Prostate cancer Flashcards
definition of prostate cancer
primary malignant neoplasm of the prostate gland
aetiology of prostate cancer
unknown
5-10% (50% <55yrs) due to inherited factors - BRCA1, BRCA2, mismatch repair adn HOXB13 which interacts with androgen receptor
RF of prostate cancer
age
race - Afro-carribean>caucasian, and Afro-carribean present at a younger age with more agressive disease
higher in N America, Europe, low in far east
FH - gene on Chr 1 implicated - x2-3 increased risk
BRCA2
high fat, meat and alcohol
reduced with soy
occupational exposure to cadmium and a lot of sexual partners suggested
high testosterone
pathology of prostate cancer
macro: 70% develops from peripheral prostatic gland, 10% from paraurethral tissue and 20% from the transition zone. 85% are diffuse multifocal tumours
micro: adenocarcinoma (95%) with variable degree of differentiation
score for prostate cancer
gleason score: grading based on histology, 2 scores given based on predominant appearance with max score of 5+5
low risk: 3+3
high risk 5+5
spread of prostate cancer
local spread into seminal vesicles, bladder and rectum.
Lymphatic spread to iliac and para-aortic nodes,
haematogenously most commonly to bone - sclerotic bony lesions (especially spine) as well as lung or liver
staging of prostate cancer
T1a - incidental <5% on TURP
T1b - incidental >5% on TURP
T1c - identified on needle biopsy
T2 - confined to prostate (a = 1 lobe, b = both)
T3 - extending through capsule
T4 - fixed tumour invading adjacent structures other than seminal vesicles
N1 - regional nodes involved
M - met
epidemiology of prostate cancer
commonest male cancer
2nd most common cause of male cancer deaths
incidence in West of 50-70/100000
microfoci of cancer found in 80% of men >80 on autopsy
incidence increases with age - 80% in men >80yrs
low risk v common in elderly pt die with rather than from
High risk – dx sooner – cure pts before met and incurable
sx of prostate cancer
asymptomatic - detected on PSA testing
lower Urinary tract obstruction (late sx) - frequency, hesitency, poor stream, nocturia and terminal dribble
haematuria
met spread:
- bone pain or spinal cord compression from bone met
malaise, anorexia, weight loss
paraneoplastic syndromes = hypercalacaemia
pain from urinary retention
signs of prostate cancer
asymmetrical hard nodular prostate with loss of midline sulcus on rectal examination
palpate bladder - urinary retention/renal failure
Ix for prostate cancer
blood
FBC
- UE
- PSA
- acid phosphatase
- LFT
- bone profile
PSA
- debatable if suitable tool in screening - values are age related and may be high in BPH, prostatitis, following catheterisation
- refinements to improve sensitivity include PSA velocity (rate of change), PSA density and free and complex PSA values.
- >100ng/mL indicate met prostatic cancer
- normal in 30% small cancers
CT/MRI
- assess extent of local invasion and node involvement
- MRI - staging
- differentiate between low and high risk prostate - low risk not visible
- PRIADs classification 1-5
TRUS and needle biopsy
- for histology
- alternatives: transperineal biopsy, template biopsy, saturation biopsy
- transperineal - Through the skin between the testes and rectum – advx – risk of infection is much lower than transrectally
isotope bone scan
- for bone met
should PSA be used as screening for prostate cancer
most men with prostatic cancer have high PSA
increases with size of the prostate, higher the PSA = more likely cancer
non-specific - also high in BPH, BMI <25, recent ejaculation, recent rectal exam, prostatitis, urinary retention, catheterisation and UTI
biopsy is needed for dx - risk of complications (bleeding, infection and urinary retention)
risks need to be counterbalanced by screening
people avoid death by screening, but screening picks up cancer that would never have become fatal
therefore screening using PSA not recommended
but anyone >50yrs can request - interpret with DRE and RF
spinal cord compression
urological emergency
due to vertebral mets
start IV dexamethasone
urgent MRI
suppress testosterone
decompress spinal cord with spinal surgery or radiotherapy
mx of V low risk prostate cancer
observation - LE less than 10yrs
2nd line - androgen deprivation therapy if sx and LE less than 5yrs
active surveillance - LE >10 yrs
* PSA annually
* DRE annually
* Biopsy adn MRI annually
LE >20 yrs - active surveillance and brachytherapy/external beam radiotherapy
mx for low risk prostate cancer/ favourable intermediate risk
less than 10 yrs
* observation
* androgen deprivation therapy (leuprorelin) if LE less than 5yrs
LE more than 10 yrs
* active surveillance
* brachytherapy
* external beam therapy
* radical prostatectomy
