Prostate cancer (URO) Flashcards
What is prostate cancer?
A malignant tumour of glandular origin (adenocarcinoma), situated in the prostate
How common is prostate cancer?
Second most common cancer in men worldwide
Fifth leading cause of cancer mortality in men worldwide
When does prostate cancer commonly happen?
Most common after 50y, median age 67y
How does prostate cancer develop?
High-grade prostatic intra-epithelial neoplasia (precursor) –> invasive prostate cancer
Spreads along capsular surface of gland –> seminal vesicles –> peri-prostatic tissues –> bladder neck
Where can prostate cancer metastasise to? (Most to least common)
- bone
- lung
- liver
- pleura
- adrenals
What are the types of prostate cancer? (3)
- adenocarcinomas - most common, arise from glandular tissues from luminal/basal cells
- transitional cell carcinoma - arises from prostatic urethra transitional epithelium cells
- small cell prostate cancer - arise from neuroendocrine cells
What are some risk factors for prostate cancer? (6)
- age >50
- positive Fx
- genetics - BRCA1/BRCA2 mutations, HOXB13
- black ethnicity
- Northwest European, Caribbean, Australian, NZ, North American and Southern African populations
- high levels of dietary fat
What are the general clinical features of prostate cancer? (3)
- often asymptomatic
- may present with complicated LUTS - urinary retention, haematuria, incontinence, flank pain, nocturia, frequency, hesitancy
- abnormal DRE - asymmetrical, hard, nodular enlargement of prostate, loss of midline sulcus
What LUTS are seen in prostate cancer? (7)
- urinary retention
- haematuria
- incontinence
- flank pain
- nocturia
- frequency
- hesitancy
What is seen on DRE in prostate cancer? (4)
- asymmetrical
- hard
- nodular enlargement of prostate
- loss of midline sulcus
What are the clinical features of advanced/metastatic prostate cancer? (6)
- fatigue & malaise
- weight loss
- bone pain
- neurological deficits (SC compression)
- lymphoedema
- paraneoplastic syndromes
What are the main investigations done for prostate cancer?
- serum PSA
- prebiopsy multiparametric MRI
- prostate biopsy (transrectal US-guided needle biopsy)
What is now the first-line investigation for prostate cancer?
Multiparametric MRI
(If PSA >3 and/or suspicious DRE)
What is the gold standard investigation for prostate cancer?
Transrectal ultrasound-guided needle biopsy
- may detect adenocarcinoma
- Gleason staging
- if 3+ on Likert scale after multiparametric MRI
What antigen can you measure to detect prostate cancer?
Prostate-specific antigen (PSA)
What is the issue with using PSA in prostate cancer?
Not cancer-specific –> elevated in benign conditions:
- BPH
- UTI
- prostatitis
At what PSA level is prostate cancer likely?
Elevated PSA >4 ng/mL - but correlate with patient age
What physical exam can you perform for prostate cancer?
DRE - asymmetrical, hard, nodular enlargement of prostate, loss of midline sulcus
Why may you do a bone scan in prostate cancer?
To check for metastases
What may be raised if there are bone metastases in prostate cancer?
ALP
Which investigations can help stage prostate cancer?
Pelvic CT/MRI
MRI spine to look for metastases causing spinal cord compression –> can lead to incontinence and weakness
What is the grading system for prostate cancer?
Gleason score (lower score = better prognosis)
- biopsy specimen given a score from 1-5 based on the degree of architectural differentiation of the tumour
- Gleason score obtained by assigning a primary grade to the predominant grade present, and a secondary grade to the second most prevalent grade
- e.g. tumour with grade 3 and grade 2 cells = Gleason score 5
What do different Gleason scores mean for prostate cancer?
- low-grade tumour: Gleason score </=6
- intermediate-grade tumour: Gleason score 7
- high-grade tumour: Gleason score 8-10
What are some differential diagnoses for prostate cancer? (2)
- BPH - prostate feels rubbery with no nodules
- chronic prostatitis - Sx of urinary frequency, dysuria, male dyspareunia and haematospermia
What is the management plan for localised (T1/T2) prostate cancer?
- watchful waiting: PSA every 6m, DRE every 12m
- PLUS active surveillance if life expectancy >10y: regular biopsy (intention to treat once Sx of disease become clinically evident)
What does localised advanced prostate cancer score on the Gleason staging system?
T3/T4
What is the management plan for localised advanced (T3/T4) prostate cancer? (2)
- radical prostatectomy +/- lymph node dissection
- radiotherapy (external beam or brachytherapy - internal radiotherapy directly to prostate)
What is a common complication of radical prostatectomy?
Erectile dysfunction
What does radiotherapy (prostate cancer) increase risk of?
Bladder, colon and rectal cancer
Proctitis
What is the management plan for metastatic prostate cancer?
Hormonal therapy (anti-androgen therapy) - combination often used:
- GnRH agonists - Goserelin
- androgen antagonists - Bicalutamide, Enzalutamide
- GnRH antagonists - Degarelix
What are the side effects of GnRH agonists (Goserelin) for prostate cancer? (4)
- gynaecomastia
- decreased libido
- ED
- infertility
What can initial treatment with GnRH agonists in metastatic prostate cancer cause, and how can we prevent this?
Tumour flare - bone pain, bladder obstruction
Give cyproterone acetate + pre-treatment with flutamide
What are some complications of prostate cancer? (5)
- erectile dysfunction - from radiation, prostatectomy or hormone therapy
- metastases - bone, lung, liver, pleura, adrenals
- compression of bladder and prostatic urethra –> pain on ejaculation + bleeding
- radiotherapy-induced effects
- hormone-induced effects
What are the NICE guidelines regarding PSA testing?
Due to these things causing increased PSA levels, testing should not be done within at least:
- 6 weeks of a prostate biopsy
- 4 weeks following a proven UTI
- 1 week of DRE
- 48h of vigorous exercise
- 48h of ejaculation
