Prostate Cancer Flashcards
Epidemiology
Most common cancer in men in the UK
26% of all male cancer diagnoses
Pathophysiology
Unclear
Widely agreed that growth of prostate cancer is influenced by androgens like testosterone and DHT
Type of prostate cancer
>95% are adenocarcinomas
Over 75% of prostate adenocarcinomas arise from the peripheral zone
20% from the transitional zone
5% in the central zone
Prostate cancers are often multifocal
Subtypes of prostate adenocarcinomas
Acinar adenocarcinoma originating in the glandular cells that line the prostate and is the most common form
Ductal adenocarcinoma that comes from cell lining of the duct. They tend to grow and metastasis faster.
Risk factors
Age
Ethnicity - Black african or Carribean ethnicity twice as likely.
FH of prostate cancer
BRCA2 or BRCA1 gene
Obesity, DM, smoking, degree of exercise
Clinical features
Usually presents with LUTS with a weak urinary stream, increased urinary frequency and urgency.
More advanced localised disease can also cause haemturia, dysuria, incontinence, haematospermia, suprapubic pain, loin pain and even rectal tenesmus.
Metastatic disease can also cause bone pain, lethargy, anorexia and unexplained wieght loss
Examinations
DRE is essential
Most arise from posterior peripheral zone so check for asymmetry, nodularity or fixed irregular mass.
Dx
BPH
Prostatitis
Bladder cancer, urinary stones, UTI and pyelonephritis
Lab test
PSA
A serum protein produced both by malignant and normal healthy cells in the prostate which can be elevated
When else might PSA be elevated?
BPH
Prostatitis
Vigorous exercise
Ejaculation
Recent DRE
Further calculations using PSA
Free:Total PSA ratio
A low ratio is associated with increased chance of diagnosig prostate cancer
Explain PSA density
Serum PSA level divided by the prostate volume which is determined on imaging.
High PSA densitiies = increased likelihood of prostate cancer
Further investigations
Current standard method for diagnosis is through biopsies of prostatic tissue
Potential methods of biopsy
Transperineal Template Biopsy
TransRectal Ultrasound guided (TRUS) biopsy
Explain Transperineal Template Biopsy
Sampling of biopsy transperineally.
This is done as a day case under general anaesthetics.
Transperineal approach allows for better access to the anterior part of the prostate and has a lower risk of infection.
Explain TransRectal UltraSound-guided TRUS biopsy
Sampling transrectally under local anaesthetics
12 cores are taken bilaterally in equal distribution from base to apex
1-2 % risk of sepsis.
Repeat prostate biopsy after previous negative biopse is recommended if there is a rise in PSA or peristently elevated.
What grading system is used for prostate cancer?
Gleason Grading System
Explain Gleason Grading System
Sample is assigned a score according to differentiation
Score is then calculated as the sum of the most common growth pattern + the second most common growth pattern seen.
Higher score = Less favourable prognosis
Imaging in prostate cancer
Multiparametic magnetic resonance imaging mp-MRI is increasinly used to aid diagnosis.
It can identify abnormal areas which can then be targetted for biopsy by MRI-ultrasound fusion or cognitive-guidance techniques.
This means that mp-MRI is sometimes being used earlier in the diagnostic pathway prior to initial biopsy.
When is staging of prostate cancer done?
Staging is typically done in intermediate and high-risk disease via CT-abdo-pelvic scan and bone scan.
General management
Specialist prostate cancer MDT meeting
PSA levels, Gleason score and T staging decides further management.
Low risk disease management
Active surveillance
Radical treatment only offered to those who show evidence of disease progression
Intermediate and high risk management
Radical treatment options should be discussed.
Intermediate risk can also be offered active surveillane.
Metastatic disease management
Chemotherapy agents and anti-hormonal agents
Castrate-resistant disease management (Hormone-relapse prostate cancer)
Further chemotherapy like Docetaxel.
Corticosteroids can also be given as third line after androgen deprivation therapy and anti-androgen therapy.
Explain the Watchful waiting and active surveillance management.
Symptom guided approach
Monitoring of patients with 3-monthly PSA
6 month to yearly DRE
Re-biopsy at 1-3 yearly intervals assessing for progression
mpMRI is also being used.
Surgical management
Radical prostatectomy removing prostate gland, resection of the seminal vesicles + any surrounding tissue.
This can be done open approach, laparoscopically or robotically
Complications of prostatectomy
ED
Stress incontinence
Bladder neck stenosis
When is radiotherapy done?
External-beam radiotherapy and brachytherapy are both commonly used as alternatives to curative intervention of localised prostate cancer.
Explain brachytherapy
Transperineal implantation of radioactive seeds of Iodine-125 directly into prostate gland
Explain external-beam radiotherapy
External-beam radiotherapy uses focused radiotherapy to target the prostate gland and limits damage to surrounding tissue.
Indications of chemotherapy
Metastatic prostate cancer.
Give examples of chemotherapies in prostate cancer.
Docetaxel and cabazitaxel.
What other chemical therapy can be done?
Androgen deprivation therapies since most prostate cancers are stimulated by circulating androgens.
GnRH receptor agonist like goserelin can be used
It becomes an LHRH agonist due to its action
Enzalutamide and abiraterone are new hormone therapies which act to lower levels of serum testosterone.
Mainstay treatment for localised or locally advanced prostate cancer
Radical prostatectomy, external-beam radiotherapy and brachytherapy.
