Prostate Carcinoma Flashcards
Epidemiology of Prostate Carcinoma.
- Commonest cancer in men and risk increases with age.
2. 2nd commonest cause of death due to cancer after lung cancer.
Risk Factors of Prostate Carcinoma (6).
- Increasing Age.
- Family History (Lynch Syndrome, Germline BRCA Mutations).
- Afro-Caribbean Ethnicity.
- Tall Stature.
- Use of Anabolic Steroids.
- Obesity.
Clinical Presentation of Prostate Carcinoma (4).
- Similar to BPH.
- Haematuria, Erectile Dysfunction.
- Constitutional Symptoms.
- Asymptomatic.
Bony Metastasis of Cancers (2).
- Prostate Bony Metastases - Osteosclerotic vs. Other Cancer Bony Metastases - Osteolytic.
- Isotope (Radionuclide/Bone Scintigraphy) Scan - IV Injection of radioactive isotope to see bone uptake using a gamma camera.
Which cancers commonly metastasise to bones? (5)
BLTPK - Breast, Lung, Thyroid, Prostate, Kidney..
Pathophysiology of Prostate Carcinoma (3).
- 95% - Adenocarcinomas (glandular epithelial cells lining the glands/ducts of prostate).
- 70% lie in Peripheral Zone and multifocal.
- Always androgen-dependent.
Lymphatic Spread of Prostatic Carcinoma.
First to Obturator Nodes and then local extra prostatic spread to the seminal vesicles (distant disease).
What is PIN?
Prostatic Intraepithelial Neoplasia - precursor of Prostatic Adenocarcinoma (asymptomatic).
What is PSA?
Prostate-Specific Antigen - a serine protease glycoprotein secreted by epithelial cells of the prostate into semen (enzymatic activity to thin thick semen into liquid consistency after ejaculation), with a small amount entering the blood.
Values of PSA in People (3).
- Upper Limit in 50s = 3.0
- Upper Limit in 60s = 4.0.
- Upper Limit in 70s = 5.0.
Differential Diagnoses of Raised PSA (7).
- Prostate Carcinoma.
- BPH.
- Prostatitis (NICE recommend postponing for 1 month after treatment).
- UTI.
- Vigorous Exercise (notably cycling - avoid for 48 hours).
- Recent Ejaculation (avoid for 48 hours).
- Prostate Stimulation e.g. DRE - avoid for 48 hours.
Staging of Prostate Carcinoma.
TNM - use CT/MRI and Bone Scan.
Grading of Prostate Carcinoma (2).
- Gleason - grade I - well-differentiated; grade V - poorly-differentiated.
- 2 scores (1-5 each) : 1st score is based on grade of most prevalent pattern; 2nd score is based on grade of 2nd most prevalent pattern.
1st Line Investigation for Suspected Localised Prostatic Carcinoma.
Multiparametric MRI of the Prostate, scored on a Likert Scale - 1 very low suspicion; 3 - equivocal; 5 - definite cancer.
Prostate Biopsy (4).
- Definitive Method to diagnose Prostate Cancer.
- TRUS (Transurethral US-Guided Biopsy) - US inserted into rectum and needle biopsy through rectal wall into Prostate under US guidance.
- 12 biopsies taken.
- With Transperineal Biopsy - around 35 biopsies; higher sensitivity; longer and GA.
Management of Prostate Carcinoma (5).
- Early Case - Watchful Waiting (or elderly, multiple co-morbidities, low Gleason).
- External Beam Radiotherapy.
- Brachytherapy.
- Hormonal Therapy.
- Surgical Management.
What is Brachytherapy?
Adverse Effects of Brachytherapy (3).
- Radioactive seeds are implanted into the prostate to deliver continuous targeted radiotherapy.
- Adverse Effects : Urinary Incontinence, Erectile Dysfunction, Long-Term Bowel/Bladder Problems.
What is External Beam Radiotherapy?
What is a major complication of EBR?
- Radiotherapy directed at the Prostate.
2. Complication : Proctitis (Rectum Inflammation) - Use Prednisolone Suppositories.
What is the rationale of Hormonal Therapy?
Prostate tissue grows in response to androgens like Testosterone so hormonal therapy aims to block Androgens to slow/stop the growth of Prostate Cancer.
What are the 3 options of Hormonal Therapy?
- Bilateral Orchidectomy (Gold-Standard).
- GnRH Agonists (Chemical Castration e.g. Goserelin).
- Androgen-Receptor Blockers e.g. Bicalutamide, Cyproterone Acetate.
What is the mechanism of action of Cyproterone Acetate?
Prevents DHT binding from intracytoplasmic protein complexes.
What is the mechanism of action of Bicalutamide?
Non-steroidal anti-Androgen that blocks Androgen receptors.
What is the mechanism of action of synthetic GnRH agonists?
Paradoxically result in lower LH levels longer term by causing overstimulation by resulting in the disruption of endogenous hormonal feedback systems.
Adverse Effect of GnRH Agonists (3).
- Testosterone level will rise initially for around 2-3 weeks before falling to cassation levels.
- ‘Tumour Flare ‘ - cover this therapy with Anti-Androgen initially.
- Tumour Flare can result in stimulation of prostate cancer growth e.g. bone pain, bladder obstruction.
What is the Surgical Management of Prostatic Carcinoma?
Total Prostatectomy - standard treatment for localised disease - obturator nodes are also removed. The bladder is rejoined to the urethra.
Prognosis of Prostate Cancer.
SLOW - 10% die in 6 months; 10% live for more than 10 years.
