Prostate Cancer

Question 1

What type of cancer is prostate cancer usually?

Answer 1

Adenocarcinoma

Question 2

What is the lifetime risk of prostate Ca?

Answer 2

1/6

Question 3

What are the risk factors of prostate Ca?

Answer 3

• Age > 50 yrs
• Blacks
• FHx of prostate Ca

Question 4

What are the symptoms of prostate Ca in early Dx?

Answer 4

Symptoms are normally insidious and rarely cause symptoms until it is advanced (hence controversy for screening)

Question 5

What are the symptoms of progressed prostate Ca?

Answer 5

• Haematuria (invasion of the bladder superiorly or urethra)
• Obstructive symptoms
• If metastases: bone pain, pathological fractures, spinal cord compression may result from osteoblastic metastases to bone

Question 6

What are the obstructive LUTS?

Answer 6

WISED:
- Weak stream
- Intermittent flow
- Straining and hesitancy
- Emptying incomplete
\+ Dribbling

Question 7

What are the common sites of metastases for prostate Ca?

Answer 7

pelvis, ribs and vertebral bodies

Question 8

List the Ix that can be performed in prostate Ca for screening, Dx, grading and staging.

Answer 8

Screening by digital rectal examination and prostate-specific antigen

Assessment of abnormalities by US guided transrectal needle biopsy (up to 20 core biopsies)

Grading by histology

Staging by CT and bone scanning

Question 9

Findings on DRE?

Answer 9

Stony hard indurations or nodules may be found. But often it can appear normal

Question 10

What is the significance of PSA results?

Answer 10

Any result that is >4ng/mL is indicated for biopsy.

A lower threshold of >3ng/mL is indicated for biopsy in younger males

Question 11

How do we grade prostate Ca? Explain the score that is used.

Answer 11

Prostate Ca is graded by its histological heterogeneity.
When a sample is obtained through US guided transrectal needle biospy.
The most prevalent pattern and the next most prevalent pattern are each assigned a grade of 1 to 5, and the two grades are added to produce a total score. Most experts consider a score ≤ 6 to be well differentiated, 7 moderately differentiated, and 8 to 10 poorly differentiated. The lower the score, the less aggressive and invasive is the tumor and the better is the prognosis.

Question 12

How do we stage prostate Ca?

Answer 12

The TNM staging for prostate Ca can be used (assesses primary tumour, regional LN mets and distant mets)

• CT is most commonly used
• Bone scan can assess metastases to bone
• MRI has an emerging role

Question 13

What are the main DDx for prostate Ca?

Answer 13

1. BPH
2. Chronic prostatitis
   can rule out both with biopsy

Question 14

What are the main DDx for elevated level of PSA?

Answer 14

1. Prostate Ca
2. Prostatitis
3. BPH
4. Instrumentation
5. STI

Question 15

What is prostate Ca treatment guided by and what are its main goals?

Answer 15

Treatment is guided by PSA level, grade and stage of tumor, patient age, coexisting disorders, and life expectancy. The goal of therapy can be

• Active surveillance
• Local (aimed at cure)
• Systemic (aimed at decreasing or limiting tumor extent)

Question 16

General Rx for:

• Very low risk
• Localised
• Outside prostate Ca

Answer 16

For localized cancer within the prostate, surgery or radiation therapy

For cancer outside of the prostate, palliation with hormonal therapy, radiation therapy, or chemotherapy

For some men who have low-risk cancers, active surveillance without treatment

Question 17

Rx for localised prostate Ca

Answer 17

Active monitoring: periodic PSA testing, biopsy, DRE

(This is the only thing required for Gleason score

Question 18

Systemic Rx options for prostate Ca outside of prostate (local spread)

Answer 18

In this scenario, curative options are not available.
Castration is opted for with either:
a. Androgen deprivation treatment: LHRH receptor agonists (Goserelin) that leads to the downregulation of the receptor NB: this type of treatment causes a burst of testosterone initially

b. Bilateral orchiectomy

AFx: decrease libido, increase weight

Question 19

Rx for bone metastases

Answer 19

To help treat and prevent complications from bone mets:

• use an osteoclast inhibitor: donosumab
• radiotherapy to specific bone mets