Tumours of the Urinary System 1 (Prostate and Testicular Cancers) Flashcards
1
Q
What is the commonest cancer in men?
A
Prostate cancer
2
Q
What is the incidence of prostate cancer?
A
- 134/100000 men/year
3
Q
How does the incidence of prostate cancer change with age?
A
- Incidence increases with age
4
Q
What are risk factors for prostate cancer?
A
- Age
- Race/ethnicity
- Geography
- Family history
- First degree relative is 2x risk
- HPC1, BRCA1 and 2
5
Q
What genes are linked to prostate cancer?
A
- HPC1, BRCA1 and 2
6
Q
How does most prostate cancer present?
A
- 80% of newly diagnosed prostate cancers are localised
- Mostly asymptomatic (do not have cancer specific symptoms)
7
Q
How is prostate cancer diagnosed?
A
- Diagnosed through opportunistic PSA testing (not screening)
- Diagnostic triad of PSA, digital rectal examination and TRUS-guided prostate biopsies
8
Q
What are some localised prostate cancer presenting symptoms?
A
9
Q
What is the presentation of metastatic prostate cancer?
A
10
Q
Is prostate cancer screened for?
A
Screening is not done for prostate cancer, but ad-hoc PSA testing is:
- Kallikrein serine protease (liquifies semen)
- Produced by glands of prostate
- Normal serum range is 0-4ug/mL
- Levels change 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
- 6.5 years 6.5 is upper limit
- Levels change with age
11
Q
What is the normal serum range of Kallikrein serine protease?
A
- Normal serum range is 0-4ug/mL
- Levels change 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
- Levels change with age
6.5 years 6.5 is upper limit
12
Q
What does PSA testing measure?
A
Kallikrein serine protease
13
Q
Elevations in PSA can occur due to?
A
- UTI
- Chronic prostatitis
- Instrumentation (catheterisation)
- Physiological (ejaculation)
- Recent urological procedure
- BPH
- Prostate cancer
14
Q
What is the half life of PSA?
A
2.2 days
15
Q
If repeated PSA tests are needed, how long should be waited before rechecking?
A
If repeat PSA needed, recheck in at least 3 weeks (ie 8 half lifes)
16
Q
What is the probability of cancer based on PSA levels?
A
17
Q
What is used to grade prostate cancers pathologically?
A
Gleason grading of prostate cancer:
- Pathologist classifies grade of prostate cancer
- Score 3 to 5 (well to poorly differentiated)
- Summate to give Gleason SUM score
- Useful prognostically and guides treatment
18
Q
What are Gleason gradings converted into?
A
ISUP grade
19
Q
For purposes of treatment and prognosis, it is useful to divide prostate cancer into 4 stages, what are these?
A
- Localised stage
- Locally advanced stage
- Metastatic stage
- Hormone refractory stage
20
Q
What can staging of localised prostate cancer be done by?
A
- Digital rectal examination (local staging)
- PSA
- Transrectal US guided biopsies
- CT (regional and distant staging)
- MRI (local staging)
21
Q
What is the treatment of localised prostate cancer?
A
- Radiotherapy
- External-beam
- Brachytherapy
- Radical prostatectomy
- Open
- Laparoscopic
- Robotic
- Others under investigation
- Cryotherapy
- Thermotherapy
22
Q
What is the treatment of locally advanced prostate cancer?
A
- Watchful waiting
- Hormone therapy followed by surgery
- Hormone therapy followed by radiation
- Hormone therapy alone
- Intermitted hormone therapy (clinical research)
23
Q
What are different types of hormonal treatment for prostate cancer?
A
- Surgical castration
- Ie bilateral orchidectomy
- Chemical castration
- Ie LHRH analogue or LHRH antagonists
- LHRH analogues eventually downregulates androgen receptors by negative feedback
- Tumour flare in first week of therapy, LHRH antagonists do not cause tumour flair
- Ie LHRH analogue or LHRH antagonists
- Anti-androgens
- Inhibit androgen receptors
- Oestrogens
- Inhibits LHRH and testosterone secretion inactivates androgens and has direct cytotoxic effects on prostatic epithelial cells
24
Q
What are examples of chemical castration?
A
- Ie LHRH analogue or LHRH antagonists
- LHRH analogues eventually downregulates androgen receptors by negative feedback
- Tumour flare in first week of therapy, LHRH antagonists do not cause tumour flair
25
How does oestrogen hormonal therapy for prostate cancer work?
* Inhibits LHRH and testosterone secretion inactivates androgens and has direct cytotoxic effects on prostatic epithelial cells
26
What are some metastatic prostate cancer complications?
* Bone
* Pain, pathological fractures, anaemic, spinal cord compression
* Rectal
* Constipation, bowel obstruction
* Ureteric
* Obstruction from renal failure
* Pelvic lymphatic obstruction
* Lymphoedema, DVT
* Lower urinary tract dysfunction
Haematuria, acute retention
27
What is the treatment for metastatic prostate cancer?
* Hormonal therapy
* Supportive treatment
* Palliative radiotherapy
* Colostomy
* Nephrostomy
* Palliative supportive care
28
How does the prognosis of prostate cancer change with stage?
29
What is the presentation of testicular cancer?
* Usually
* Painless lump
* Less often
* Tender inflamed swelling
* History of trauma (although trauma is not a risk factor)
* Symptoms/signs from nodal or distant metastases
* Para-aortic lymph nodes
* Chest
* Bone
30
What is one of the commonest cancers in young men?
Testicular cancer
31
What are risk factors for testicular cancer?
* Higher risk if Caucasians
* Risk also higher in testicular maldescent, infertility, atrophic testis, previous cancer in contralateral testis
32
In what decade of life is the peak incidence of testicular cancer?
* Peak incidence in 3rd decade
33
What is the aetiology of testicular cancer?
* Aetiology is unknown but testicular germ cell neoplasia in situ is a precursor lesion
34
What are different types of tumour markers for testicular cancer?
* AFP (alpha-fetoprotein)
* Teratoma
* BHCG (human chorionic gonadotrophin)
* Seminoma
* LDH (lactate dehydrogenase)
* Non-specific marker of tumour breakdown
35
What does AFP stand for?
Alpha-fetoprotein
36
Alpha-fetoprotein is a biomarker for what?
Teratoma
37
BHCG stands for what?
Human chorionic gonadotrophin
38
Human chorionic gonadotrophin (BHCG) is a biomarker for what?
Seminoma
39
LDH stands for?
Lactase dehydrogenase
40
Lactate dehydrogenase is a tumour biomarker for what?
* Non-specific marker of tumour breakdown
41
What investigations are done to diagnose testicular cancer?
* Lump in testicle is treated as tumour until proven otherwise
* Differential diagnosis
* Infection
* Epididymal cyst
* Missed testicular torsion
* MSSU
* Testicular ultrasound scan and chest x-ray
* Tumour markers
42
What is the differential diagnosis of testicular cancer?
* Infection
* Epididymal cyst
* Missed testicular torsion
43
What are the different pathological types of testicular cancer?
* Germ cell tumour (95%) vs non-germ cell tumour (5%)
* Germ cell tumour (GCT)
* Seminomatous GCT (classical, spermatocytic or anaplastic)
* Affects mainly 30-40 years olds
* Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT)
* Affects mainly 20-30 year olds
* Non GCT (sex cord/stromal)
* Leydig
* Sertoli
* Lymphoma rare
44
Are germ cell tumours or non-germ cell tumours more common?
* Germ cell tumour (95%) vs non-germ cell tumour (5%)
45
What does GCT stand for?
Germ cell tumour
46
What are the different kinds of germ cell tumours?
* Seminomatous GCT (classical, spermatocytic or anaplastic)
* Affects mainly 30-40 years olds
* Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT)
* Affects mainly 20-30 year olds
47
What are the different kinds of non-GCTs?
* Leydig
* Sertoli
* Lymphoma rare
48
Which age group does seminomatous GCT and non-seminomatous GCT normally affect?
Seminomatous - 30 to 40 years
Non-seminomatous - 20 to 30 years
49
What is grading of testicular cancer an assessment of?
Aggressiveness
50
What is grading of testicular cancer based on?
* Based on histological assessment of differentiation
* Low grade is well differentiated
* High grade is poorly differentiated
51
What is staging an assessment of?
Assessment of spread
52
What are the 3 ways that testicular cancer can spread?
* Local spread
* Such as local invasion to adjacent structures
* Regional spread
* Lymphatic invasion
* Distant spread
* Lungs, bone, liver
53
Where does testicular cancer commonly metastasis to?
Lungs
Bone
Liver
54
What system is used to stage testicular cancer?
TNM system
55
What investigations are done to stage testicular cancer?
* Local staging via pathological assessment or orchidectomy specimen
* Nodal staging via CT scan
* Distant staging via chest, abdomen and pelvis CT scan
* Tumour markers also provide staging and prognostic information
56
What are the different stages of testicular cancer?
* Stage 1 – disease is confined to the testis
* Stage 2 – infradiaphragmatic nodes involved
* Stage 3 – supradiaphragmatic nodes involved
* Stage 4 – extralymphatic disease
57
What is stage 1 testicular cancer?
* Stage 1 – disease is confined to the testis
58
What is stage 2 testicular cancer?
* Stage 2 – infradiaphragmatic nodes involved
59
What is stage 3 testicular cancer?
* Stage 3 – supradiaphragmatic nodes involved
60
What is stage 4 testicular cancer?
* Stage 4 – extralymphatic disease
61
What is the prognosis of testicular cancer?
Good if treated
62
What is the treatment of testicular cancer?
* Radical orchidectomy is essential
* Occasionally may need biopsy of normal contralateral testis if high risk for tumour
* Further treatment depends on tumour type, stage (TNM) and grade
* 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
63
What is the further treatment of low grade testicular cancer?
* Orchidectomy followed by
* Surveillance or
* Adjuvant radiotherapy (SGCT only) or
* Prophylactic chemotherapy
64
What is the further treatment of nodal disease, persistent tumour markers or relapse on surveillance testicular cancer?
* Combination chemotherapy (BEP) or
* Lymph node dissection (NSGCT only)
65
What is the treatment for testicular cancer with metastasis?
* First line chemotherapy
* Second line chemotherapy
