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Oncology > Prostate Cancer > Flashcards

Prostate Cancer Flashcards

1
Q

What is the most common cancer in men?

A

Prostate cancer

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2
Q

Where does the prostate lie?

A

At base of bladder

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3
Q

What is the function of the prostate?

A

Produce prostatic fluid which mixes which sperm

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4
Q

What are the three zones of the prostate?

A

Central zone
Transitional zone - lies next to urethra
Peripheral zone - lies posterior

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5
Q

In which zone does BPH develop?

A

Central

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6
Q

Which zone is most commonly affected by prostate cancer?

A

Peripheral

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7
Q

Why is DRE important in detecting prostate cancer?

A

Can tell:

  1. if it is enlarged
  2. if it has nodules, is firm or asymmetric
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8
Q

What is the clinical T staging for prostate cancer?

A

T1: tumour on biopsy, DRE normal
T2: tumour palpable on DRE, not has not spread outside prostate
T2a: tumour if half or less of one lobe
T2b: tumour is more than half of 1 lobe, but not both
T2c: tumour is both lobes but within prostatic capsule
T3: tumour spread beyond prostatic capsule
T3a: tumour has spread through capsule on one or both sides
T3b: tumour has invaded 1 or both seminal vesicles
T4: tumour has invaded other nearby structures

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9
Q

What produces PSA?

A

Normal and cancerous prostate cells

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10
Q

What is the role of PSA?

A

Helps to liquefy seminal fluid to allow sperm to move from freely
Also dissolves cervical mucus

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11
Q

How can you measure PSA levels?

A

Serum levels

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12
Q

What must you remember about PSA levels?

A

Normal levels of PSA raise with age

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13
Q

What things may cause an increased serum PSA?

A 
BPH
Prostate cancer
Prostatitis
UTI
Biopsy
Catheterisation
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14
Q

What things may cause a decreased PSA?

A

Ejaculation
Prostatectomy
Hormonal therapy

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15
Q

How sensitive is PSA for prostate cancer?

A

Not very - hence the PSA threshold for investigation is quite low

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16
Q

How is the definitive diagnosis of prostate cancer made?

A

Biopsy

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17
Q

How is prostate biopsy performed?

A

Transrectally (under US guidance)

Occasionally trans-perineally if it is an anterior tumour

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18
Q

What grading system is used to grade prostate cancer?

A

Gleason (1-5)

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19
Q

What are gleason grades 1 + 2?

A

Very well differentiated and form glands similar to normal prostate tissue
Rarely tumours

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20
Q

What are gleason grades 3 + 4?

A

Cancer appears progressively less well differentiated

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21
Q

What is gleason grade 5?

A

Least differentiated

Sheets of malignant looking cells that do not form glands at all

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22
Q

Usually a mixture of gleason grades are seen on biopsy, so how does the pathologist decide what the gleason grade is?

A

Primary grade = most prevalent pattern
Secondary grade = second most prevalent pattern

Sum primary and secondary grades to get gleason score

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23
Q

What do the gleason scores represent?

A

Gleason <6 is not cancer
Gleason 6 = well, differentiated, non-aggressive tumour
Gleason 7 = moderately differentiated disease, moderately aggressive
Gleason 8, 9, 10 = highly aggressive tumour that is poorly differentiated

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24
Q

How does non-metastatic prostate cancer tend to present?

A

Lower urinary tract symptoms (LUTS)

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25
Q

What are the two types of LUTS?

A

Storage symptoms

Voiding symptoms

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26
Q

What are storage symptoms?

A 
Urinary frequency
Nocturia
Urgency
Urinary stress
Urge incontinence
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27
Q

What are voiding symptoms?

A 
Poor urinary flow
Hesistancy
Straining 
Intermittency 
Incomplete emptying
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28
Q

What investigations should men with LUTs have?

A

Urinalysis
Abdominal Ex
DRE

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29
Q

When should PSA be measured?

A

LUTS + abnormal prostate on DRE or patient concerned about prostate cancer

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30
Q

Name a good subjective and objective measure of a man’s urinary symptoms

A

Subjective: international prostate symptom score

Objective: uroflowmetry

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31
Q

How does uroflowmetry work?

A

Urination into flowmeter which measures the cumulative weight of urine with time –> ml/s rate

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32
Q

What is a generally acceptable uroflowmetry score?

A

> 15ml/sec

33
Q

What is a generally unacceptable uroflowmetry score?

A

<10ml/sec

This suggests significant outflow obstruction

34
Q

How might metastatic prostate cancer present?

A

Bone pain, pathological fracture
Spinal cord compression
Marrow failure (anaemia, bleeding, infections)
Constitutional symptoms of metastatic disease (e.g. anorexia, wt loss, fatigue, malaise)

35
Q

Why do we not screen for prostate cancer?

A

It doesn’t decrease deaths from prostate cancer
Overdiagnosis of prostate cancers that were unlikely to affect the men
Most men with prostate cancer will die of something else before they die of prostate cancer

36
Q

How can prostate cancer spread?

A

Direct invasion into prostatic capsule/seminal vesicles

Lymphatic spread to pelvis and para-aortic lymph nodes

Haematogenous spread to bones

37
Q

What staging investigations are commonly used in prostate cancer?

A

MRI pelvis
Bone scan
CT chest and abdo sometimes

38
Q

What things can be used to risk assess patients with prostate cancer?

A

T stage
Gleason score
PSA

39
Q

What things would put someone in a high risk group for prostate cancer?

A 
PSA >20
or
Gleason score 8-10
or
Clinical T stage T3A/B or T4
40
Q

What things would put someone in an intermediate risk group for prostate cancer?

A 
PSA 10-20
or
Gleason score 7
or
Clinical T stage T2B/C
41
Q

What things would put someone in an low risk group for prostate cancer?

A 
PSA <10
and
Gleason score 6
and
Clinical T stage T1 or T2A
42
Q

What investigations are required for low risk patients with prostate cancer?

A

MRI prostate as risk of nodal and bony mets so low

43
Q

What investigations are required for intermediate risk patients with prostate cancer?

A

MRI of pelvis and bone scan

44
Q

What investigations are required for high risk patients with prostate cancer?

A

MRI pelvis, CT abdo and pelvis and bone scan

45
Q

How does TNM staging work?

A

T - see as prev. flashcard

N - nodal involvement
N0 - no spread to regional lymph nodes, N1 - spread

M - mets - M0 - no mets, M1 - mets (M1a: cancer spread beyond regional nodes; M1b: cancer spread to bone, M1c: cancer spread to other sites)

46
Q

Is metastatic prostate cancer curable?

47
Q

What palliative treatments are available for prostate cancer?

A

Systemic - hormonal, chemo, biologics, bisphosphonates

Local/regional - radiotherapy/TURP for urinary symptoms

48
Q

What drives most prostate cancers?

A

Circulating androgens, e.g. testosterone

Therefore reducing circulating testosterone is v. effective

49
Q

What are the ways hormonal therapy can work?

A
  1. Reducing testicular production of testosterone (androgen deprivation therapy)
  2. Blocking testosterone effects at its receptor
  3. Reducing production of androgens from other sources
50
Q

How can ADT be achieved?

A 
Orchidectomy (surgical castration)
GnRH agonists (chemical castration)
GnRH antagonists (chemical castration)
51
Q

How can you block testosterone effect at its receptor?

A

Anti-androgens, e.g. cyproterone acetate or bicalutamide

52
Q

How can you reduce the production of testosterone from other sources?

A

Adrenal production of androgens can be downregulated with prednisolone

Autocrine production of androgens by prostate cancer cells can be reduced by steroid synthesis inhibitors

53
Q

How long do prostate cancers remain hormone sensitive?

A

Usually about 18 months

54
Q

What happens after the cancer progresses despite androgen deprivation?

A

It is labelled as castrate resistant prostate cancer

Median survival is 1-2 years

55
Q

What does GnRH stimulate?

A

Anterior pituitary to produce LH and FSH

56
Q

What does LH do in men?

A

Stimulates Leydig cells to make testosterone

57
Q

What does FSH do in men?

A

Stimulates spermatogenesis

58
Q

Give examples of GnRH agonists

A

Goserelin and triptorelin

59
Q

How do GnRH agonists work?

A

Cause initial spike in LH before tonic stimulation at anterior pituitary leads to downregulation of LH

60
Q

How do you prevent the LH spike at the initiation of GnRH agonist treatment being an issue?

A

Give anti-androgens for the first 2 weeks of treatment as flare can lead to rapid prostate cancer growth

61
Q

How do GnRH antagonists work?

A

Cause rapid reduction in LH

62
Q

Give an example of a GnRH agonist

63
Q

What are the treatment options for men with localised prostate cancer?

A

Radical - prostectomy, radical radiotherapy, brachytherapy

Monitoring options - watchful waiting, active surveillance

Cryotherapy, HIFU

Palliative hormonal therapy, TURP or radiotherapy

64
Q

What is active surveillance?

A

Monitoring with a view to radical therapy if the cancer progresses

65
Q

What is watchful waiting?

A

Monitoring with a view to palliative therapy if the cancer becomes symptomatic

66
Q

What is radical prostectomy?

A

Removal of the whole prostate gland, usually with seminal vesicles and pelvic lymph node dissection

67
Q

What is TURP?

A

Not curative for prostate cancer

Involves coring out centre of prostate gland in order to improve urinary flow

68
Q

How can radical prostectomy be performed?

A

Retropubically, perineal, laparoscopically

69
Q

What additional treatments do patients receiving radical radiotherapy for prostate require in the three risk groups?

A

Low - none
Intermediate - 6m hormonal therapy prior
High - 24-39 hormonal therapy

70
Q

What is a major CI for brachytherapy?

A

Obstructive symptoms as brachytherapy causes significant swelling of the prostate gland

Others:
IPSS >10
Qmax <10
Prior TURP
Prostate volume >50ml
71
Q

Who should be considered for active surveillance?

A

Those with low risk prostate cancer that is unlikely to act aggressively

72
Q

What may be involved in active surveillance?

A

3 monthly visit for DRE and PSA

Repeat biopsies after 1 year, 4 years and 7 years

73
Q

What may be indications for coming off of active surveillance?

A

Patient preference to get radical therapy
Steadily rising PSA
Increase in gleason score 7 or more

74
Q

Who is watchful waiting for?

A

Patients with localised disease where radical treatment would be inappropriate and who wish to delay palliative treatment until symptoms develop

75
Q

What does watchful waiting involve?

A

No active monitoring but if they develop symptoms they must inform their GP

76
Q

What are the pros and cons of radical prostectomy?

A

Cons - Risk of erectile dysfunction, urinary incontinence
Major surgery

Pros - improves obstructive symptoms

77
Q

What are the pros and cons of radical radiotherapy?

A

Cons - risk of rectal damage, unlikely to resolve LUTS, risk of erectile dysfunction

Pros - no major surgery, low risk of urinary incontinence

78
Q

What are the pros and cons of radical brachytherapy?

A

Cons - may worsen LUTS for 2-3m, radioactive seeds in prostate (protect contacts)

Pros - single treatment, less invasive, reduced risk of erectile dysfunction

Oncology (5 decks)

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