder (65 Gy)
- rectum (60 Gy)
- small bowel (40 Gy)
- femoral heads (52 Gy)
Acute RT side effects
- erythema
- fatigue
- bladder irritation
- radiation proctitis-diarrhea, bleeding, rectal urgency
- erectile dysfunction
Chronic RT side effects
- impotency
- cystitis, hematuria, incontinence
- proctitis
- rectal ulcers/fistulas
- lymphedema
