Prostate Cancer

Question 1

Epidemiology

Answer 1

Most common cancer in men in the UK

26% of all male cancer diagnoses

Question 2

Pathophysiology

Answer 2

Unclear

Widely agreed that growth of prostate cancer is influenced by androgens like testosterone and DHT

Question 3

Type of prostate cancer

Answer 3

>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

Question 4

Subtypes of prostate adenocarcinomas

Answer 4

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.

Question 5

Risk factors

Answer 5

Age

Ethnicity - Black african or Carribean ethnicity twice as likely.

FH of prostate cancer

BRCA2 or BRCA1 gene

Obesity, DM, smoking, degree of exercise

Question 6

Clinical features

Answer 6

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

Question 7

Examinations

Answer 7

DRE is essential

Most arise from posterior peripheral zone so check for asymmetry, nodularity or fixed irregular mass.

Question 8

Dx

Answer 8

BPH

Prostatitis

Bladder cancer, urinary stones, UTI and pyelonephritis

Question 9

Lab test

Answer 9

PSA

A serum protein produced both by malignant and normal healthy cells in the prostate which can be elevated

Question 10

When else might PSA be elevated?

Answer 10

BPH

Prostatitis

Vigorous exercise

Ejaculation

Recent DRE

Question 11

Further calculations using PSA

Answer 11

Free:Total PSA ratio

A low ratio is associated with increased chance of diagnosig prostate cancer

Question 12

Explain PSA density

Answer 12

Serum PSA level divided by the prostate volume which is determined on imaging.

High PSA densitiies = increased likelihood of prostate cancer

Question 13

Further investigations

Answer 13

Current standard method for diagnosis is through biopsies of prostatic tissue

Question 14

Potential methods of biopsy

Answer 14

Transperineal Template Biopsy

TransRectal Ultrasound guided (TRUS) biopsy

Question 15

Explain Transperineal Template Biopsy

Answer 15

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.

Question 16

Explain TransRectal UltraSound-guided TRUS biopsy

Answer 16

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.

Question 17

What grading system is used for prostate cancer?

Answer 17

Gleason Grading System

Question 18

Explain Gleason Grading System

Answer 18

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

Question 19

Imaging in prostate cancer

Answer 19

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.

Question 20

When is staging of prostate cancer done?

Answer 20

Staging is typically done in intermediate and high-risk disease via CT-abdo-pelvic scan and bone scan.

Question 21

General management

Answer 21

Specialist prostate cancer MDT meeting

PSA levels, Gleason score and T staging decides further management.

Question 22

Low risk disease management

Answer 22

Active surveillance

Radical treatment only offered to those who show evidence of disease progression

Question 23

Intermediate and high risk management

Answer 23

Radical treatment options should be discussed.

Intermediate risk can also be offered active surveillane.

Question 24

Metastatic disease management

Answer 24

Chemotherapy agents and anti-hormonal agents

Question 25

Castrate-resistant disease management (Hormone-relapse prostate cancer)

Answer 25

Further chemotherapy like Docetaxel.

Corticosteroids can also be given as third line after androgen deprivation therapy and anti-androgen therapy.

Question 26

Explain the Watchful waiting and active surveillance management.

Answer 26

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.

Question 27

Surgical management

Answer 27

Radical prostatectomy removing prostate gland, resection of the seminal vesicles + any surrounding tissue.

This can be done open approach, laparoscopically or robotically

Question 28

Complications of prostatectomy

Answer 28

ED

Stress incontinence

Bladder neck stenosis

Question 29

When is radiotherapy done?

Answer 29

External-beam radiotherapy and brachytherapy are both commonly used as alternatives to curative intervention of localised prostate cancer.

Question 30

Explain brachytherapy

Answer 30

Transperineal implantation of radioactive seeds of Iodine-125 directly into prostate gland

Question 31

Explain external-beam radiotherapy

Answer 31

External-beam radiotherapy uses focused radiotherapy to target the prostate gland and limits damage to surrounding tissue.

Question 32

Indications of chemotherapy

Answer 32

Metastatic prostate cancer.

Question 33

Give examples of chemotherapies in prostate cancer.

Answer 33

Docetaxel and cabazitaxel.

Question 34

What other chemical therapy can be done?

Answer 34

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.

Question 35

Mainstay treatment for localised or locally advanced prostate cancer

Answer 35

Radical prostatectomy, external-beam radiotherapy and brachytherapy.