8 - Prostate Flashcards by Oscar Akande

What is the epidemiology of prostate cancer?

Most common malignancy in men (2nd most common in UK)
1 in 6 men
Peak incidence 75-79
More common and higher mortality in black men

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What are some risk factors for prostate cancer?

Remember prostate cancer is androgen dependent

Increasing age
Family history
Black African or Caribbean origin
Obesity
Anabolic steroids
BRCA mutation

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What are the two most common sites of prostate cancer metastases?

Bone
Lymph nodes

Majority of prostate cancer is slow growing!

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What are the different types of prostate cancer and where do they occur in the prostate?

Most common (95%): adenocarcinomas

Rarer: transitional cell, squamous cell and neuroendocrine cancers

Majority in the peripheral zone!!!

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How may prostate cancer present?

Asymptomatic
LUTS:
- Nocturia
- Frequency
- Hesitancy
- Urgency
- Dribbling
- Overactive bladder
- Retention
Visible haematuria
Abnormal DRE (hard, nodular, enlarged, asymmetrical)

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What are some symptoms of advanced prostate cancer?

Haematuria
Blood in semen
Lower back pain/bone pain secondary to bony metastasis
Weight loss
Anorexia

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What should prompt you to do a DRE and how would it feel if there was prostate cancer?

DRE should be considered in men with:

LUTS (e.g. nocturia, frequency, hesitancy, urgency or retention)
Haematuria
Unexplained symptoms that may be explained by advanced prostate cancer (e.g lower back pain, bone pain, weight loss)
Erectile dysfunction
Other reasons to be concerned of prostate cancer (e.g. elevated PSA)

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What is PSA and why may it be raised?

Prostate specific antigen produced by epithelial cells of prostate to liquefy semen

Common causes of a raised PSA are:

Prostate cancer
Benign prostatic hyperplasia
Prostatitis
UTIs
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation

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Any man over the age of 50 can request a PSA. What do you need to counsel men on before a PSA test?

May be raised for many other reasons (false positives 75%)
May provide false reassurance if not raised (false negatives 15%)

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What do men need to avoid before a PSA test?

Active or recent UTI (last 6 weeks)
No ejaculation, anal sex or prostate stimulation for 48 hours
No vigorous exercise for 48 hours
Had a urological intervention in the past 6 weeks

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What should prompt a PSA test?

Asymptomatic but man >50 requests it
LUTS (e.g. nocturia, frequency, hesitancy, urgency or retention)
Visible haematuria
Erectile dysfunction
Unexplained symptoms (e.g lower back pain, bone pain, weight loss)

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What are the first line investigations in the GP if somebody presents with symptoms of prostate cancer?

DRE
Urine Dip
PSA

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What is the referral criteria for a two week wait for prostate cancer?

Abnormal prostate (‘feels malignant’) on DRE
PSA level is elevated above age-specific range (>4)

Clinician discretion must be used, a normal PSA and normal DRE do not exclude prostate cancer

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What investigation is done for suspected prostate cancer on the two week wait and how is it scored?

Multiparametric MRI

Likert scale

1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer

3 or more then need a biopsy

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If the Likert score is 3 or more, what is the next investigation offered for suspected prostate cancer?

Prostate Biopsy

Transperineal
Transrectal (TRUS)

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What are the complications of a prostate biopsy?

Pain (particularly lower abdominal, rectal or perineal pain)
Bleeding (blood in the stools, urine or semen)
Infection
Urinary retention due to short term swelling of the prostate
Erectile dysfunction

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What are some further investigations done to grade prostate cancer if metastases are suspected?

Bone isotope scan
CT
Gleason grading

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What is the Gleason grading score and how do you interpret it?

Based on the histology from the prostate biopsies

Less differentiation means higher grade and poorer prognosis

The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7)

First number is grade of the most prevalent pattern in biopsy
Second number is grade of second most prevalent pattern in biopsy

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What are the three ways of predicting prognosis with prostate cancer?

TNM staging
Gleason grade
Risk stratification

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What is the risk stratification in local disease with prostate cancer?

PSA, Gleason, TNM

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What information do you need to give men who are about to undergo treatment for prostate cancer?

Discuss all relevant management options.
Inform men that treatment may result in:

– altered physical appearance

– altered sexual experience

– possible loss of sexual function, ejaculation and fertility

– changes in urinary function

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What are the different treatment options for localised prostate cancer?

Active surveillance
Radical prostatectomy
Radical radiotherapy

Offer adjuvant hormonal therapy for a minimum of 2 years to men receiving radiotherapy who have a Gleason score of ≥ 8

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What is watchful waiting/active surveillance in the treatment of prostate cancer and who is this suitable for?

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Active Surveillance

Regular annual PSA measurements, DRE, multiparametric MRI and biopsies
Done to avoid over treatment and side effects of radio/surgery
Candidates: low risk local disease

Watchful waiting

No interventions, only if symptoms
Elderly and many comorbidities

How is intermediate/high risk locally advanced prostate cancer managed?

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Radical prostatectomy: removal of the entire prostate gland and surrounding tissues. Can be completed as open, laparoscopic or robotic procedure
Radical radiotherapy: external beam radiotherapy (EBRT) and brachytherapy
Adjuvant hormone therapy if having radiotherapy as radical treatment

What are the side effects of radical prostatectomy and radical radiotherapy?

**_Prostatectomy_** * Urinary incontinence * Erectile dysfunction * If open post op issues like pain, post op ileum, pneumonia, atelectasis but robotic avoids this **_Radiotherapy_** Local effects: * ***Proctitis*** * Urinary incontinence * Erectile dysfunction (less than above) * ***Risk of bowel/bladder cancer*** * Bowel fibrosis * Bladder fibrosis * Radiation cystitis * Diarrhoea Systemic effects: * Nausea * Tiredness * Loss of hair in treatment area

Proctitis and Bowel cancer are a common complication of external beam radiotherapy for prostate cancer. How can this be managed?

Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge

When is hormone therapy given in prostate cancer, what are the different types and how do they work?

Given **alongside radical radiotherapy** in local disease or to **slow progression in metastatic disease** Aim is to **lower androgens** as prostate cancer is androgen dependant

How does Goserelin act as chemical castration?

GnRH agonist 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

If Goserelin is given this can cause a short term increase in testosterone. If there is any metastases in the spine this can lead to spinal cord compression from rapid growth. How can we prevent this?

Give a androgen receptor antagonist e.g Bicalutamide and Enzalutamide

What are the side effects of hormone therapy in prostate cancer?

**Sexual** * Decreased libido * Erectile dysfunction * Infertility * Gynecomastia **Metabolic** * Weight gain * Osteoporosis * Diabetes * Ischaemic heart disease **Haematological** * Anaemia * Fatigue

When may chemotherapy be used in prostate cancer treatment?

**Docetaxel** * Locally advanced * Metastatic

How is metastatic prostate cancer managed?

* Docetaxel chemotherapy * Androgen deprivation therapy * Bilateral orchidectomy offered as an alternative to androgen deprivation therapies * Palliative care

How often should you check PSA levels of a man with prostate cancer being treated?

**Watchful waiting in primary care:** at least annually **Radical treatment:** – at least 6 weeks after treatment – at least every 6 months for the first 2 years – at least once a year after the first 2 years.

How can ED from prostate cancer treatment be managed?

How can urinary incontinence from prostate cancer treatment be managed?

How can the side effects from prostate cancer hormonal treatment be managed?

* Progestogens for hot flushes * Radiotherapy or tamoxifen for gynacomastia

How can painful bone metastases in prostate cancer be managed?

* Strontium 98 radiotherapy * Bisphosphonates

What is the 5 year survival with prostate cancer?

86%

Why is screening not done for prostate cancer?

* No evidence it decreases mortality * Overdiagnosis

This patient has prostate cancer, what could be the differentials for this presentation?

Look for cachexia and anaemia

What investigations should you do for Mr Warren when suspecting progression of prostate cancer?

Bone scan to look for bone metastases, MRI to rule out spine compression, CT lumbosacral spine to rule out compression fracture

What is the difference between transperineal and TRUS biopsy?

TRUS is LA and transperineal is GA template biopsy

How can you account for a large prostate in the PSA test?

PSA density

When should you do a bone scan in prostate cancer?

* PSA\>20 * Gleason \>8 * T\>3

What screening is done for prostate cancer?

Opportunistic when requested or when symptoms

What is the referral criteria for renal and bladder cancer and what investigations are done at the 2 week wait? NB image

**_Bladder Cancer_** * **Over 45 with….** * Unexplained visible haematuria without UTI or * Visible haematuria that persists or recurs after treatment of UTI * **Over 60 with….** * Unexplained non-visible haematuria and dysuria or raised WCC or * Persistent or recurrent UTI **_Renal Cancer_** * **Over 45 with….** * Unexplained visible haematuria without UTI or * Visible haematuria that persists after treatment of UTI

What are some differentials for haematuria?

**Visible:** Urological **Non visible:** Nephrological

What is the referral criteria for testicular cancer and what investigation is done?

* Non-painful enlargement or change in shape or texture of the testis * Direct access US and AFP, bhCG, LDH

What is the referral criteria for penile cancer?

* A penile mass or ulcerated lesion where a STI has been excluded or treated * Unexplained or persistent symptoms affecting the foreskin or glans e. recurrent phimosis and balantitis

What are the treatment options for bladder TCC?

* **TURBT:** diagnosis and management * **Radical Cystectomy with reconstruction:** see image * **Intravesical chemotherapy** * **Palliative radio** * **Immunotherapy**

What is the treatment for upper urinary tract TCC?

How does RCC present and what are some risk factors for this?

* Haematuria * Palpable mass * Incidental finding on imaging

What are the treatment options for RCC?

* Surveillance * Radical nephrectomy * Palliative immunotherapy

What are the different histological types of testicular cancer?

What are the risk factors for penile cancer?

8 - Prostate Flashcards

(55 cards)