Prostate cancer/BPH Flashcards
Where does prostate cancer occur often histologically?
peripheral zone (65% of histological division)
can spread to ejaculatory duct and seminal vesicle
Where does BPH occur often histologically?
transitional zone
What are RF for prostate cancer?
- 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
Symptoms of prostate cancer?
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
DRE for prostate cancer
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
Investigations of prostate cancer
PSA prostate MRI biopsy --> Gleason score bone scan CBE: anaemia of chronic disease LFT: high ALP due to bone metastasis
What values of PSA indicate likely prostate cancer?
- 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
Different types of PSA tests to improve accuracy?
% 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
Communications with patients before PSA tests
Recurrent UTI, after cycling/vigorous exercise, recent ejaculation, spa pathing –> need to inform patient not to do so before PSA screening
What are some pros and cons of PSA
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
What is happening with prostate cancer biopsy?
- 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
What is Gleason Score?
How is it calculated?
- 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
Lifestyle management of prostate cancer
- Get regular prostate screening
- Maintain a healthy weight
- Exercise
- Less fat diet
- Smoking cessation
Observations vs active surveillance
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
What are some non-lifestyle management?
- Androgen Deprivation Therapy (ADT)
- External beam radiotherapy (EBRT)
- Brachytherapy
- Prostatectomy +/- lymph node dissection
What happens in ADT?
why we need to administer both GnRH agonists + anti-androgen
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
What happens in EBRT?
Precise delivery of radiation (x rays) to cancerous tissue
minimise dose to normal tissues
What happens in Brachytherapy?
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
What are some risk factors of BPH?
- Age over 50 yo
- Family history
- Non-Asian race
- Smoking
What are some symptoms of BPH?
- 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)
BPH findings on DRE
Symmetrically enlarges
Smooth, firm, non-tender prostate
Rubbery/elastic texture
Assess sphincter tone
Mech for lower urinary tract symptoms in BPH
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
What are some investigations for BPH?
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
What are some behavioural management of BPH?
- 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
What are some pharmacological management of BPH?
Alpha adrenoceptor antagonists
5 alpha reductase inhibitor
androgen receptor antagonists
sildenafil (phosphodiecterase 5 inhibitor)
MOA and side effect of Alpha adrenoceptor antagonists
5 alpha reductase inhibitor
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
What is gold standard surgical treatment of BPH?
transurethral resection of prostate (TURF)
prostate size < 80g and worsening of symptoms
side effect: retrograde ejaculation, bleeding, hyponatremia
