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
Low risk
Moderate risk
High risk
(PSA, Gleason score, Stage)
Low:
PSA 20
Gleason 8-10
Stage pT3/4
When is watchful waiting an option
Short life expectancy
When is active surveillance an option
and what does it involve
Low grade, good F/U, still considering more curative treatment if disease progresses
When is bracytherapy an option
Low volume, low PSA
ERBT an option
Locally advance, older patients
Radical prostatectomy an option
Young, high risk disease
Prognostic factors
Tumor stage
Tumor grade
PSA value
PSA velocity
