Urological Cancer Flashcards
What are the symptoms and signs of prostate cancer?
Localised disease can present with lower urinary tract symptoms (LUTS):
- Urinary frequency
- Nocturia
- Weak/interrupted flow
- Urinary urgency
More advanced localised disease may also cause:
- haematuria
- dysuria
- incontinence
- haematospermia
- suprapubic pain
- loin pain
- rectal tenesmus.
Metastatic disease may cause:
- bone pain
- lethargy
- anorexia
- unexplained weight loss.
Differential diagnosis of prostate cancer (3)?
- 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
Which laboratory tests must be performed in patients presenting with symptoms indicative of prostate cancer?
- Serum PSA
- FBP
- U&E
A 54 year old male patient presents to you with urinary frequency, nocturia x 3, and hesitancy. What should you, the GP, do next?
- Full history - are there infective symptoms? Drug history? Family history?
- Urinalysis for glycosuria/infection
- CBG
- DR examination (size/shape/symmetry/texture/firmness/nodules/bogginess?
- Serum PSA/FBP/U&E
Serum PSA has low specificity. In what conditions/circumstances is it elevated?
- Prostate cancer
- BPH
- Prostatitis
- Vigorous exercise
- Post-ejaculation
- Recent DR examination
Outside of serum PSA what additional investigation(s) are required to diagnose prostate cancer?
PROSATIC TISSUE BIOPSY GOLD STANDARD! TWO OPTIONS:
Transperineal biopsy – this involves sampling prostatic tissue transperineally in a systematic manner, done as a day case under general anaesthetic. The transperineal approach allows better access to the anterior part of the prostate and also has a lower risk of infection
TransRectal UltraSound-guided (TRUS) biopsy– this involves sampling the prostate transrectally, usually under local anaesthetic. Generally 12 cores are taken bilaterally in equal distribution from base to apex. Transrectal biopsies are associated with a 1-2% risk of sepsis.
Discuss the Gleason Grading System for prostate cancer
- Scoring system based on histology
- 1 = well-differentiated (small, uniform glands)
- 5 = anaplastic (very rarely gland forming)
- Sum of most common histological growth pattern and most aggressive pattern
- Lowest score = 3+3
- Higher scores = poor prognosis
- In practice is used in conjunction with TNM staging and PSA levels to determine prognosis
What are the gold-standard radiological investigations?
MRI pelvic + isotope bone scan
Which three parameters are used in informing the management of prostate cancer (risk stratification)?
- PSA levels
- Gleason score
- Clinical stage
*discussed at MDT
What management options are available in prostate cancer?
- Active surveillance
- Radical prostatectomy
- Brachytherapy
- Radiotherapy
Management in low-risk prognostic grouping?
Active surveillance (3-monthly PSA, 6 month to yearly DRE, and re-biopsy at 1-3 yearly intervals assessing for progression and intervening at the appropriate time)
Management in intermediate to high risk prognostic groups?
Radical treatment options should be discussed with all men with intermediate risk disease and high risk disease with realistic disease control. Those with intermediate risk can also be offered active surveillance (should not be offered for high risk disease)
Management in metastatic disease?
Chemotherapy agents and anti-hormonal agents can be used in metastatic prostate cancer
What is the mainstay surgical management and what are the side-effects?
- Laparoscopic radical prostatectomy (remove prostate gland, seminal vesicles, +/- removal of pelvic lymph nodes)
- Side-effects = erectile dysfunction, stress incontinence and bladder neck stenosis
Discuss the two modalities of radiotherapy used in prostate cancer
- External-beam radiotherapy and brachytherapy - curative intervention for localised prostate cancer
- Brachytherapy involves the transperineal implantation of radioactive seeds (usually Iodine-125) directly into the prostate gland, whilst external-beam radiotherapy uses focused radiotherapy to target the prostate gland and limiting damage to surrounding tissues.
