Prostate / urological cancer and Head & Neck cancer Flashcards
State the ages and frequency for cervical cancer screening
25 - 65
25-50 = every 3 years
50-65 = every 5 years
State some risk factors for prostate cancer
- Age (rare under 50)
- Close family history
- Ethnicity (African heritage)
- Genetic conditions (BRCA1 / BRCA2)
State some signs or symptoms for prostate cancer
Can be asymptomatic = had PSA
Lower urinary tract symptoms
OBSTRUCTIVE SYMPTOMS
- Hesitancy
- Poor and/or intermittent stream
- Straining
- Prolonged micturition
- Feeling of incomplete bladder emptying
- Dribbling
STORAGE SYMPTOMS
- Frequency
- Urgency
- Urge incontinence
- Nocturia
Bone pain, often back pain (metastatic)
Ejaculatory problems (rare)
State investigations in the prostate cancer diagnosis
- PSA blood test
- DRE
- Biopsy (transperineal with local anaesthetic)
- MRI prostate prior to biopsy (only if radical approach)
State some common causes of raised PSA
- Prostate cancer
- Urinary infection
- Prostatic inflammation (prostatitis)
- Large / enlarged prostate (benign prostatic hyperplasia)
- Acute urinary retention
- Vigorous exercise especially cycling
- Sexual activity
State % of patients with normal PSA can have prostate cancer
15% of patients with normal PSA can have prostate cancer
What % of men will have a raised PSA
10%
State some factors influencing treatment decisions for prostate cancer
- Age
- PSA
- MRI staging e.g. T stage and N stage
- Gleason Grade (score - low magnification grading)
- Bone scan (metastasis)
State what the Gleason’s score is and how the scoring system works
Score is based on how much the cancer looks like healthy tissue when viewed under a microscope
Biopsy area where the cancer is most obvious and another area of growth
- Each area a score from 3 to 5
- The scores are added together
- Overall score between 6 and 10 (higher the numbers, worse it is)
State the medicine used most often for hormone castration
LHRH agonist (acts on leydig cells in the testes, which then) - prevents pulsatile release of GNRH
Given for life
Initial surge in testosterone, from initial stimulation of GNRH
This is a flare - need to give an anti-androgen e.g. bicalutamide
If PS < 2 and hormone sensitive - can have chemotherapy
State some established curative intent treatments for localised (non-metastatic) prostate cancer
+ active surveillance if low risk
- Prostatectomy (robotic)
- Conformal radiotherapy (+ GnRH agonists for 3-6 months e.g. Gosarelin)
- Brachytherapy
State the treatment options for the following risk levels for non-metastatic prostate cancer:
Low risk (Gleason’s score = 6)
Intermediate risk (Gleason’s score = 7)
High risk (Gleason’s score = 9-10)
Low risk (Gleason’s score = 6):
- Active surveillance
Intermediate risk (Gleason’s score = 7):
- Active surveillance
- Radical radiotherapy (+ GnRH agonists for 3-6 months e.g. Gosarelin)
- Robotic prostatectomy
High risk (Gleason’s score = 9-10):
- Radical radiotherapy (+ GnRH agonists for 3-6 months e.g. Gosarelin)
- Robotic prostatectomy
State the follow up for prostate cancer treated radically
Check PSA levels:
– at least 6 weeks after treatment
– at least every 6 months for the first 2 years
– at least once a year after the first 2 years
After 2 years, can be discharged to primary care if PSA stable and no complications from treatment
Which patients benefit most from robotic prostatectomy
- Younger men < 70
- BMI < 35
- Localised high-risk non-metastatic prostate cancer
- Locally advanced non-metastatic
State some side effects for radical radiotherapy (prostate)
- Erectile dysfunction (up to 1/3)
- Urinary symptoms (LUTS)
- Urinary incontinence (1%)
List the potential benefits and harms of PSA screening
Benefits:
- Low cost
- More sensitive and specific that DRE alone
- Early detection of prostate cancer
Harms:
- False positives = unnecessary biopsy
- False negatives = missed cases
- Overdiagnosis = unnecessary interventions for clinically insignificant disease
- Potential complications from interventions e.g. erectile dysfunction
List some ways in which locally advanced or metastatic prostate cancer can present
- LUTS
- Back pain / pelvic pain
- Haematuria
- Haematochezia
- Haematospermia
- Spontaneous hip fracture
State some differentials for haematuria
- Cancer e.g. renal, bladder, advanced prostate
- Renal stones
- Infection
- Inflammation
- BPH / enlarged prostate
- Schistosomiasis (parasite)
- Nephritic syndrome e.g. IgA nephropathy
- Haemolytic uraemic syndrome
- Henoch-Schönlein Purpura
State some investgations for haematuria
- Urine cytology
- Flexible cystoscopy
- USS KUB or CT urogram
State 3 tumour markers for testicular cancer
- Alpha fetoprotein
- hCG
- LDH
State some risk factors for bladder cancer
- Smoking (45%)
- Occupational exposure (6%)
- Ionising radiation
State some management steps for bladder cancer based on the following severities
- Non-muscle invasive
- Muscle invasive
- Systemic
Non-muscle invasive:
- Surveillance cystoscopy (if low risk)
- Intra-vesicular chemotherapy (medium and high risk)
- Intra-vesicular BCG (high risk)
- Radical cystectomy if high risk
Muscle invasive
- Radical cystectomy
- Radiotherapy
Systemic - palliative approach:
- Chemotherapy
- Immunotherapy
State some presenting symptoms for renal cell carcinoma
- May be incidental finding
- Haematuria
- Palpable mass (adult polycystic kidney disease)
State some risk factors for penile cancer
- Increased age (over 50)
- Phimosis
- Hygeine / smegma
- HPV 16 & 18
- Psoriasis treatment (PUVA)
State the first line treatment for testicular cancer
Inguinal orchidectomy
Outline common sites of metastasis for prostate cancer
LLB
Lung
Liver
Bone
+ lymph nodes
Outline common sites of metastasis for head and neck cancers
LLB
Lung
Liver
Bone
List the main types of thyroid cancer
- Papillary
- Follicular
- Medullary thyroid carcinoma
- Anaplastic (poor prognosis)
List some risk factors for thyroid cancer
- Existing thyroid disease (Hashimoto’s, goitre)
- Radiation exposure
- Family history (certain genetic disorders such as multiple endocrine neoplasia)
- Female
- Obesity
- SLE
List some presenting symptoms for thyroid cancer
- Neck lump / goitre
- Hoarse voice
- Dysphagia
- Odynophagia
- Dyspnoea
- Stridor
- Weight loss / anorexia
- Lethargy / fatigue
- Bone pain (metastatic disease)
State some differentials for neck lumps (thyroid cancer)
- Benign thyroid disease
- Thyroglossal cyst
- Lymphadenopathy
- Laryngitis (hoarse voice)
- Laryngeal cancer (hoarse voice)
List some investigations for suspected thyroid cancer
- ECG (can cause arrhythmias)
- Urinalysis (phaeochromocytoma)
- Thyroid function tests
- Thyroid autoantibodies
- Plasma calcitonin and carcinoembryonic antigen (if suspicious for MEN)
- USS
- CT / MRI
- Fine needle aspiration
Outline how thyroid cancer is generally managed
- Surgery
- Radioactive remnant ablation
- Lifelong Levothyroxine replacement
+/- adjuvant therapy in some cases e.g. anaplastic
Serum thyroglobulin is a marker used to monitor for signs of disease recurrence
State some differentials for a detectable prostate mass / enlargement on DRE
- Prostate cancer
- BPH
- Normal (benign) asymmetry
- Prostatitis
- Cyst
- Prior TURP/biopsy scar
State 2 GnRH agonists and describe how they work for managing prostate cancer
Goserelin (Zoladex)
Leuprorelin (Prostap)
Stimulate GnRH receptors on the anterior pituitary, leading to large release of LH/FSH leading to increased testerone initially.
However over few days/weeks and continuous stimulation, GnRH receptors become desensitised and less production of LH/FSH leading to a reduction of testosterone production (hypogonadotropic hypogonadism)
State 2 cancers associated with Epstein Barr viral infection
Burkitt’s lymphoma
Nasopharyngeal cancers
List the most common cellular type of cancer of head and neck
Squamous cell carcinoma
List some risk factors for head and neck cancer
Non-modifiable:
- Male
Modifiable:
- Alcohol
- Tobacco
- Betel quid (oral cancer)
- HPV (mainly type 16, most significantly linked to oropharyngeal cancer)
- EBV infection (nasopharyngeal cancer)
- Occupational wood dust / asbestos exposure (sinonasal cancer)
- Immunodeficiency
- Prior radiation to area
List some premalignant conditions for head and neck cancers (esp. oral)
- Leukoplakia (white patches)
- Erythroplakia (red patches)
- Erythroleukoplakia (mixed red and white patches)
- Oral lichen planus
- Actinic cheilitis
Lifetime risk of transformation ranging from 0-20%
List some potential presenting features for oral cavity cancers
- Oral mass (typically painless) e.g. inner lip / tongue / floor of the mouth / hard palate
- Cervical lymphadenopathy
+ Constitutional symptoms e.g. fever, weight loss, night sweats
(Less commonly = non-specific e.g. oral cavity bleeding / localised pain / neck lump / jaw swelling)
List some potential presenting features for oropharyngeal cancers
- Painful swallow (odynophagia)
- Dysphagia (problems swallowing)
- Tonsillar lump / asymmetrical tonsil
- Neck lump / cervical lymphadenopathy
- Feeling of “something in the throat
+ Constitutional symptoms e.g. fever, weight loss, night sweats
List some potential presenting features for nasopharyngeal cancers
- Neck lump
- Unilateral conductive hearing loss
+ Constitutional symptoms e.g. fever, weight loss, night sweats
List some potential presenting features for laryngeal cancers
- Hoarse voice
- Dysphagia
- Persistent cough
- Referred ear pain
- Stridor (if advanced)
+ Constitutional symptoms e.g. fever, weight loss, night sweats
List some investigations to consider for suspected head and neck cancers
- Flexible nasendoscopy
- Biopsy of lesion (method depends on location)
If solely lymphadenopathy = ultrasound-guided fine needle aspiration (FNA)
Imaging:
- MRI imaging of the head and neck
- If strong suspicion, CT neck and chest
(may use PET-CT if cancer of unknown origin)
What should a patient be assessed for, before radiotherapy specifically for head and neck cancers
Assessment of dental health prior to radiotherapy
Suggest some additional considerations for the management of patients with head and neck cancers
- Smoking / alcohol cessation
- Nutrition with route of feeding
- Assessment of dental health prior to radiotherapy
Generally, outline how head and neck cancers are managed
- Surgical resection +/- adjuvant radiotherapy (may need flap reconstruction for oral cavity lesions)
- Primary radiotherapy +/- adjuvant chemotherapy
- Chemotherapy
Outline how oral cavity cancers are generally managed
Small tumours:
- Wide local excision +/- neck dissection
Advanced tumours:
- Surgical resection +/- flap reconstruction
- Neck dissection (adjuvant radiotherapy or chemotherapy)
Outline how tonsillar + tongue cancers are generally managed
Small tumours:
- Surgical resection +/- neck dissection or radiotherapy
Advanced tumours:
- Primary radiotherapy +/- adjuvant chemotherapy
Outline how laryngeal cancers are generally managed
Small tumours:
- Surgical resection +/- bilateral neck dissection
- Primary radiotherapy +/- adjuvant chemotherapy
Advanced tumours:
- Laryngectomy with post-operative radiotherapy +/- adjuvant chemotherapy
- Primary radiotherapy +/- adjuvant chemotherapy
State some potential complications of head and neck cancer treatments
- Radiotherapy
- Surgical
- Chemoradiotherapy
Radiotherapy:
- Local skin reaction
- Mucositis
- Hair loss
- Xerostomia (salivary glands)
- Difficulty swallowing
- Osteonecrosis (rare long term)
- Secondary cancers (rare long term)
Surgical:
- Damage to local nerves (accessory, vagus, hypoglossal, or mandibular
- Damage to lymphatic system (chyle leak)
- Pharyngocutaneous fistula (following laryngectomy)
- Dysphagia (pharyngeal/oesophageal strictures)
Chemoradiotherapy:
- Chronic pain
- Persistent hoarse voice
- Hearing loss
State some hormonal therapies that can be used in the management of prostate cancer
LH blockers e.g. Goserelin = stops production of LH, reduces production of testosterone by the testes
Anti androgens = blocks testosterone receptors on the cancer cells
GnRH blocker = blocking GnRH stops the testicles producing testosterone (at the level of the ant. pituitary)
