Urology: Prostate Cancer Flashcards
Adenocarcinoma of the prostate most commonly found in which part of the prostate? [1]
Peripheral prostate
Signs and symptoms of:
Early stage prostate cancer? [6]
Late stage prostate cancer? [3]
Early stage:
* Often asymptomatic
* Urinary frequency
* Poor flow
* Nocturia
* Dribbling
* Renal obstruction
* Haematuria / Haematospermia
* Nodular hard craggy prostate on DRE
If metastised:
* Weight loss
* Bone pain
* Anaemia
What investigations should you conduct for prostate cancer:
- Indication of cancer? [2]
- For diagnosis? [2]
- For staging? [1]
- To investigate metastasis? [1]
PSA (raised) & hard, irregular DRE: indicates cancer
Multiparametric MRI is now commonly the first line investigation in the diagnosis of prostate cancer.
Transrectal US & biopsy: for diagnosis
Bone scan: for metastasis
CT: for staging
Describe the two forms of prostate biospy [2]
There are two options for prostate biopsy:
Transrectal ultrasound-guided biopsy (TRUS):
- ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate. Guided biopsies are taken through the wall of the rectum, into the prostate.
Transperineal biopsy
- involves needles inserted through the perineum. It is usually under local anaesthetic.
A guided biopsy is offered to patients with a Likert score of [] or greater
A guided biopsy is offered to patients with a Likert score of 3 or greater
3 = Chance of clinically significant cancer is equivocal
4 = Clinically significant cancer is likely to be present
5 = Clinically significant cancer is highly likely to be present
State 5 non-cancerous causes of PSA increase [6]
benign prostatic hypertrophy (BPH)
prostatitis
digital rectal examination (DRE)
urethral catheterisation
urinary tract infection (UTI)
prostatic biopsy
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
What levels normal PSA? [1]
What is the upper limit of normal PSA:
- under age of 50 [1]
- over the age of 70 [1]
Normal range varies w/ age, but generally < 4 ng/ml
Upper limit of normal PSA:
< 2.7 ng/ml if under 50;
< 7.2 over 70
How does prostatic cancer appear in T2 MRI? [1]
What radiological score do you use from MRI imaging to score prostatic cancer? [1]
T2 MRI:
- Tumour is dark; lighter area is healthy
PIRADS Score (1-5; low cancer - 5 is high)
Name this form of prostate biopsy [1]
Trans-rectal ultrasound: OUT OF USE due to high infection rate and limited number of biopsies able to take
Name this form of taking prostate biopsies [1]
Why is it better than trans rectal biopsy? [1]
Template / transperineal biopsy (BP)
Less infections; more biopsies can be taken
Which histological scoring system is used to grade prostate cancers? [1]
Describe how you use this scoring system [2]
Gleason score [1-5]
Because prostate cancers are heterogenous; Gleason score is a score made from:
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
In prostate cancer, what classification system is used for staging? [1]
In prostate cancer, what classification system is used for histological grade? [1]
In prostate cancer the TNM classification is used for staging whilst the Gleason score gives the histological grade
What are well, moderately and poorly differentiated Gleason scores? [3]
Well differentiated: Score 2-4
Moderately differentiated: Score 5-7
Poorly differentiated: Score 8-10
Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a [] scale.
Describe the differences in results given from this scale. [5]
The results are reported on a Likert / PIRADS scale
1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer
Name two differentials for prostate cancer [2]
How would you investigate to differentiate between them and prostate cancer? [3]
BPH: positive prostate biopsy
Chronic prostatitis: leukocytes
indicative of inflammation
What are the prognostic factors in prostate cancer? [3]
- Pre-treatment PSA levels
- Tumour stage (TNM)
- Tumour grade (Gleason)
Describe the treatment types for localised prostate cancer [4]
Radical prostatectomy (if < 75 and fit): can be open, laparoscopic or robotic surgery
Focal therapy:
- Brachytherapy (radioactive seeds)
- Cryotherapy
- HIFU (High frequency focused ultrasound)
Radiotherapy
Radiotherapy & androgen deprivation (stops stimulating the cancer to grow):
- Androgen-receptor blockers such as bicalutamide
- GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Explain how a GnRH agonist works to treat prostate cancer [3]
Gonadotropin-releasing hormone (GnRH) agonist: cause a ‘chemical castration’.
GnRH (also called luteinising hormone-releasing hormone or LHRH) is the hormone that stimulates LH/FSH release from the anterior pituitary.
Initially it causes an increase in LH/FSH release.
However, the persistent presence of an agonist causes downregulation of receptors on the pituitary gland leading to reduced LH/FSH release.
Goserelin is a commonly used GnRH agonist (brand name Zoladex).
Describe the treatment types and mechanisms for metastasied prostatic cancer [7]
Anti-androgen therapy:
- Synthetic GnRH agonist: Goserelin; causes lower LH levels by causing overstimulation; causes testosterone levels to initially rise then fall after 2/3 weeks
- GnRH antagonists: Degarelix; suppress testosterone without flare
- Non-steroidal anti-androgen: Bicalutamide: blocks androgen receptor
Steroidal anti-androgen: cytoproterone acetate
Androgen synthesis inhibitor: abiraterone
Bilateral orchidectomy: rapidly decreases testosterone levels
Chemotherapy with docetaxel
Where is the most common cause of prostatic metastasis? [1]
Why is this clinically significant? [2]
Bone; can cause skull and spinal cord compression: urological emergency
Management of Cord Compression due to prostatic cancer? [3]
(mainly) Radiotherapy
Rest and dexamethasone
Neurosurgery (if urgent decompression required)
What does an infected / inflamed prostate feel like? [1]
An infected or inflamed prostate (prostatitis) may be enlarged, tender and warm.
What does a cancerous prostate feel like? [2]
A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule
A 70-year-old patient with prostate cancer is commenced on goserelin therapy. A week after starting treatment, he attends a local emergency department complaining of worsened lower urinary tract symptoms and new onset back pain.
Which treatment may have helped avoid this deterioration? [1]
Flutamide, a synthetic antiandrogen, can be used preemptively to attenuate the tumour flare through its antagonistic effects at androgen receptors.
What is proctitis? [1]
Name three causes of proctitis [3]
Proctitis is inflammation of the lining of the rectum.
Causes:
- radiotherapy
- inflammatory bowel disease
- infection.
How long after ejaculation and vigorous exercise should you wait before measuring PSA? [1]
How long after protastitis and UTI exercise should you wait before measuring PSA? [1]
ejaculation and vigorous exercise: wait 48hrs
protastitis and UTI: wait 1 month
What is an aide for memorising upper age limit of PSA levels? [1]
(Age-20) / 10
What is the purpose of cyproterone acetate?
Directly reducing the growth of prostate cancer
Increase luteinizing hormone secretion
Increase testosterone levels
Prevent paradoxical increase in symptoms with GnRH agonists
Reduce dose of GnRH agonists required for the intended effect
What is the purpose of cyproterone acetate?
Directly reducing the growth of prostate cancer
Increase luteinizing hormone secretion
Increase testosterone levels
Prevent paradoxical increase in symptoms with GnRH agonists
Reduce dose of GnRH agonists required for the intended effect
Prostate cancer: GnRH agonists may cause ‘tumour flare’ when started, resulting in bone pain, bladder obstruction and other symptoms
Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH antagonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH antagonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH agonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH agonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
