Tumours of the Urinary System 1 (Prostate Cancer and Testicular Cancer) Flashcards
prostate cancer
where is the prostate gland?
what is the commonest cancer in men?
prostate
what is the aetiology and risk factors of prostate cancer?
• Age
• Race/Ethnicity - African or Afro-Caribbean men living in Western countries vs East Asian or Asian men living in Western countries
• Geography - Northwest Europe/North America/Caribbean/ Australia vs Asia/Africa/Central & South America
• Family history - first degree relative 2x risk, HPC1; BRCA1 & 2
where do most prostate cancers start?
Most prostate cancers start in the peripheral zone
80% of newly diagnosed prostate cancers are __________
localised
are most asymptomatic or symptomatic?
Mostly asymptomatic (i.e. do NOT have cancer-specific symptoms)
How is prostate cancer diagnosed?
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
localised prostate cancer:
what are the presenting symptoms in local disease?
weak stream
hesitancy
sensation of incomplete emptying
frequency
urgency
urge incontinence
UTI
localised prostate cancer:
what are the presenting symptoms in locally invasive disease?
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
metastatic prostate cancer:
presenting symptoms in distant metastases
bone pain or sciatica
paraplegia secondary to spinal cord compensation
lymph node enlargement
lymphoedema, particularly in the lower limbs
loin pain or anuria due to obstruction of the ureters by lymph nodes
metastatic prostate cancer:
presenting symptoms in widespread metastases
lethargy (e.g. due to anaemia, uraemia)
weight loss and cachexia
MCQ: 1. What is the commonest mode of presentation for prostate cancer?
a. Frank haematuria
b. Asymptomatic (i.e. incidentally noted)
c. Acute urinary retention
d. Symptoms of benign prostatic enlargement and obstruction
e. Bone pain
B
Screening leads to ___________ and ____________ of harmless cancers
over-diagnosis
over-treatment
How to avoid under-treatment of aggressive cancers?
Answer: Ad-hoc PSA testing!!
what is PSA?
Prostate-specific antigen
- Kallikrein serine protease - liquifies semen
- Produced by glands of prostate - may leak into serum
- 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 may cause elevations in PSA?
- UTI
- chronic prostatitis
- instrumentation (e.g. catheterisation)
- physiological (e.g. ejaculation)
- recent urological procedure
- BPH
- prostate cancer
what is PSAs half life?
2.2 days
What is the probability of cancer based on PSA?
Levels of PSA and cancer probability (PPV):
0-1.0: 5%
- 0-2.5: 15%
- 5–4.0: 25%
- 0-10: 40%
>10: 70%
What is Gleason Grading of Prostate Cancer?
- Pathologist classifies grade of prostate cancer
- Score 3-5 (well to poorly differentiated)
- Summated to give Gleason SUM core
- e.g. 3 + 4 = 7
•Useful prognostically and guides treatment
Grading system is changing to ISUP grade group
what are the stages of prostate cancer?
• For purposes of treatment and prognosis, useful to divide prostate cancer into 4 stages :
- Localised stage
- Locally advanced stage
- Metastatic stage
- Hormone refractory stage
how is staging of localised prostate cancer done?
- Digital rectal examination (local staging)
- PSA
- Transrectal US guided biopsies
- CT (regional and distant staging)
- MRI (local staging)
what is the treatment of localised prostate cancer?
- Watchful waiting
- Radiotherapy - External-beam, Brachytherapy
- Radical prostatectomy - Open, Laparoscopic, Robotic
- Others under investigation - Cryotherapy, Thermotherapy
what are the types of hormonal therapy for prostate cancer?
- Surgical castration (i.e. bilateral orchidectomy)
- Chemical castration (i.e. LHRH analogue – goserelin, leuprorelin; or LHRH antagonists)
- LHRH analogues eventually downregulates androgen receptors by negative feedback
- tumour flare in first week of therapy (hence need anti-androgen during this period)
- LHRH antagonists DO NOT cause tumour flare
- 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
how does each stage of cancer relate to its prognosis?
what is the treamtent of localised disease?
- The following are reasonable treatment options for low-risk localised prostate cancer except:
a. External beam radiotherapy
b. Active surveillance
c. Brachytherapy
d. Radical prostatectomy
e. Radical chemotherapy
e
- The following statements about screening for prostate cancer are true except:
a. PSA is the best available screening test
b. Compared with ad-hoc opportunistic PSA testing, screening for prostate cancer is beneficial because it saves lives
c. If screening is advocated, it should be performed for men at risk of prostate cancer rather than the entire male population
d. Screening for prostate cancer is not currently advocated
e. For suspicious cases detected by screening, there is a need to undergo a definitive test to confirm or exclude presence of prostate cancer
Testicular cancer
what is the presentation of testicular cancer?
Presentation - Usually:
• 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
what is the incidence and aetiology of testicular cancer?
- One of the commonest cancers of young men
- Peak incidence in third decade
- Racial - higher risk in Caucasians
- Risk higher in testicular maldescent; infertility; atrophic testis; and previous cancer in contralateral testis
- Aetiology is unknown but Testicular Germ Cell Neoplasia In-Situ is a precursor lesion
what are tumour marker sin testicular cancer?
- Blood for tumour markers is taken immediately before and serially after surgery
- Types of tumour markers:
- AFP (alpha-fetoprotein) (teratoma)
- bHCG (Human Chorionic Gonadotrophin) (seminoma)
- LDH (Lactate dehydrogenase) (non-specific marker of tumour burden)
what is the diagnosis of testicular cancer?
- Lump in testis = testicular tumour until proven otherwise
- MSSU
- Testicular ultrasound scan and CXR
- Tumour markers
What are some differential diagnoses for testicular cancer?
• Differential diagnoses:
- infection (i.e. epididymo-orchitis)
- epididymal cyst
- missed testicular torsion
what is the treatment for testicular cancer?
- Radical orchidectomy is essential (surgery to remove your testicle and the spermatic cord)
- Occasionally may need biopsy of ‘normal’ contralateral testis if high risk for tumour
- Further treatment depends on tumour type, stage (TNM) and grade
- For testicular cancer, the main lymphatic spread to regional lymph nodes occurs in which group of lymph nodes?
a. Scrotal lymph nodes
b. Inguinal lymph nodes
c. Pelvic lymph nodes (i.e. internal iliac chain)
d. Mediastinal lymph nodes
e. Para-aortic lymph nodes
i think c
maybe e as says on first testicular cancer card
- When performing radical inguinal orchidectomy for testicular cancer:
i. Where is the incision made?
ii. Why is the incision made here?
what are the different pathologies of testicular cancer?
- Germ cell tumour (GCT) (95%) vs Non-GCT (5%)
- GCT:
- Seminomatous GCT (classical, spermatocytic, or anaplastic)
- Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT)
• Non-GCT (sex cord/stromal):
- Leydig
- Sertoli
- Lymphoma rare
Seminoma and Non-seminomatous mainly affect who?
- Seminoma
- Mainly affects 30-40 year olds
• Non-seminomatous
- Mainly affect 20-30 year-old
- Often mixed
what does grading of testicular cancer mean?
Grading = assessment of AGGRESSIVENESS
what are the different grades of testicular cancer?
•Based on histological assessment of differentiation
- Low grade = well differentiated
- High grade = poorly differentiated
what does stagig of testicular cancer mean?
Staging = assessment of SPREAD
Stage using TNM system
What ways can spread occur in?
•Spread occurs in 3 ways:
- local spread (i.e. local invasion to adjacent structures)
- regional spread (lymphatic invasion)
- distant spread (lungs, bone, liver)
how can you stage testicular cancer?
- Local staging (via pathological assessment of orchidectomy specimen)
- Nodal staging (via CT scan)
- Distant staging (chest, abdomen and pelvis) (via CT scan)
- Tumour markers also provide staging and prognostic information
what are the different stages of testicular cancer?
- Stage I - disease is confined to the testis
- Stage II - Infradiaphragmatic nodes involved
- Stage III - Supradiaphragmatic nodes involved
- Stage IV - extralymphatic disease
Further treatment following orchidectomy depends on tumour type, stage (TNM) and grade
what are some futher treatments?
Low stage, negative markers:
- Orchidectomy, followed by:
- Surveillance; or
- Adjuvant radiotherapy (SGCT only); or
- Prophylactic chemotherapy
Nodal disease, persistent tumour markers, or relapse on surveillance:
- Combination chemotherapy (BEP); or
- Lymph node dissection (NSGCT only)
Metastases:
- First-line chemotherapy
- Second-line chemotherapy
Prognosis good if treated:
Stage 1: 5-year survival – 99%
Stage 2/3: 5-year survival – 96%
Stage 4: 5-year survival – 73%
