Tumours of Prostate and Testicles Flashcards by Eilidh Seaton

Where does prostate cancer affect

Peripheral zone

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What type of cancer if prostate

Adenocarcinoma

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What are the symptoms of prostate cancer

Asymptomatic - Dx on PSA
Prostate obstruction Sx / similar to BPH
- Frequency
- Poor flow
- Terminal dribbling 
- Incomplete emptying 
- Overflow incontinence
Haematuria
Suprapubic pain
Erectile dysfunction 
Impotence
Incontinence 
Anuria 
Haemospermia 
Rectal symptoms
Lethargy
UTI 
Weight loss / fatigue / bone pain suggests mets

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Why don’t you tend to get BPE symptoms

In peripheral zone not transitional

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How does mets present / complications of prostate cancer

Renal failure
Sciatica if in sacrum 
Spinal cord compression 
Paraplegia due to cord compression
Lymphoedema
Bone pain
Pathological fractures - CXR if present 
Features of bone marrow failure

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Where does prostate cancer spread

Local - seminal vesicle / bladder (gives pelvic pain and urinay Sx)
Lymph
Haematagenous - pelvis / bone

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What are the RF for prostate cancer

Age 
Ethnicity - black 
FH
Increased testosterone / use of steroid
BRCA 2 / HBC1
Diet 
Obesity

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How do you investigate suspected prostate cancer

PSA - not good for screening for good for progression
Do this prior to DRE
DRE
FBC, U+E, bone profile

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What does DRE show

Hard irregular prostate

Loss median sulcus

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What is diagnostic for prostate cancer

MRI scan = 1st line now due to complications of biopsy
MRI guided biopsy depending on result of MRI
TRUS (trans rectal USS) guided biopsy
Allows Dx and Gliasen

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What is 1st line to stage

MRI = 1st line was TRUS
CT for nodes if higher risk
Bone scan for mets if higher risk

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When should you refer for further investigation

PSA >3

Abnormal DRE

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What can elevate PSA

Age
Cancer
BPH 
Prostatiits / UTI
Catheter
Ejaculation
DRE
Urine retention

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What else can be done

Rectal swab for sensitivity if need Ax post biopsy

Micturating cystogram for bladder Sx

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What are complications of biopsy

Infection

Bleeding - PR or haematuria

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What do you give before biopsy

Prophylactic Ax

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What do you grade

Glieesen grade

Each side 3,4,5

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What do you do for localised disease

Watch and wait
Active surveillance
Radical RT
- External beam therapy
- Brachytherapy 
Radical prostatectomy = standard + seminal vesicle + pelvic LN 
TURP

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When would you watch an wait

Unfit

Low Gliasen

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When do you do active surveillance

If fit but no symptoms as complications of Rx will worsen

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What does TURP do

Relieve obstructive Sx but NOT curative

Use if not fit for radical prostatectomy

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What do you do for locally advanced

Same

Hormone therapy

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What does hormone therapy do

Delays progression
Doesn’t cure
Testosterone drives cancer so suppress

What are options of hormone therapy

GnRH agonist (goreslin)
- First stimulates receptors and causes an increase in Sx
- Bone pain / cord compression / AKI / acute retention / coagulation abnormalities causing fatal CVS
- Give with anti-androgen - (Flutamide / Cryprecipitte) 3 days prior to starting
GnRH antagonist
Anti-androgen
Oestrogen
BIlateral orchidectomy

What is symptomatic Rx

Analgesia Biphosphonates for hypercalcaemia RT for bone mets or spinal compression

What is active surveillance

PSA level + DRE every few months | Biopsy /MRI annual or if any concern

What is watchful waiting

Waiting for symptoms to show

What are prognostic factors

Pre-treatment PSA Gleason Tumour stage - T from DRE Tumour grade

What are complications of RT and prostactetmoy

``` Rectal, bladder and colon cancer Proctitis Urethral stricture Erectile dysnfction Urinary incontinence ```

What is the commonest malignancy in the young

Testicular cancer | Must rule out if any swelling in young

What is the most common testicular cancer

Germ cell = 90% Non seminomatous = most common germ - Teratoma - Yolk - Choriocarcinma - Raised AFP + bHCG Seminomatous - No raised AFP but can have raised bHCG

What are non germ cell

Leydic Sertoli Lymphoma Sarcoma

How does testicular cancer present Where does it metastasis too

``` Painless lump Irregular Hard without fluctuantance or transillumination Haemospermia Tender inflamed lump Pre-aortic LN = abdo mass Secondary hydrocele Gynaecomastia Hormone secretion AFP and LDH increases ``` Lungs = SOB so always get a CXR if suspect Liver Brain

What are the RF for testicular cancer

``` Young Caucasian Testicular maldescent Infertility Atrophic testic Previous cancer Klienfelter Mumps Orchitis ```

How do you Dx

``` FBC MSSU USS scotrum = 1st line Biopsy = NOT as will seed tumour Can only Dx by excision and histology Do bHCG / ALP / AFP if USS suggest cancer ```

How do you stage

CT CAP | CXR for lung mets (typically cannon-ball)

What tumour markers in resticular cancer and how do you monitor after Rx

AFP BHG - non-seminoamtous LDH Often normal in seminomas Monitoring = tumour marker and imaging

How do you treat testicular cancer and mets

``` Radical orchiectomy Biopsy contralateral RT in SGCT Chemotherapy if nodal or mets Seminoma have slightly better prognosis Surveillance every 18-24 months with CT + tumour marker ```

What are your differentials

``` Hydrocele Varicocele Epndidymal cyst Inguinal hernia True testicular lump Torsion Infection ```

What is a sign of renal cancer

L varicocele - always do renal USS

Complications of prostatectomy (diff to TURP)

Erectile dysfunction Incontinence Urethral stenosis

What does penile cancer tend to be

SCC

What are RF

``` HPV Multiple partner Smoking Pre-malignant Bowens ```

Presentation

``` Painless sore or ulcer Bleeding Discharge Inguinal lympahdenopathy Many present late ```

Where does it spread too

``` Inguinal and iliac nodes Distant to para-aortic and mediastinal nodes Liver Lung Bone Brain ```

How do you Dx

Biopsy / cytology of lesion or nodes SNB USS / MRI for depth of invasion CT CAP / bone scan for stage

When do you reassess nodes

4-6 weeks after treatment of primary

How do you follow up

Assessment of primary / nodes | CT if N2

How do you treat early disease

Laser therapy Excision biopsy RT

How do you treat T2-T4

Surgery = mainstay Palliative chemo or RT Bilateral lymphadenoectomy

How do you treat inguinal LN

Surveillance if T1NO Bilateral lymhpadenctomy if T2-T4 +- chemo / RT if N1 Palliative chemo or RT if N3

What is protective against penile cancer

Circumcision

What does prognosis depend on

Seminoma better prognosis than teratoma High T stage Age LN +ve

What are SE of hormonal therapy

``` Impotence Flushing Sweats Muscle weakness Osteoporosis Gynaecomastia Weight gain Depression ```

How do you follow up teratoma / non-seminatous

CT and AFP and bHCG