Tumours of the Urinary System 1 (Prostate Cancer and Testicular Cancer) Flashcards
Who is most likely to get prostate cancer?
•75% of new cases are aged >65 years
What are the prostatic zones?
Peripheral zone = prostatic cancer
How is the diagnosis of prostate cancer made?
Diagnosed through opportunistic PSA testing (not screening!)
Diagnostic triad of PSA, digital rectal examination and TRUS-guided prostate biopsies
PSA is prostate specific but not necessarily cancer-specific
What are the localised prostate cancer presenting symptoms?
Local disease:
Weak stream
Hesitancy
Sensation of incomplete emptying
Frequency
Urgeny
Urge incontinence
UTI
What are symptoms of locally invasive disease of prostate cancer?
Haematuria
Perineal and suprapubic pain
Impotence
Incontinence
Loin pain or anuria resulting from obstruction of the ureters
Symptoms of renal failure
Haemospermia
Rectal symptoms including tenesmus
What are presenting symptoms of metastatic prostate cancer?
Bone pain or sciatica
Paraplegia secondary to spinal cord compression
Lymph node enlargement - loin pain or anuria due to obstruction of the ureters by lymph nodes
Lymphoedema - lower limbs
Widespread mets - lethargy (anaemia or uraemia), weight loss and cachexia
Why isn’t there screening for prostate cancer?
–Screening leads to over-diagnosis and over-treatment of harmless cancers
What is the normal range of PSA?
•Normal serum range 0-4.0 mg/mL
–Age-related range - Levels increase with age
- < 50 years : 2.5 is upper limit
- 50-60 years : 3.5 is upper limit
- 60-70 years : 4.5 is upper limit
- >70 years : 6.5 is upper limit
What causes elevation in PSA?
- UTI
- chronic prostatitis
- instrumentation (e.g. catheterisation)
- physiological (e.g. ejaculation)
- recent urological procedure
- BPH
- prostate cancer
What is the half life of PSA, when should a repeat PSA be carried out?
Half-life of PSA 2.2 days
If repeat PSA needed, recheck in 3 weeks (i.e. 8 half-lives)
Levels of PSA and cancer probability (PPV):
0-1.0: 5%
- 0-2.5: 15%
- 5–4.0: 25%
- 0-10: 40%
>10: 70%
How is prostate cancer graded?
Gleason score
How does the gleason score work?
The cancer is analysed - cell types are given a score from 3-5 (well to poorly differentiated)
The most common cell type number is then added to the second most common cell type number
What are the 4 stages of prostate cancer?
–Localised stage
–Locally advanced stage
–Metastatic stage
–Hormone refractory stage
How do we stage localosed prostate cancer?
- Digital rectal examination (local staging)
- PSA
- Transrectal US guided biopsies
- CT (regional and distant staging)
- MRI (local staging)
What is treatment for localised prostate cancer?
- Watchful waiting
- Radiotherapy
–External-beam
–Brachytherapy
•Radical prostatectomy
–Open
–Laparoscopic
–Robotic
•Others under investigation
–Cryotherapy
–Thermotherapy
What is the treatment of locally advanced prostate cancer?
- Watchful waiting
- Hormone therapy followed by surgery
- Hormone therapy followed by radiation
- Hormone therapy alone
- Intermitted hormone therapy (clinical research)
What are the types of hormonal therapy for prostate cancer?
- Surgical castration (i.e. bilateral orchidectomy)
- Chemical castration (i.e. LHRH analogue – goserelin, leuprorelin, etc.)
–eventually downregulates androgen receptors by negative feedback
–tumour flare in first week of therapy (hence need anti-androgen during this period)
•Anti-androgens
–inhibits androgen receptors
•Oestrogens (i.e. diethylstilboestrol)
–inhibits LHRH and testosterone secretion, inactivates androgens and has direct cytotoxic effect on prostatic epithelial cells
What are the complications of me tastatic and hormonerefractory prostate cancer?
•Complications :
–Bone : pain, pathological fractures, anaemia, spinal cord compression
–Rectal : constipation, bowel obstruction
–Ureteric : obstruction resulting in renal failure
–Pelvic lymphatic obstruction : lymphoedema, DVT
–Lower urinary tract dysfunction : haematuria, acute retention
What is the treatment for metastatic and hormone refractory prostate cancer?
- Immediate hormonal therapy is mainstay of treatment
- Supportive treatment : e.g. palliative radiotherapy to bony metastases, colostomy, nephrostomy, zoledronic acid, palliative care support, etc.
- Hormone refractory stage will be reached in 18-24 months of treatment
–Diethylstilboestrol can be tried (high risk of thromboembolic and cardiovascular complications); median response time 4 months
–Docetaxel has survival benefit of 3 months
–Median survival of HRPC stage is 10 months
Stage and prognosis
Treatment of localised disease
ERBT - External Beam Radio Therapy
the treatment of cancer, especially prostate cancer, by the insertion of radioactive implants directly into the tissue.
What is the presentation of testicular cancer?
Usually a painless lump
Less often:
- tender inflamed swelling
- history of trauma (although trauma NOT a risk factor)
- symptoms/signs from nodal or distant metastasis
- para-aortic lymph nodes
- chest
- bone
Who is at risk of testicular cancer?
Peak incidence is in the third decade of life
Racial - higher risk in caucasians
•Risk higher in testicular maldescent; infertility; atrophic testis; and previous cancer in contralateral testis
What are the tumour biomarkers for testicular cancer and when are they taken?
Types of tumour markers:
–AFP (alpha-fetoprotein) (teratoma)
–bHCG (Human Chorionic Gonadotrophin) (seminoma)
–LDH (Lactate dehydrogenase) (non-specific marker of tumour burden)
How is the diagnosis of testicular cancer made?
- Lump in testis = testicular tumour until proven otherwise
- Differential diagnoses:
- infection (i.e. epididymo-orchitis)
- epididymal cyst
- missed testicular torsion
- MSSU
- Testicular ultrasound scan and CXR
- Tumour markers
What is the treatment for testicular cancer?
- Radical orchidectomy is essential
- Occasionally may need biopsy of ‘normal’ contralateral testis if high risk for tumour
(Take out the testicle, check the other side)
•Further treatment depends on tumour type, stage (TNM) and grade
What are the two types of testicular cancer?
Either germ cell tumour (95%) or non germ cell tumour (5%)
What are the types of germ cell tumour?
–Seminomatous GCT (classical, spermatocytic, or anaplastic)
–Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT)
What are the non-germ cell tumours?
-Leydig
Sertoli
Lyphoma (rare)
Who is affected by tumours (seminoma and non-seminomatous germ cell tumours)
•Seminoma
–Mainly affects 30-40 year olds
•Non-seminomatous
–Mainly affect 20-30 year-old
–Often mixed
What is testicular cancer grading based on?
Assessment of aggressiveness - histological assessment of differentiation - Low grade - well differentiated
High grade - poorly differentiated
What is testicular cancer staging based on?
Staging = assessment of spread
Spread occurs in 3 ways
•Spread occurs in 3 ways:
- local spread (i.e. local invasion to adjacent structures)
- regional spread (lymphatic invasion)
- distant spread (lungs, bone, liver)
•Stage using TNM system
How is assessment of staging made?
Local?
Nodal?
Distant?
Local - pathological assessment of testicle (orchidectomy specimen) - makes sure cancer is localised to the testicle
Nodal staging (via CT scan)
Distant staging (chest, abdomen and pelvis- CT scan)
Tumour markers also provide staging and prognostic information
Staging 1,2,3 and 4
- Staging
- Stage I - disease is confined to the testis
- Stage II - Infradiaphragmatic nodes involved
- Stage III - Supradiaphragmatic nodes involved
- Stage IV - extralymphatic disease
What is the treatment for low stage negative markers?
Orchidectomy, followed by:
Surveillance; or
Adjuvant radiotherapy (SGCT only); or
Prophylactic chemotherapy
What is the treatment for nodal disease, persistent tumour biomarkers or relapse on surveillance?
Combination chemotherapy (BEP)
Lymph node dissection (NSGCT only
What is the treatment for Metastases
First line chemotherapy
Second line chemotherapy
