Chapter 21: Prostate Flashcards by Liz Pennington

Hematoceles of the the tunica vaginalis are uncommon but may be seen in what 2 conditions?

Following testicular torsions
Pts w/ systemic bleeding disorders

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Accumulation of lymph in the tunica vaginalis that is almost always found in pts w/ elephantitis

Chylocele

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Varioceles (aka dilated vein in speramtic cord) is often times asymptomatic but have been implicated as contributing factor to what?

Infertility

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In which anatomic zone of the prostate do most hyperplasias arise?

Where do most carcinomas arise?

Hyperplasias in the transitional zone (TZ)
Carcinomas in the peripheral zone (PZ)

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4 most common organisms implicated in acute bacterial prostatits?

1) E. coli
2) Gram (-) rods
3) Enterococcus spp.
4) Staphylococci

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How does acute bacterial prostatitis present clinically (sx’s)?

Diagnosed how?

Fever + chills + dysuria
Dx: urine culure

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Chronic bacterial prostatitis may present with what sx’s?

Pts often have a hx of what?

Low back pain + Dysuria + Suprapubic/perineal discomfort
May also be asymptomatic
Often have a hx of recurrent UTI’s (cystitis, urethritis)

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Diagnosis of chronic bacterial prostatitis is made how?

(+) leukocytosis in prostatic secretions
(+) bacterial cultures

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What is the most common type of prostatitis?

Chronic abacterial prostatitis

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How does chronic abacterial prostatitis differ from chronic bacterial prostatitis based off of history and cultures?

No hx of recurrent UTI’s
(+) leukocytosis of prostatic secretions w/ negative bacterial cultures

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What is the most common cause of Granulomatous Prostatitis seen in the US?

Fungal granulomatous prostatitis seen in whom?

Instillation of BCG for tx of superficial bladder cancer = attenuated mycobacterial strain
Fungal causes is typically only seen in immunocompromised pts

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Which method of diagnosis for men w/ sx’s of acute or chronic bacterial prostatitis is contraindicated as it may lead to sepsis?

Biopsy

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Is nodular hyperplasia of the prostate considered a pre-malignant lesion?

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What % of individuals w/ microscopic evidence of BPH have clinically detectable enlargement of the prostate?

50%

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What is the believed to be the ultimate cause of BPH and which cells are proliferating and which cells have impaired cell death?

DHT-induced GF’s act by increasing proliferation of stromal cells
Act by decreasing the death of epithelial cells, which causes increased accumulation of sensecent cells

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Which cells of the prostate are responsible for the production of DHT from T; thus responsible for the androgen-dependent prostatic growth?

Via what enzyme?

Stromal cells
Type 2 5α-reductase

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Is there increased epithelial cell proliferation in BPH?

No clear evidence of increased epithelial cell proliferation

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Binding of DHT to AR’s in stromal and epithelial cells leads to an increase in which 2 important GF’s?

1) TGF-β
2) FGF

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Nodular hyperplasia of the prostate originates almost exclusively where?

Inner periurethral (transition zone)

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In some cases of BPH, nodular enlargement may project up into the floor of the urethra as a hemispheric mass directly beneath mucosa of urethra, which is termed?

Median lobe hypertrophy

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What is the major clinical problem in those with BPH?

Urinary obstruction

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The inability to empty the bladder in BPH causes an increased risk for?

Infections

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Can diagnosis of BPH be made with a needle biopsy?

No, biopsies are too small and do not usually sample the TZ

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What has been the gold standard invasive procedure for moderate to severe cases of BPH that are not responding to other therapies or in circumstances of recurrent urinary retention?

Transurethral Resection of the Prostate (TURP)

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What are 3 recommendations for treating mild-moderate BPH that do not require medical or surgical therapy?

1) ↓ fluid intake (especially before bed) 2) Moderating alcohol and caffeine intake 3) Following timed voiding schedules

What is the most common form of cancer in men?

Adenocarcinoma of the Prostate

Cancer of the prostate is typically a disease in men of what age?

Older than 50 yo --\> **65-75 yo**

Which race has a high incidence of prostate cancer and which race has a low incidence?

- **Most** frequently in **blacks** - **Uncommon** in **Asians**

Which gene is of particular interest in the difference of prostate cancer risk among races? This gene contains a polymorphic sequence of?

- **X-linked AR gene** - Repeats of codon **CAG** (glutamine)

How does the length of the polymorphic sequence of CAG repeats in X-linked AR gene affect the sensitivity of AR's to androgens? Which race has the shortest repeat and which has the longest repeats?

- **Shorter stretches** = ↑↑↑ sensitivity of AR --\> common in **blacks** - **Longer** **stretches** = ↓↓↓ sensitivity of AR --\> common in **asians** \*Whites have **intermediate** stretches of repeats

What type of relationship exists between the length of CAG repeats of the X-linked AR gene and rate of developing prostate cancer?

Inverse relationship

Activation of which pathway and loss of which tumor suppressor by prostate tumors allow for them to bypass the need for the AR altogether?

- ↑ **PI3K/AKT signaling** - Loss of ***PTEN*** tumor suppressor

Germline mutations in which tumor suppressor gene is associated with 20x ↑ risk for prostate cancer?

*BRCA2*

What is a common chromosomal rearrangement implicated in prostate cancer?

- Juxtaposition of **ETS family TF gene** (**ERG** or **ETV1**) next to the androgen-regulated ***TMPRSS2* promoter** - ***TMPRSS2-ERG fusion***

The ETS gene under control of the *TMPRSS2* promoter is common in which race affected by prostate cancer? Overexpression of ETS TF's cause epithelial cells to become more what?

- Seen in **50%** of cases in **caucasians** - Makes epithelial cells **more invasive**

What is the most common epigenetic alteration in prostate cancer? Which chromosome?

**Hyper**methylation of ***GSTP1* *gene*** on chromosome **11**

Amplification of which locus (i.e., chromosome) containing which gene is a common genetic alteration seen in prostate cancer?

**Amplification** of **8q24** locus containing ***MYC oncogene***

Which factors indicate that prostatic intraepithelial neoplasia (PIN) is a putative precursor lesion for prostate cancer? Is PIN considered CIS?

- Both PIN and cancer **predominate** in **peripheral zone** and are uncommon in other zones - Prostate cancers have **high frequency** of PIN - Share many of the **molecular changes** **\*NOT** considered CIS!\*

Majority of prostate cancer arises in which zone and on which aspect (anterior/posterior) of the gland?

Arise in **peripheral zone**, classically in **posterior location** ## Footnote \*Posterior location allows for palpation during DRE

Where does lymphatic spread and hematogenous spread of prostate cancer go?

- **Lymphatic** ---\> **Obturator** nodes and then **para-aortic** - **Hematogenous** --\> **Axial skeleton**

The bony metastases of prostatic cancer are called what? Which bones are commonly involved in descending order of frequency?

- **Osteoblastic metastases** - **Lumbar spine** \> **prox. femur** \> **pelvis** \> **thoracic spine** \> **ribs**

In contrast to benign glands, how do prostate cancer glands differ morphologically? Which feature typical of benign glands is missing?

- Are **MORE** **crowded** and **LACK** branching and papillary infolding - The **OUTER** **basal cell layer** typical of **benign glands** is **ABSENT**

Which histological finding on biopsy is specific for prostate cancer?

Perineural invasion

Immunohistochemical stain for which marker is a sensitive diagnostic marker that can be used in conjunction w/ biopsy?

α-methylacyl-coenzyme A-racemase (**AMACR**)

What are the 2 best prognostic predictors for prostate cancer?

**Grade** and **Stage**

What is used to grade prostate cancer? What does a grade 1 represent vs. grade 5?

- **Gleason** **system** - **Stage 1** = most well-differentiated w/ round, uniform, neoplastic glands packed into well-circumscribed nodules - **Stage 5** = no glandular differentiation, cells infiltrating stroma in form of cords, sheets, and nests

The most well-differentiated prostate cancers will have a Gleason score of? Least well-differentiated have score of?

- **Most well-differentiated** = 2 (1+1) - **Least** = 10 (5+5)

Which range of Gleason Scores is considered to represent the most-well differentiated tumors with an **excellent** prognosis?

**Grades** of **2-6**

Which range of Gleason Scores is considered to represent the poorly differentiated tumors with a aggressive biologies and least potential for cure?

**Grades** 8-10

Majority of potentially treatable prostatic cancer detected w/ needle biopsy have Gleson scores of?

**Scores** of **6-7**

What diagnostic study is required to confirm the diagnosis of prostate cancer?

**Transrectal needle biopsy**

Ratio between the serum PSA value and volume of prostate gland is known as?

PSA density

The rate of change of PSA with time is known as what?

PSA velocity

DRE and detection of PSA levels are useful in detection of prostate cancer, but lack what 2 things?

**Sensitivity** and **specificity**

The real value of PSA for prostate cancer comes in its utility for assessing what?

PSA = best for monitoring response to therapy

Which 2 additional genetic markers have increased sensitivity and specificity of detecting prostate cancer compared to just PSA alone?

1) Urinary **PCA3 = noncoding RNA** overexpressed in 95% of pts 2) Screening urine for ***TMPRSS2-ERG*** fusion DNA

What is the most common treatment for clinically localized prostate cancer?

Radical prostatectomy

Advanced metastatic prostate carcinoma is treated via?

- Androgen deprivation therapy by: - Orchiectomy or - Using synthetic analogs of LHRH

Ductal adenocarcinoma of the prostate arising in larger periurethral ducts may show signs/sx's similar to what malignancy? What are these signs/sx's?

- Similar to **urothelial cancer** - **Hematuria** + urinary **obstruction** sx's

What is the prognosis of ductal adenocarcinomas of the prostate?

Poor

Prostate cancer that reveals abundant mucinous secretions are termed what?

**Colloid carcinoma** of the **prostate**

What is the significance of small-cell cancer of the prostate (aka neuroendocrine carcinoma)?

- **Most aggressive** variant - Almost **all** cases = **rapidly fatal**

What is the most common tumor to secondarily involve the prostate? 2 distinct patterns of involvement exist, what are they?

- **Urothelial cancer** 1) **Large invasive** urothelial cancer which **directly invade** from bladder --\> prostate 2) **Carcinom in situ** of bladder that extends into the prostatic urethra and down into prostatic ducts and acini

What are the mesenchymal tumors that can arise in the prostate?

- Same ones that involve **bladder** may also involve prostate - Unique mesenchymal tumors arising from the **prostatic stroma**

What is used for staging of prostate cancer?

**TNM** designation ## Footnote - **T** = **depth** of **invasion** of primary tumor - **N** = regional **lymph node** involvement - **M** = distant **metastases**

Chapter 21: Prostate Flashcards

(65 cards)