Tumours of the Urinary System 1 (Prostate Cancer and Testicular Cancer)

Question 1

At what age do men tend to get diagnosed with prostate cancer?

Answer 1

75% of new cases are aged >65 years

1% of new cases are aged <50 years

However, 45% of new cases <70 years

Question 2

How does prostate cancer tend to present?

Answer 2

• Mostly asymptomatic

- May have bladder outflow obstruction
weak stream / urgency / incontinence / incomplete emptying

Question 3

What is the optimal diagnostic triad for prostate cancer?

Answer 3

PSA (prostate specific antigen)

Digital rectal examination

TRUS-guided prostate biopsies

Question 4

What are normal and age adjusted values for PSA testing?

Answer 4

Normal serum range 0-4.0 microg/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

Question 5

What are some possible causes of elevated PSA?

Answer 5

• UTI
• chronic prostatitis
• instrumentation (e.g. catheterisation)
• recent urological procedure
• BPH (benign prostatic hyperplasia)
• prostate cancer

Question 6

What is the probability of prostate cancer based on different PSA levels?

Answer 6

2. 5–4.0: 25%
3. 0-10: 40%

> 10: 70%

(looking for a value over 10microg/mL)

Question 7

What scale is used to grade prostate cancer? What values indicate an aggressive cancer?

Answer 7

• Gleason Score

Scores of 6 or less suggest that the cancer is likely to grow slowly. Scores of 8 or higher describe cancers that are likely to spread more rapidly.

Question 8

What are the 4 “stages” prostate cancers are often divided into?

Answer 8

1. Localised stage
2. Locally advanced stage
3. Metastatic stage
4. Hormone refractory stage

Question 9

What investigations are used to stage prostate cancer?

Answer 9

Digital rectal examination (local staging)
PSA
Transrectal US guided biopsies
CT (regional and distant staging)
MRI (local staging)

Question 10

What are the treatment options for localized prostate cancer?

Answer 10

• Radiotherapy
• Radical prostatectomy (open / laparoscopic / robotic laparoscopic)
• Hormone therapy

Question 11

What are some hormone therapy options for the treatment of prostate cancer?

Answer 11

• Surgical castration (bilateral orchidectomy - christ)
• Chemical castration (LHRH analogues)
• Anti-androgens
• Oestrogens

Question 12

What are some presentations of testicular cancer?

Answer 12

• Usually: painless mass

Less often: tender swelling, metastatic symptoms

Question 13

Who is most at risk of testicular cancer?

Answer 13

• Men in third decade

- Caucasians

Question 14

What are some serum biomarkers that can indicate testicular cancer?

Answer 14

AFP (alpha-fetoprotein) (teratoma)

(beta)HCG (Human Chorionic Gonadotrophin) (seminoma)

LDH (Lactate dehydrogenase) (non-specific marker of tumour burden)

Question 15

What investigations can be done for diagnosis of testicular cancer?

Answer 15

• Serum biomarkers
• testicular palpation
• MSSU
• Testicular USS

Question 16

What is the usual treatment plan for testicular cancer?

Answer 16

• Radical orchidectomy
• Chemo / radiotherapy as needed
• Biopsy contralateral testicle if high tumour risk

Question 17

What is the most common type of testicular cancer? What are the two divisions of this type of cancer?

Answer 17

Germ cell tumour (GCT)

• Seminoma: tend to spread slowly. Secrete human chorionic gonadotropin (HCG)
• Nonseminomatous: variable in appearance and prognosis. Secrete alpha fetoprotein (AFP) mostly (can secrete HCG in some cases)

Question 18

Which groups of men are typically affected by seminomas and nonseminomatous tumours?

Answer 18

Seminoma
Mainly affects 30-40 year olds

Non-seminomatous
Mainly affect 20-30 year-old

Question 19

How are testicular tumours graded?

Answer 19

Grading based on aggressiveness, which is determined by level of differentiation of tumour cells

• Low grade = well differentiated
• High grade = poorly differentiated

Question 20

How are testicular cancers staged? What investigations are used for staging?

Answer 20

Staged based on level of spread (TNM staging)

Local staging (via pathological assessment of orchidectomy specimen)
Nodal staging (via CT scan)
Distant staging (chest, abdomen and pelvis via CT scan)

Question 21

What are the stages of testicular cancer?

Answer 21

Stage I - disease is confined to the testis

Stage II - Infradiaphragmatic nodes involved

Stage III - Supradiaphragmatic nodes involved

Stage IV - extralymphatic disease

Question 22

What is the prognosis like for testicular cancer?

Answer 22

Depends on stage, but good if treated:

Stage 1: 5-year survival – 99%
Stage 2/3: 5-year survival – 96%
Stage 4: 5-year survival – 73%