Prostate cancer

Question 1

Aetiology

Answer 1

Unknown
High fat diet
Genetic
African descent

Question 2

Epidemiology

Answer 2

Most prevalent cancer in men
50% risk of PCa at age 50
3% lifetime risk of cancer death
Diagnosis most commonly 70s

Question 3

Pathology- type

Answer 3

Adenocarcinoma in >95% of cases

Question 4

Anatomical location

Answer 4

60-70% in peripheral zone

10-20% in transition zone

Question 5

Recommendations for PSA screening

Answer 5

Currently not recommended as screening

Potential for over-diagnosis/over treatment

Question 6

Clinical features

Answer 6

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

Question 7

Method of spread

Answer 7

Local invasion
Lymphatic to regional nodes->obturator, iliac, presacral, para-aortic
Hematogenous dissemination early

Question 8

History

Answer 8

Storage, voiding symptoms
Hematuria, dysuria
Wt loss/anorexia, bone pain
Family history

Question 9

DRE findings

Answer 9

Hard, nodular, irregular
Feels like a knuckle
When palpable->60-70% have spread beyond the prostate

Question 10

When to TRUS

Answer 10

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

Question 11

Investigations

Answer 11

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

Question 12

PSA increased in other conditions

Answer 12

• Prostatic massage (but DRE does not change PSA levels)
• Needle biopsy
• Cystoscopy
• BPH
• Prostatitis
• Advanced age

Question 13

How to refine the PSA

Answer 13

Age-adjusted PSA
PSA velocity
Quantifying bound and free forms

Question 14

Staging

Answer 14

Low-grade tumour: Gleason score ≤6
Intermediate-grade tumour: Gleason score 7
High-grade tumour: Gleason score 8 to 10

Question 15

Random statistics about TURP for BPH and cancer

Ca in sample of BPH, location and solid nodules being malignant

Answer 15

10-15% TURP for BPH haveCa
25% Ca in same sample as BPH
70% in peripheral zone
50% solid nodules on DRE
are malignant

Question 16

Relationship of free:total PSA and maignancy

Answer 16

+in cancer and post-ejaculation

Question 17

TRUS purpose and risks/complications

Answer 17

To define anatomy and localise

Risk of septicemia even when given prophylactic antibiotics
Short term->hematospremia, blood on feces, difficulty voiding

Question 18

Management options

Answer 18

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

Question 19

Androgen deprivation therapy

Answer 19

non-steroidal anti-androgen plus luteinising hormone-releasing hormone [LHRH] agonist or antagonist

Bicalutamide or flutamide
\+
Leuprorelin or goserelin or degarelix
\+
Toremifene

Question 20

Expectant management

Answer 20

Acute surveillance
PSA checked at least 6 monthly
DRE every 12 months

Question 21

Why is bisphosphonate recommended, denosumab, toremifene

Answer 21

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

Question 22

Complications of radiotherapy

Answer 22

Impotence
Rectal proctitis
Incontinence

Dysuria
Frequency, urgency

Diarrhea
Rectal bleeding

Long term->rectal bleed, ED, gynaecomastic, hot flushes

Question 23

Recommendations for followup

Answer 23

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.

Question 24

Staging

Answer 24

• 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

Question 25

Low risk
Moderate risk
High risk
(PSA, Gleason score, Stage)

Answer 25

Low:
PSA 20
Gleason 8-10
Stage pT3/4

Question 26

When is watchful waiting an option

Answer 26

Short life expectancy

Question 27

When is active surveillance an option

and what does it involve

Answer 27

Low grade, good F/U, still considering more curative treatment if disease progresses

Question 28

When is bracytherapy an option

Answer 28

Low volume, low PSA

Question 29

ERBT an option

Answer 29

Locally advance, older patients

Question 30

Radical prostatectomy an option

Answer 30

Young, high risk disease

Question 31

Prognostic factors

Answer 31

Tumor stage
Tumor grade
PSA value
PSA velocity