Prostate Cancer Flashcards
Prostate Cancer is an androgen dependent cancer, give 5 risk factors
Age
Family History
Genetics (BRCA2)
Race (African American)
High Pesticide exposure
Describe the typical histology of Prostate Cancer
95% Adenocarcinoma
75% in Peripheral Zone
Describe a low histological grade of Prostate Cancer (i.e Gleason 6)
Small and slow growing, typically confined to Prostate
Describe a high histological grade of Prostate Cancer (i.e Gleason 8-10)
Grow faster, invade through prostate capsule and infiltrate adjacent organs
Can disseminate
Describe the PSA level cut offs for biopsy
40-50y - 2.5
50-60y - 3.5
60-70y - 4.5
>70y - 6.5
Give four reasons against a nationalised Prostate Screening programme
-75% raised PSA is not cancer
-15% cancer does not have raised PSA
-Unable to distinguish between active and slow growing
- May over treat a slow growing prostate cancer that never would’ve become symptomatic
Give two reasons for a Prostate 2ww referral
Malignant feeling of Prostate OE
PSA> limit
How can a suspected Prostate Cancer be investigated?
-Bloods
-Urine Dip
-MRI - if staged at more than 3 on MRI scoring, then biopsy
The International Prostate Symptom Score rates prostatic symptoms from 0 to 5. State 5 of the parameters
Incomplete emptying
Frequency
Intermittency
Urgency
Weak Stream
Describe the typical presentation of localised Prostatic cancer
50% asymptomatic with elevated PSA
Weak stream, hesitancy, frequency, urgency
Describe the typical presentation of locally invasive Prostatic cancer
Haematuria
Haematosermia
Perineal pain
Impotence
Describe the typical presentation of metastatic Prostatic cancer
Bone pain/sciatica
Paraplegia
LN enlargement
Describe how a suspicious prostate would feel on DRE
Hard and irregular
Asymmetry
Nodule within one lobe
Adhesion to surrounding tissue
What staging is used for Prostate Cancer?
TNM
Gleason Grading is the best prognostic indicator for Prostate Cancer. What is it?
Two most common times of glandular growth patterns from biopsy are graded (can be heterogenous in which case it is just double)
Describe the histological score 1
Small uniform glands with minimal nuclear changes
Describe the histological score 2
Medium acinii separated by stromal tissue
Describe the histological score 3
Marked variation in glandular size and organisation
Infiltration of stroma by neighbouring tissues
Describe the histological score 4
Atypical cytology with extensive infiltration
Describe the histological score 5
Sheets of undifferentiated cells
What does a total Gleason score of less than 4 mean?
Well differentiated
10y risk of progression is 25%
What does a total Gleason score of 5-7 mean?
Moderately differentiated
10y risk is 50%
What does a total Gleason score of more than 7 mean?
Poorly differentiated
10y risk is 75%
How do Gleason scores convert to a risk?
Low risk is 6 or less
Intermediate risk is 7
High risk is 8-10
What is the NICE guidelines for management of low risk prostate cancer?
Offered the choice between active surveillance, radical prostatectomy and radical radiotherapy
What is the NICE guidelines for management of intermediate/high risk prostate cancer?
Should be offered non surgical radical management (eg radiotherapy and androgen deprivation)
Watchful waiting is a management option in non metastatic Prostate Cancer. What is it?
Continually monitored by GP
Any management will be focussed on symptom control rather than curative
Active Surveillance is a management option in non metastatic Prostate Cancer. What is it?
Regular monitoring of patients who might benefit from full curative treatment in the future
Eg if they had a life expectancy of less than 10 years anyway, treatment may be delayed to preserve QoL
What are the key differences between Watchful Waiting and Active Surveillance?
Active Surveillance requires more hospital based tests (WW is monitored by GP) and at any point treatment aims to cure
What is a radical prostatectomy?
Removal of prostate gland, resection of seminal vesicles and surrounding tissue to get margin, and bilateral pelvic lymph node dissection
Laproscopic preferred
There are two types of Radical Radiotherapy for Prostate Cancer (that work just as well as Prostatectomy). Describe External Beam Therapy
CT planned - conformational therapy
Normally after 3-6m of anti-androgen therapy
OR
Can do immune modulated radiotherapy, where different strength radiation beams are targeted to limit healthy tissue damage.
Can cause radiation cystitis/proctitis/impotence
There are two types of Radical Radiotherapy for Prostate Cancer (that work just as well as Prostatectomy). Describe Brachytherapy
Transperineal implantation of radioactive seeds into the prostate
Contraindicated if previous TURP/prostate volume extremes
Anti Androgen therapy is first line for metastatic disease alongside bilateral orchidectomy (but can be adjuvant/neoadjuvant/stand alone). What are LHRH analogues?
Eg Goserelin
Initial stimulation of pathway leads to eventual downregulation
Cause an initial flare of testosterone for around 10 days (so requires cover with an anti androgen)
Name an Anti-Androgen
Flutamide
Name an LHRH antagonist
Degarelix
What are the two methods of Anti-Androgen therapy?
Continuous (can cause quicker progression to androgen independent state)
Intermittent (stopped and started depending on PSA)
Give two short term and two long term complications of androgen therapy
Short term: Impotence, Loss of Libido
Long term: Muscle wasting, Osteoporosis
Describe the use of radiotherapy in metastatic prostate disease
Normally to alleviate painful bones or spinal cord compression
What would be the non hormonal chemotherapy agent of choice in Prostate cancer?
Docetaxel
What should be done before a prostate biopsy to ensure it’s justified?
Multi parametric MRI
Give a complication of Trans-Rectal Biopsy and how it is avoided
Prostatitis (may go on to gram neg sepsis)
Given IV antibiotic cover throughout procedure
Give two complication of Transperineal Biopsy
Pain
Urinary Retention
Haematuria
Patients are asked to wait to leave after their biopsy until they’ve successfully passed urine
What are the two different method of Prostatectomy?
Laproscopic
Open
Give two advantages and a disadvantage of Laproscopic Prostatectomys
Advantages - small incisions only, quicker operation time
Disadvantages - Can cause post op Ileus due to air insufflation
What are the two surgical angle approaches for Prostatectomy?
Transperineal
Retro Pubic
What are three parameters for low risk prostate cancer?
PSA<10
Gleason<6
TNM- 1-2a
What are the three parameters for intermediate risk prostate cancer?
PSA 10-20, Gleason 7, TNM 2b
What are the parameters for high risk prostate cancer?
PSA>20
TNM >2c
Gleason 8-10
What are the treatment options for low risk
Active Surveillance or Watchful waiting
Or radical therapy
What are the treatment options for intermediate risk?
Radical therapy
Typically 3-6m anti-androgen therapy
What are the treatment options for high risk prostate cancer?
Mainly anti-androgen therapy
