Prostate Cancer Flashcards
What is prostate cancer?
Adenocarcinoma of the Prostate (also transitional cell and rarely small cell or squamous cell) and most common non-cutaneous cancer in men.
How common is prostate cancer?
2nd most common cause of male cancer death. 80% have histological prostate cancer at death if 80+. Cancer totally dependant on Testosterone.
What are the risk factors for prostate cancer?
Age
Some inheritance – HPC1 and BRCA
Obesity
Ethnic origin (afro-Caribbean and African-American)
What are the signs and symptoms of prostate cancer?
Lower urinary tract symptoms although usually a sign of BPH as prostate cancer usually occurs peripherally and BPH centrally. These include: nocturia, hesitancy, poor stream, terminal dribbling or obstruction.
Bone pain, back pain and weight loss in advanced disease
Usually an incidental finding from PSA, DRE or TURP for BPH
What investigations should be done in suspected prostate cancer?
PSA
DRE – showing hard irregular craggy surface
Multiparametric MRI and bone scan for staging
TRUS (transrectal USS) biopsy – more common to do trans perineal, biopsy avoided in 80+
Bone scan using Technetium in high patient risk or those with bone pain
What can cause PSA to be raised other than prostate cancer?
PSA – seminal anticoagulant is increased with prostatic cancer but also in for other reasons so should do at least 2: • Urinary retention • Inflammation e.g. UTI, prostatitis • Instrumentation • BPH • Exercise • Ejaculation
When shouldn’t PSA be done according to NICE?
NICE advise that, as PSA levels may be increased, testing should not be done within at least:
• 6 weeks of a prostate biopsy
• 4 weeks following a proven urinary infection
• 1 week of digital rectal examination
• 48 hours of vigorous exercise
• 48 hours of ejaculation
What does a PSA >100 indicate?
If PSA is >100 you are likely to have mets
How is prostate cancer staged?
Gleason grading – 3-5 based on differentiation. Add the most common with the next most common seen on biopsy. Grade 7 has two variants – 4+3 and 3+4.
What are the TNM staging criteria for prostate cancer?
TNM T1 = clinically unapparent Tumour T2 = clinically apparent, T2a one lobe <50%, T2b one lobe >50%, T2c both lobes T3 = spreading outside the capsule T4 = invading local structures
How is low risk vs high risk decided for prostate cancer?
Gleason plus TNM plus PSA gives you a risk category
Low Risk PSA < 10, Gleason =/< 6 and =/< T2b
High risk PSA > 20, Gleason >/=8 and >/= T2c
How is prostate cancer managed?
Radical Prostatectomy – only really better than radiotherapy in younger patients and not offered to those over 73. Incontinence and impotence important risks.
Radiotherapy external beam or seeds – patient choice
Hormone treatment (this never cures the cancer) responds for limited time until the cancer develops its own testosterone supply. Can be used neo adjuvant or adjuvant. Done using GnRH agonists (goserelin/leuprorelin) with cover from an anti-androgen (bicalutamide) over the initial surge in testosterone which could otherwise lead to cord compression or metastasis.
What is the difference between active surveillance and watchful waiting/deferred hormone treatment/delayed treament?
Active Surveillance (treatable but unlikely to progress) – Monitor PSA/DRE 6 monthly aim to avoid unnecessary treatment but treat radically if needed. PSA every 6 months DRE every 12months
Watchful waiting/Deferred hormone treatment/Delayed treatment – older patients with co-morbidities. Start hormone therapy if development of mets or systemic disease.
What is benign prostatic hyperplasia?
Benign growth of prostate tissue from the inner transitional zone. Very common especially as men get older.
What are the clinical features of BPH?
Lower urinary tract symptoms – nocturia, hesitancy, post micturition dribble, terminal dribbling, incomplete emptying, straining, poor stream, frequency and urgency. Haematuria Stones Overflow incontinence Retention UTI
What investigations should be done in BPH?
DRE and PSA
MSU and Us and Es
USS
TRUS (or perineal)
What lifestyle advice can be given to manage BPH?
Lifestyle advice – avoid caffeine, alcohol, relax when voiding, void twice in a row to aid emptying. Control urgency using distraction methods. Pelvic floor exercises and bladder training exercises
What drugs can be used to manage BPH and what are the side effects of these drugs?
Drugs – useful in mild disease or whilst awaiting intervention. Alpha blockers are 1st line as they reduce smooth muscle tone such as tamsulosin alfuzosin or doxazosin. SE include drowsiness, depression, dizziness, low BP, dry mouth, ejaculatory failure and extra pyramidal signs.
5-Alpha reductase inhibitors can be added such as finasteride which reduces the conversion of testosterone to DHT (must use condoms as excreted in semen). SE – erectile dysfunction, reduced libido, and gynaecomastia.
Combination therapy is supported.
What surgical options are there to manage BPH?
TURP (trans urethral resection of prostate)
TUIP (trans urethral incision of prostate) fewer side effects and similar benefit. Best in those with smaller prostates.
TULIP (trans urethral laser induced prostatectomy)
Retropubic prostatectomy or robotic prostatectomy
What are the side effects of TURP?
Side effects of TURP include urinary symptoms, and sexual dysfunction, retrograde ejaculation (and so reduced volume of ejaculate) urethral trauma and strictures. Following surgery people should avoid driving and sex for 2 weeks
What is TURP syndrome?
TURP syndrome is a rare and life-threatening complication of transurethral resection of the prostate surgery. It occurs due to irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection. This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
How does TURP syndrome present?
TURP syndrome typically presents with CNS, respiratory and systemic symptoms
What are the risk factors for TURP?
- Surgical time > 1 hr
- Height of bag > 70cm
- Resected > 60g
- Large blood loss
- Perforation
- Large amount of fluid used
- Poorly controlled CHF
