Tumours of the urinary system 1 (Testicular and Prostate cancer) Flashcards
What is the most common cancer diagnosed in men?
Prostate cancer
Aetiology and RFs for prostate cancer
Age
Race/Ethnicity
Geography
Family history - first degree relative 2x risk
Which genes are related to prostate cancer?
HPC1
BRAC1 and 2
What are McNeal’s’ prostatic zones?
Transition zone
Central zone
Anterior fibromuscular stroma
Peripheral zone
4 areas of the prostate
Which zone is most commonly affected?
Peripheral zone
80% of newly diagnosed prostate cancers are what?
Localised
How are most prostate cancer cases diagnosed
Incidentally through opportunistic PSA testing as most patients are asymptomatic
At present, is there a screening programme for prostate cancer?
No
What is the PSA test
A blood test to help detect prostate cancer - it’s not completely reliable though.
It’s prostate specific but not necessarily cancer-specific
What triad of tests are used in the diagnosis of prostate cancer?
PSA test
Digital rectal examination (rectal exam)
TRUS-guided prostate biopsies
Symptoms of local invasive disease associated with prostate cancer
Haematuria
Perineal and suprapubic pain
Impotence - can’t get an erection or orgasm
Incontinence
Loin pain or anuria - obstruction of ureters
Symptoms of renal failure
Haemospermia - blood in semen
Symptoms of metastatic prostate cancer
Bone pain or sciatica
Paraplegia secondary to spinal cord compression
Lymph node enlargement
Lymphoedema - particularly in lower limbs
Loin pain or anuria due to obstruction of the ureters by lymph nodes
Widespread metastases - lethargy, weight loss and cachexia
Why can screening be detrimental?
It leads to over-diagnosis and over-treatment of harmless cancers
How can under-treatment of aggressive cancers (like prostate cancer) be avoided?
Ad-hoc PSA testing
What does the PSA test detect?
Prostate specific antigen
It’s produced by glands of the prostate - may leak into the serum
Levels in serum increase with age
What is the normal range of Kallikrein serine protease in serum?
0-4.0 ug/ml
When might you expect to see an elevation in PSA (6)
UTI Chronic prostatitis Instrumentation - catheterisation Physiological - ejaculation BPH - enlarged prostate Prostate cancer
What is the probability of cancer in relation to levels of PSA?
0-1.0 = 5% 2.5-4.0 = 25% >10 = 70%
What is the name given to the grading score for prostate cancer
Gleason grading of prostate cancer
score 3-5 (well to poorly differentiated)
Useful prognostically and guides treatment
Summated to give Gleason SUM core
How does the ISUP grade group work?
Grades prostate cancer from 1-5
For purposes of treatment and prognosis prostate cancer is divided into 4 stages, what are they?
Localised stage
Locally advanced stage
Metastatic stage
Hormone refractory stage - no longer responds to hormone therapy
What investigations/imaging can be done to stage localised prostate cancer?
Digital rectal examination (local staging)
PSA
Transrectal US guided biopsies
CT (regional and distant staging)
MRI (local staging)
Treatment options for localised prostate cancer?
Watchful waiting
Radiotherapy
Radical prostatectomy
Cryotherpay, thermotherapy
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)
Types of hormonal therapy for prostate cancer
Anti-androgens
Oestrogens
Chemical castration
PSA levels in localised, locally advanced and metastatic disease
Localised - <20
Locally advanced - 20-100
Metastatic - >100
What is the prognosis for metastatic prostate cancer
Median survival 3-5 years
Recommended treatment for low-risk localised disease
Active surveillance
Surgery
EBRT
Brachytherapy
Recommended treatment for intermediate risk localised disease
Surgery with external beam radiotherapy (EBRT) +/- HT
Brachytherapy
What is Brachytherapy?
A form of radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment.
Localised treatment
Recommended treatment for high-risk localised disease
External beam radiation therapy (EBRT) + HT
Presentation of testicular cancer?
Usually a painless lump
Can sometimes have tender inflamed swelling, history of trauma (although this is not a RF)
LUTS associated with localised disease in prostate cancer
Hesitancy
Frequency/urgency
weak/ poor stream
Straining
Dribbling
Nocturia
Where does prostate cancer most often spread to in metastases?
Bone
Lymph nodes
What is one of the most common cancers in young men?
Testicular cancer
When is a man’s risk of testicular cancer higher?
Testicular maldescent Infertility Atrophic testis Previous cancer in contralateral testis Caucasian men
What is a precursor lesion of testicular cancer?
Testicular Germ Cell Neoplasia In-Situ is a precursor lesion
Types of tumour markers in testicular cancer? (3)
AFP (alpha-fetoprotein) (teratoma)
Beta-HCG (Human Chorionic Gonadotrophin) (seminoma)
LDH (Lactate dehydrogenase) (non-specific marker of tumour burden)
How is testicular cancer diagnosed?
A lump in the testes is considered a tumour until proven otherwise
MSSU
Testicular USS and CXR
Tumour markers - blood test
Differential diagnoses for a lump in the testes
Infection
Epididymal cyst
Missed testicular torsion
Treatment of Testicular cancer
Radical orchidectomy is essential - removal of testes
Occasionally may need biopsy of ‘normal’ contralateral testis if high risk for tumour
Further treatment depends on tumour type, stage (TNM) and grade
Types of testicular cancer
Germ cell tumour (GCT) - 95%
Non GCT - 5%
Classes of GCT
Seminomatous GCT (classical, spermatocytic, or anaplastic) - mainly affects 30-40 y/o
Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT) - mainly affects 20-30 y/o
Types of Non-GCT (sex cord/stromal)
Leydig
Sertoli
Lymphoma rare
Testicular cancer - grading (aggressiveness)
Based on histological assessment of differentiation
Low grade = well differentiated
High grade = poorly differentiated
Testicular cancer - staging (spread)
Stage using TNM system. Tumour markers also provide staging and prognostic information
Spread occurs in 3 ways:
- local spread (i.e. local invasion to adjacent structures - pathological assessment)
- Regional spread (lymphatic invasion - CT scan)
- Distant spread (Lungs, bone, liver) using CT
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
Treatment of low stage testicular cancer with negative markers
Orchidectomy, followed by:
Surveillance; or
Adjuvant radiotherapy (SGCT only); or
Prophylactic chemotherapy
Treatment of nodal stage of testicular cancer with persistent tumour markers or relapse on surveillance
Combination chemotherapy (BEP - 3 drugs)
or
Lymph node dissection (NSGCT only)
Treatment of metastases associated with testicular cancer
First-line chemotherapy
Second-line chemotherapy
What is the prognosis of testicular cancer like?
Good if treated
Stage 1 - 5 year survival - 99%
Stage 4 - 5 year survival = 73%
