Urological Cancers Flashcards
Prostate cancer is the ______ most common cancer in men
Prostate cancer is the _____ most common cause of cancer related death in men
- Most common cancer in men
- Second most common cause of cancer related death in men (lung if most common)
Remind yourself of the structure of the prostate
- Main zones to be aware of: peripheral, central, transitional
- Vas deferens pass through central zone
- Urethra passes through transitional zone
- 70% cancers are in the peripheral zone but tumours are often multifocal(in comparison to BPH which primarily affects the transition zone) b
What type of cancer are most prostate cancers?
Most (>95%) are adenocarcinomas and around 70-75% arise in the peripheral zone. Prostate adenocarcinomas can be divided into:
- Acinar adenocarcinoma: glandular cells (most common)
- Ductal adenocarcinoma: cells that line ducts of prostate gland
State some risk factors for prostate cancer- highlighting the most important
- Advancing age
- Family history (by FH referring to if they have 1st degree relative diagnosed before age 60yrs. 4x risk)
- BRCA2 mutation (5-7x risk)
- Black african ethnicity > white > asian
Other less significant risk factors: obesity, diabetes, smoking, lack of exercise
State some symptoms & signs of prostate cancer
May be symptomatic; alternatively may be asymptomatic but had abnormal DRE (hard, nodular, enlarged, loss of median sulcus) or raised PSA
- Lower urinary tract symptoms (frequency, hesitancy, poor stream, terminal dribble, nocturia)
- Haematuria
- Haematospermia
- Erectile dysfunction
- Bone pain
- General symptoms of malignancy: malaise, anorexia, weight loss
- Ejaculatory problems (rare)
Discuss limitations of DRE
DRE can only detect tumours in posterior and lateral aspects of prostate hence must always also perform PSA; likewise, PSA should always be done with DRE (as can have normal PSA but abnormal prostate)
PSA can be raised due to a number of causes other than prostate cancer; state some
- BPH
- Urinary infection (always dipstick and if there is infection repeat PSA in 4-6 weeks)
- Prostatitis
- Acute urinary retention
- Vigorous exercise (notably cycling)
- Recent ejaculation or prostate stimulation
What investigations would you do if you suspect prostate cancer?
- DRE
- PSA
- Multiparametric MRI prostate/pelvis (increasingly performed pre-biopsy as it helps decide appropriate biopsy technique since TRUS cannot access anterior whereas trasperineal allow you to access more of the prostate. Use Likert scale; if >/=3 then offer biopsy)
-
Biopsy
- TRUS (transrectal ultrasound): local anaesthetic, put ultrasound in rectum to visualise prostate and take biopsy via the rectum)
- Trasperineal/template biopsy: used to be under GA however now moving towards LA. Allows better access to anterior prostate and has less risk of infection. Put ultrasound in rectum but put needle through perineal region
- Isotope bone scan: look for bony metastases. Radioactive isotope via IV injection, wait few hours then use gamma camera to take pictures.
- PET scan: look for metastases
Compare advantages and disadvantages of TRUS biopsies and transperineal/template biopsies for prostate cancer
TRUS
- Quicker
- LA (although transperineal is increasingly being done under LA also as opposed to GA)
Transperineal/template
- Allows better access to anterior portion of prostate
- Lower infection risk
State some potential complications of a TRUS biopsy
- Pain
- Fever
- Rectal bleeding
- Haematuria
- Sepsis (1%)
When should you refer a man via 2WW according to NICE?
Refer the man urgently using a suspected cancer pathway referral (for an appointment within 2 weeks) if:
- Digital rectal examination (DRE) reveals a hard, nodular prostate (suggestive of cancer) or
- PSA levels are above the age-specific reference range
What grading system do we use to score prostate cancer?
Briefly describe this grading system
Gleason Grading System
- Based on the histology (level of differentiation) from the prostate biopsies
- Score between 1 and 5 (greater the score, the more poorly differentiated the tissue is)
- Gleason score is:
- Most common differentiation/grade + second most common differentiation/grade seen (e.g. 3+4=6)
- If there is also a small amount of a third differentiation this is often put in brackets after e.g. 3+4 (5)=7
- We can use Gleason score to determine risk level:
- >/=6 is low risk
- 7 is intermediate risk
- 8-10 is high risk
What staging is used for prostate cancer?
TNM
T for Tumour:
- TX – unable to assess size
- T1 – too small to be felt on examination or seen on scans
- T2 – contained within the prostate
- T3 – extends out of the prostate
- T4 – spread to nearby organs
N for Nodes:
- NX – unable to assess nodes
- N0 – no nodal spread
- N1 – spread to lymph nodes
M for Metastasis:
- M0 – no metastasis
- M1 – metastasis
State some common sites for metastases in prostate cancer
- Bone- SCLEROTIC
- Lymph nodes
- Liver
- Lungs
State some factors that influence treatment decisions for prostate cancer
- Age (need to have 10yrs or more of life left for treatments such as radical prostatectomy)
- DRE (DRE findings can correlate to T stage e.g. T1/T2 may have normal prostate, T3 have irregular/nodular prostate, T4 all nodules can merge so it feels smooth but it will be heard and there will be loss of gutters)
- PSA
- Biopsies (Gleason grade & extent)
- MRI pelvis (N&M stage)
-
Bone scan (N&M stage)
*
When deciding how to manage prostate cancer we can split in into three categories; state these
- Localised prostate cancer (T1/T2= cancer not spread outside prostate)
- Localised advanced prostate cancer (T3/T4= cancer spread to nearby sites/organs outside prostate but not to distant sites)
- Metastatic prostate cancer
Discuss the management of localised prostate cancer
(T1/T2; PSA <20; N0; M0)
Curative Intent Options
- Active surveillance (Sources vary but PSA every 3-4/6 months, DRE every 6-12 months, MRI scan/biopsy etc.. every 1-3yrs)
- Radical prostatectomy (robotic approach is standard)
-
Radiotherapy
- External beam
- Brachytherapy (less commonly used now)
Palliative Intent Options
- Watchful waiting and giving hormones for symptoms
Discuss the management of locally advanced prostate cancer
Various options which may be used in combination:
- Radical prostatectomy
- Radiotherapy (external beam or brachytherapy)
- Hormonal therapy
Discuss the management of metastatic prostate cancer
Treatment (although inevitably all will relapse)
-
Hormone therapy
- Surgical castration (bilateral orchidectomy)
-
Medical castration
- GnRH agonists (+ anti-androgen at start)
- Chemotherapy (docetaxel)- if good performance status
Palliative
- Single dose radiotherapy
- Bisphosphonates e.g. zoledronic acid
Explain how hormone therapy works for prostate cancer
Explain how hormone therapy works for prostate cancer
What must be give pts prior to starting GnRH agonists?
- Growth of prostate is stimulated by androgens hence if decrease androgens we can decrease growth
- GnRH is usually released in a pulsatile fashion; if we give GnRH agonists continually desensitisation occurs resulting in decreased LH and FSH production leading to decreased androgen production
- Give pts bicalutamide (a non-steroidal anti-androgen) when starting an GnRH agonist to stop tumour flare (which is idea that when you initially give GnRH agonist it increases androgen production). Usually have a 10-14 days of bicalutamide prior to starting GnRH agonist and continue the bicalutamide for 4-6 weeks.
State some examples of hormone treatments used in prostate cancer
- Goserelin (zoladex)
- Leuprorelin (Prostap)
Discuss the management of metastatic castrate resistant prostate cancer
- Add antiandrogen e.g. Bicalutamide
- Consider prednisolone + docetaxel chemotherapy (if WHO performance status 0-2)
- If docetaxel resistant and PS 0-2 consider:
- Enzalutamide (androgen antagonist that is 5x stronger than bicalutamide)
- Prednisolone + abiraterone (irreversibly blocks cytochrome P17 which is involved in production of testosterone)
State some common side effects of radical prostatectomy
- Erectile dysfunction (sometimes nerve sparing techniques can be used)
- Urinary incontinence
State a key side effect/complication of external beam radiotherapy for prostate cancer
-
Proctitis (inflammation of rectum) causing pain, altered bowel habit (frequency & urgency), rectal bleeding & discharge, altered bladder habits
- ~⅓ experience long term minor increase in bowel frequency & rectal bleeding
- Erectile dysfunction (40%)
*Can give prednisolone suppositories to help proctitis
State some common side effects of brachytherapy for prostate cancer
- Cystitis (dysuria, increased frequency)
- Proctitis (pain, increased frequency, rectal bleeding & discharge)
- Erectile dysfunction
- Incontinence
- Increased risk of bladder cancer
- Increased risk of rectal cancer
State some common side effects of hormone therapy
- Hot flushes
- Gynaecomastia
- Fatigue/lethargy
- Osteoporosis
- Sexual dysfunction
- Reduced libido
- Varying degrees of erectile dysfunction