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DAQ 1 revision Case 1-4 > Prostate cancer/BPH > Flashcards

Prostate cancer/BPH Flashcards

1
Q

Where does prostate cancer occur often histologically?

A

peripheral zone (65% of histological division)

can spread to ejaculatory duct and seminal vesicle

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2
Q

Where does BPH occur often histologically?

A

transitional zone

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3
Q

What are RF for prostate cancer?

A
  • Advanced age > 50 yo
  • Family history first degree relatives
  • Black ethnicity
  • Smoking
  • Genetic disposition
  • BRCA 2
  • lynch syndrome (hereditary non-polyposis colorectal cancer/HNPCC)
    predisposes to different cancer types: endometrial, ovarian, prostate, intestinal, pancreatic
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4
Q

Symptoms of prostate cancer?

A

lower back pain (MOST COMMON PC of metastatic disease)

Early stage
Irritative: frequency, urgency, incontinence, nocturia
Obstructive: hesitancy, poor stream, terminal dribbling, sensation of incomplete voiding
- dysuria
- painful ejaculation and erectile dysfunction

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5
Q

DRE for prostate cancer

A

NOT SCREENING
Early stage: localised hard nodules
Advanced: asymmetric areas, frank nodules
Only detect posterior and lateral aspects of prostate gland
Urologists are more experienced so do not do it routinely in GP settings

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6
Q

Investigations of prostate cancer

A 
PSA
prostate MRI
biopsy --> Gleason score
bone scan
CBE: anaemia of chronic disease
LFT: high ALP due to bone metastasis
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7
Q

What values of PSA indicate likely prostate cancer?

A
  • Repeat PSA to ensure no transient conditions affect PSA level
  • > 4 ng/mL: prostate cancer is not likely
  • 4-10 ng/mL: 25% chance of prostate cancer, also indicate BPH, inflammation
  • > 10 ng/mL: > 50% chance of prostate cancer
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8
Q

Different types of PSA tests to improve accuracy?

A

% free PSA

  • helpful when PCA between 4-10
  • < 10% free PSA suggests presence of cancer
  • benign cells produce more free PSA

PSA velocity
- How fast PSA increases 3 samples taken at least 18 months apart –> rapid climb

PSA density

  • PSA vs prostate size
  • It is normal for naturally larger prostate to produce more PSA

PSA doubling
- Similar to velocity: measures how long it takes for PSA levels to double

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9
Q

Communications with patients before PSA tests

A

Recurrent UTI, after cycling/vigorous exercise, recent ejaculation, spa pathing –> need to inform patient not to do so before PSA screening

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10
Q

What are some pros and cons of PSA

A

Pros

  • Detect pre-symptomatic prostate cancer – >better prognosis
  • Easy, non-expensive screening

Cons
- Slow developing: detection of cancer may never become life-threatening
- Psychological ramifications of over diagnosis
- PSA is not specific to prostate cancer, could also indicate BPH, prostatitis
o transient increase due to activities
o Inc is normal with ageing

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11
Q

What is happening with prostate cancer biopsy?

A
  • Guided by ultrasound/MRI depending on which is more available, but MRI has been more popular due to its sensitivity (TRUS-guided, MRI-guided)
  • 10-12 scores are taken during biopsy (5 or 6 per side)
  • risks: bruising, bleeding, infection/sepsis, trouble urinating, hematuria
  • report: presence of tumour, Gleason score
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12
Q

What is Gleason Score?

How is it calculated?

A
  • Assign one Gleason grade to the most predominant pattern and a second most predominant pattern
  • They are added together to determine Gleason score
    (3+4 = 7)

<6 –> low risks
7 (3+4) –> favourable intermediate risks
7 (4+3) –> unfavourable intermediate risks
8, 9-10 –> high/very high risks

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13
Q

Lifestyle management of prostate cancer

A
  • Get regular prostate screening
  • Maintain a healthy weight
  • Exercise
  • Less fat diet
  • Smoking cessation
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14
Q

Observations vs active surveillance

A

Observations
- Monitoring course of disease with view to deliver palliative therapy when symptoms arise

Active surveillance
- Monitoring with additional use of prostate biopsies until symptoms become clinically evident so we can treat with definitive treatment

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15
Q

What are some non-lifestyle management?

A
  • Androgen Deprivation Therapy (ADT)
  • External beam radiotherapy (EBRT)
  • Brachytherapy
  • Prostatectomy +/- lymph node dissection
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16
Q

What happens in ADT?

why we need to administer both GnRH agonists + anti-androgen

A

reduce testosterone production to slow the growth of cancer

GnRH agonists lower the amount of testosterone made by testicles/adrenals
o Tumour flare: when GnRH is first given, testosterone will briefly go up before falling to low levels
o Tumour flare can be lethal in metastasis, for example, if cancer has already spread to spine, it could cause more pain or paralysis
o Anti-androgen is given for a few weeks to avoid tumour flare

  • Effect won’t be forever, as it would become hormone-resistant
  • Side effect
    Low libido, erecting problems
    Hot flushes, mood swings
    Loss of muscle strength
17
Q

What happens in EBRT?

A

Precise delivery of radiation (x rays) to cancerous tissue

minimise dose to normal tissues

18
Q

What happens in Brachytherapy?

A

Placing radioactive seeds in prostate

  • Low dose
    Permanent implantation of radioactive sources without any incision
  • High dose
    Temporary: radioactive seeds are removed after a few minutes.
    Confined to the prostate and a small volume of surrounding tissue
19
Q

What are some risk factors of BPH?

A
  • Age over 50 yo
  • Family history
  • Non-Asian race
  • Smoking
20
Q

What are some symptoms of BPH?

A
  • Lower urinary tract symptoms
    o Irritative: frequency, urgency, urge, incontinence, nocturia
    o Obstructive: hesitancy, straining to urinate, poor stream, terminal dribbling, sensation of incomplete voiding
    o Gross haematuria
  • Smoking, medication (diuretics, anticholinergics)
21
Q

BPH findings on DRE

A

Symmetrically enlarges
Smooth, firm, non-tender prostate
Rubbery/elastic texture
Assess sphincter tone

22
Q

Mech for lower urinary tract symptoms in BPH

A

Ageing –> inc testosterone –> testosterone metabolised into DHT by enzymes in prostate –> DHT binds to androgen receptor in prostate cells –> hyperplasia of prostate –> prostate is encapsulated by fibromuscular tissues so grows inwards –> compress urethra and bladder outlet –> bladder smooth muscle hyperplasia –> inc sensitivity of detrusor muscle –> dec capacity of holding urine so trigger detrusor contraction early

23
Q

What are some investigations for BPH?

A

urinary tract ultrasound: assess prostate volume, bladder wall and residual urine, any hydronephrosis

PSA: BPH vs cancer

serum creatinine/eGFR: exclude primary renal function/high pressure bladder obstruction

24
Q

What are some behavioural management of BPH?

A
  • Reduce intake of mild diuretics: Caffeine, alcohol
  • Bladder irritants
    Acidic, spicy foods
  • Evening/prior to travel fluid intake limit
  • Bladder training and pelvic floor exercise
    Timed voiding regimens ‘by the clock’  effective in reducing LUT symptoms
25
Q

What are some pharmacological management of BPH?

A

Alpha adrenoceptor antagonists

5 alpha reductase inhibitor

androgen receptor antagonists

sildenafil (phosphodiecterase 5 inhibitor)

26
Q

MOA and side effect of Alpha adrenoceptor antagonists

5 alpha reductase inhibitor

A

Alpha adrenoceptor antagonists
- SM relaxation in prostate and bladder neck

5 alpha reductase inhibitor
- inhibit conversion of testosterone to DHT –> reduce prostate growth/volume –> relieve LUTS

side effect: erectile dysfunction

27
Q

What is gold standard surgical treatment of BPH?

A

transurethral resection of prostate (TURF)

prostate size < 80g and worsening of symptoms

side effect: retrograde ejaculation, bleeding, hyponatremia

DAQ 1 revision Case 1-4 (5 decks)

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