Prostate cancer Flashcards
Pathophys prostate cancer
- Growth of prostate influenced by androgens
- Majority are adenocarcinoma - exact cause unknown
- Most arise from peripheral zone
- Often multifocal
Two types of prostate adenocarcinomas
- Acinar - originates from glandular cells that line prostate gland, most common
- Ductal - originates from cells that line the ducts of prostate gland, grows and metastasise further than acinar adenocarcinomas
Main RF for prostate cancer
- Age
- Ethnicity - Black African or Caribbean
- FH of prostate cancer
- Genetics - BRCA1 or 2 mutation
Other less significant modifiable RF for prostate cancer
- Obesity
- Diabetes
- Smoking - increased risk of prostate cancer death
- Degree of exercise
Symptoms of prostate cancer
Localised: LUTS
* Weak stream
* Frequency
* Urgency
Advanced localised:
* Haematuria
* Dysuria
* Incontinence
* Haematospermia
* Suprapubic pain
* Loin pain
* Rectal tenesmus
Metastatic:
* Bone pain
* Lethargy
* Anorexia
* Unexplained weight loss
DRE for prostate cancer
- Essential as most arise from posterior peripheral zone
- Assymetry?
- Nodularity?
- Fixed, irregular mass?
What is PSA?
- Prostate specific antigen
- Serum protein produced by malignant and healthy cells of prostate gland
- Can be elevated secondary to cancer
Other conditions, other than malignancy, that can elevate PSA
- BPH
- Prostatitis
- UTI
- Recent urological surgery
- Urinary retention
- DRE - can raise but thought to be <0.3ng/mL so should not affect interpretation
What further calculations can be done using PSA?
- Free:total PSA ratio - used to increase accuracy of PSA 4-10
- Low free:total ratio is associated with increased chance of diagnosing prostate cancer
- PSA density - serum PSA level divided by prostate volume identified on imaging
Prostate cancer screening?
- No national screening program
- Research needed into determining benefit of widespread screening, overdiagnosis and overtreatment
- If offered PSA screening test, need counselling prior to test
First line imaging for suspected prostate cancer (re PSA or DRE findings)
- Multi-parametric MRI scan of prostate
- Identifies abnormal areas which can be targeted for biopsy
Multiparametric - several different MRI techniques combined
Two biopsy options for prostate
- Transperineal - most common, less risk of infection
- Transrectal US guided biopsy (TRUS)
Transperineal biopsy
- Via template biopsy using grid like template, sampling in systematic manner
- OR free hand biopsy where sampling guided by intraprocedure US and mpMRI
TRUS biopsy
- Sample of prostate transrectally
- Using USS as guidance then sampling in systematic manner
What to do if previous negative biopsy but persistent raised PSA or suspicious DRE?
Repeat biopsy
Histological grading of prostate cancer
- Gleason grading
- Based on histological appearance
- Assigned to score according to differentiation
- Gleason score is then most common growth pattern + 2nd most common growth pattern
Lowest gleason score
- 3+3
- Higher scores = poorer prognosis
Determining prognosis of prostate cancer
- Gleason score
- TNM
- PSA levels
Gleason scoring
Imaging for staging prostate cancer
- Done in intermediate or high risk disease
- CT chest abdomen pelvis AND PET-CT nuclear medicine scan
Management of localised prostate cancer
- Relates to risk stratification based on PSA levels, Gleason score and T staging (from TNM)
- Low, intermediate and high
Risk stratification NICE localised prostate cancer values
Management of low risk localised prostate cancer
- Active surveillance
- Radical treatments offered to those who show disease progression
Management of intermediate and high risk disease
- Radical treatments discussed with all men with intermediate risk and high risk with realistic disease control
- Intermediate can also be offered active surveillance
Management of metastatic disease
- Chemotherapy
- Antihormonal agents
Management castrate resistant disease
- Further chemotherapy agents eg Docetaxel
- Corticosteroids 3rd line (after androgen deprivation and anti-androgen therapy with hormone relapsed cancer)
What does active surveillance of prostate cancer entail?
- 3 monthly PSA
- 6 month DRE
- Re-biopsy at 1-3 yearly intervals assessing for progression
- mpMRI also increasingly being used
- Intervening at appropriate time
What is ‘watchful waiting’?
- Symptom guided approach
- Therapy is deferred and initiated at a time of symptomatic disease, intent is NOT curative
- Offered for older patients with lower life expectancy usually, can be offered at any stage, no predefine f/u, management guided by patient goals
Main surgical management prostate cancer
- Radical prostatectomy - open, laparascopic or robotically
- Removal of prostate gland, resection of seminal vesicles along with surrounding tissue +/- dissection of pelvic lymph nodes
Side effects of radical prostatectomy
- Erectile dysfunction
- Stress incontinence
- Bladder neck stenosis
Alternative curative therapies for localised prostate cancer
- Radiotherapy - external beam and brachytherapy
What does brachytherapy involve?
Transperineal implantation of radioactive seeds directly into prostate gland
What is external beam radiotherapy?
- Focused radiotherapy targetted to the prostate gland
- Limiting damage to surrounding tissues
Anti-androgen therapy for prostate cancer - how does it help?
Prostate cancer cells undergo apoptosis when deprived of testosterone
Options for anti-androgen therapy
- Anti-androgens - Bicalutamide
- Gonadotrophin releasing hormone receptor (GnRH) agonists - Goserelin
- GnRH antagonists - Degarelix
- Surgical castration
- Newer hormone therapies - Enzalutamide, Abiraterone
Chemotherapy used in metastatic prostate cancer
Docetaxel or Cabazitaxel
