Prostate cancer Flashcards
Aetiology
Unknown
High fat diet
Genetic
African descent
Epidemiology
Most prevalent cancer in men
50% risk of PCa at age 50
3% lifetime risk of cancer death
Diagnosis most commonly 70s
Pathology- type
Adenocarcinoma in >95% of cases
Anatomical location
60-70% in peripheral zone
10-20% in transition zone
Recommendations for PSA screening
Currently not recommended as screening
Potential for over-diagnosis/over treatment
Clinical features
DRE->nodularity, enlarged \+PSA Nocturia Urinary frequency Urinary hesitancy Dysuria Hematuria Wt loss Lethargy Bone pain Palpable LN
Obstructive symptoms usually late->due to development in periphery first then moving to the centre
Method of spread
Local invasion
Lymphatic to regional nodes->obturator, iliac, presacral, para-aortic
Hematogenous dissemination early
History
Storage, voiding symptoms
Hematuria, dysuria
Wt loss/anorexia, bone pain
Family history
DRE findings
Hard, nodular, irregular
Feels like a knuckle
When palpable->60-70% have spread beyond the prostate
When to TRUS
Prostate-Specific Antigen (PSA), Digital Rectal Examination (DRE), and
Transrectal Ultrasonography (TRUS)
• If PSA level >10 ng/mL, TRUS with biopsy is indicated, regardless of DRE findings.
• If DRE is abnormal, TRUS with biopsy is indicated, regardless of PSA level.
• If PSA is
Investigations
Initial
PSA
Testosterone-N->baseline for when androgen deprivation therapy considered
LFTs-N->baseline, risk of hepatitis when androgen deprivation therapy
FBC->N unless mets
Renal function
Prostate biopsy w/ TRUS
Tests to consider: Bone scan Plain xrays pelvic CT pelvic MRI
PSA increased in other conditions
- Prostatic massage (but DRE does not change PSA levels)
- Needle biopsy
- Cystoscopy
- BPH
- Prostatitis
- Advanced age
How to refine the PSA
Age-adjusted PSA
PSA velocity
Quantifying bound and free forms
Staging
Low-grade tumour: Gleason score ≤6
Intermediate-grade tumour: Gleason score 7
High-grade tumour: Gleason score 8 to 10
Random statistics about TURP for BPH and cancer
Ca in sample of BPH, location and solid nodules being malignant
10-15% TURP for BPH haveCa 25% Ca in same sample as BPH 70% in peripheral zone 50% solid nodules on DRE are malignant
Relationship of free:total PSA and maignancy
+in cancer and post-ejaculation
TRUS purpose and risks/complications
To define anatomy and localise
Risk of septicemia even when given prophylactic antibiotics
Short term->hematospremia, blood on feces, difficulty voiding
Management options
Localised->prostatectomy, expectant Locally invasive->radiation therapy + androgen deprivation Metastatic-> Low risk disease, low LE Watchful waiting/expectant
When >20 year survival/Intermediate disease Expectant Brachytherapy EBR Radical prostatectomy +/- LN dissection
High risk:
Radical prostatectomy
Metastatic:
1st line: androgen deprivation therapy ± docetaxel
plus: denosumab or bisphosphonate or toremifene
adjunct: systemic radiotherapy
adjunct: external beam radiotherapy
2nd line: hormonal therapy or chemotherapy
adjunct: denosumab or bisphosphonate or toremifene
3rd line: sipuleucel-T
adjunct: denosumab or bisphosphonate or toremifene
Androgen deprivation therapy
non-steroidal anti-androgen plus luteinising hormone-releasing hormone [LHRH] agonist or antagonist
Bicalutamide or flutamide \+ Leuprorelin or goserelin or degarelix \+ Toremifene
Expectant management
Acute surveillance
PSA checked at least 6 monthly
DRE every 12 months
Why is bisphosphonate recommended, denosumab, toremifene
Prevent skeletal related events in patients with metastases
Bisphosphonate->improves overall survival
Denosumab->human monoclonal antibody inhibits RANKL
Toremifine->SERM-> improved BMD, bone turnover, serum lipid
Complications of radiotherapy
Impotence
Rectal proctitis
Incontinence
Dysuria
Frequency, urgency
Diarrhea
Rectal bleeding
Long term->rectal bleed, ED, gynaecomastic, hot flushes
Recommendations for followup
PSA should be checked every 6 months for 3 to 5 years and annually thereafter and a digital rectal examination (DRE) should be performed annually looking for signs of local or distant recurrence.
Staging
• Stage A—nonpalpable, confined to prostate • Stage B—palpable nodule, but confined to prostate • Stage C—extends beyond capsule without metastasis • Stage D—metastatic disease
