Urological Flashcards
What is the most common symptom of metastatic prostate cancer?
Lower back pain
Prostate cancer - risk factors?
AGE (increasing)
(60% prev. in men over 75s)
FAMILY HISTORY
4x more likely if one 1st degree relative diagnosed with CaP before age 60
GENETICS
although rare, also play a part, as men who possess the BRCA2 or BRCA1 gene are at greater risk. (BRACA2 MORE SIGNIFICANT)
ETHNICITY
Black or carabian
HEIGHT
Tall stature
USE OF ANABOLIC STEROIDS
LESS SIGNIFICANT + MODIFIABLE
obesity, diabetes mellitus, smoking (associated with increased risk of prostate cancer death), and degree of exercise (considered protective).
What subtypes of prostate cancer are most common?
95%: ADENOCARCINOMA
- Acinar adenocarcinoma
- Ductal adenocarcinoma
Where does the most common type of prostate cancer originate from?
Acinar adenocarcinoma – originates in the glandular cells that line the prostate gland
Where does the second most common type of prostate cancer originate from?
Ductal adenocarcinoma – originates in the cells that line the ducts of the prostate gland
Which type of prostate adenocarcinoma tends to grow and metastasise faster?
Ductal adenocarcinoma (as opposed to the more common, acinar adenocarcinoma)
Examples of LUTS that prostate cancer may present with?
Localised disease can present with lower urinary tract symptoms (LUTS) including:
weak urinary stream
increased urinary frequency
urinary urgency
terminal dribbling
nocturia
What symptoms might more advanced prostate cancer present?
More advanced localised disease may also cause:
Haematuria
Dysuria
Incontinence
Haematospermia
Suprapubic pain
Loin pain
Rectal tenesmus.
Any metastatic disease may cause, amongst others:
Bone pain
Lethargy
Anorexia
Unexplained weight loss.
From what area do most prostate adenocarcinomas arise from?
The posterior peripheral zone.
DDx for prostate cancer?
Benign prostatic hyperplasia (BPH) – a non-cancerous enlargement of the prostate gland, will also cause LUTS symptoms initially
Prostatitis – inflammation of the prostate gland; patients usually present with perineal pain, with neutrophils seen on urinalysis
Other causes of haematuria – these may include bladder cancer, urinary stones, urinary tract infections, and pyelonephritis
A Digital Rectal Examination (DRE) is essential if a diagnosis of prostate cancer is suspected*, as most prostate adenocarcinomas arise from the posterior peripheral zone.
What should be checked for and what might various findings present?
The examination should be checking for evidence of asymmetry, nodularity, or a fixed irregular mass.
A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus (the dip in the middle between the right and left lobe). There may be generalised enlargement in prostatic hyperplasia.
An infected or inflamed prostate (prostatitis) may be enlarged, tender and warm.
A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule. Any of these features can indicate prostate cancer and warrant further investigation. In primary care, these findings require a two week wait urgent cancer referral to urology.
What is the standard method for diagnosing prostate cancer?
The current standard method for diagnosing prostate cancer is through biopsies of prostatic tissue:
Although there are two potential methods, there is a general trend towards performing only transperineal due to the decreased risk of infection:
Transperineal biopsy – can be done either as a template biopsy (A), which used a grid-like template, sampling of prostatic tissue in a systematic manner, or as a freehand biopsy, where sampling is guided by both intra-procedure ultrasound and mpMRI
TransRectal UltraSound-guided (TRUS) biopsy (B) – this involves sampling the prostate transrectally, using ultrasound as guidance and then sampling of prostatic tissue in a systematic manner
Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a Likert scale, scored as:
1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer
What is recommended after previous negative prostatic tissue biopsy for men with rising or persistently elevated PSA and/or suspicious DRE?
Repeat prostate biopsy after previous negative biopsy is recommended for men with rising or persistently elevated PSA and/or suspicious DRE.
How are prostate cancers graded?
The Gleason grading system is a scoring system by which prostate cancers are graded, based upon their histological appearance.
It is specific to prostate cancer and helps to determine what treatment is most appropriate. The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).
The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):
The first number is the grade of the most prevalent pattern in the biopsy
The second number is the grade of the second most prevalent pattern in the biopsy
What Gleason score is considered a low risk?
6 or below
What Gleason score is considered an intermediate risk?
7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
What Gleason score is considered to be hight risk?
8 or above is deemed to be high risk
