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Describe carcinoma of the prostate?

This is the most common cancer in men, 10% of cancer mortality. There is an increasing incidence, due to earlier detection. Hormonal factors - androgens. There is variable biological behaviour.


Describe incidence of carcinoma prostate?

1. Incidental tumours (post-mortem studies) - found that all populations have high incidence of these tumours and they increase with age.
2. Clinically important tumours - marked variation (20x higher in black americans than japanese) and the incidence changes with migration.


Describe the aetiology of carcinoma prostate?

1. Genetic factors - familial incidence and higher in black americans.
2. Environmental - diet.


Describe prostatic zones?

1. Transitional zone (TZ) - this is around the urethra, site of BPH (benign prostatic hyperplasia) and some carcinomas occur here.
2. Peripheral zone (PZ) - atrophy and mostly carcinomas occur here.


What are the clinical features of prostate cancer?

There are no specific symptoms - obstructive symptoms appear late. There is also examination- firm area/nodule.


Describe the diagnosis of prostate cancer?

1. PSA - prostate specific antigen in the serum, not an optimal test as there are some prostate cancers that don't increase PSA (also other causes of PSA).
2. DRE - digital rectal examination that will pick up some prostate cancers.
3. TRUS/MRI - trans rectal ultrasound, isn't really a diagnostic tool. Useful to image the prostate, so that when biopsies are done the ultrasound can help to see where to put the needle in.
4. Biopsy - 6 biopsies (left, right, middle, upper and lower on left and right). It is done if any of the above are abnormal.


What is the characteristic of prostate cancer?

It is so infiltrated that it doesn't really change the shape (doesn't increase the mass or size).


What is the microscopic appearance of prostate cancer?

Diffusely invades into the prostate, some of the dilated gland spaces get occupied. In an adenocarcinoma there are large nuclei and there is an absence of basal cells.


Describe the "Gleason Grading"?

This is the grading of prostate cancer. There are five pattern (1-5). You add the two most common patterns for a score. For example: gleason score 7 (3+4), however 4+3 = 7 is a different grade. The prognosis (deaths) of prostate cancer are related not only to the primary pattern but the secondary patten as well.


Describe the microscopy of the grades?

1. Well defined, very regular glands.
2. Quite regular as well.
3. Less regular - lowest pattern that they use.
4. Glands are fused together.
5. Diffusely infiltrating single cells and strands or collections of solid tumour.


What are the problems with gleason grading?

Scores of 2-5 are no longer used. The lowest score is actually 6, but patients (and doctors) perceive of this in the midline of the range. Earlier combination of scores into groups lumped, 7 (3+4) with 7 (4+3), although the prognosis is different.


Describe the progression of prostatic cancer?

1. Local spread - spread to extraprostatic fat, seminal vesicles, and other pelvic (rectum, bladder).
2. Lymph nodes - pelvic, aortic (may block off ureters and cause renal impairment).
3. Distant metastasis - particularly vertebral bodies. Sometimes this is the way in which prostate cancer can present, the first sign is weakness of the leg form collapsing vertebra causing neurological problem via pinching of the nerves.


Describe extraprostatic spread?

this is when the tumour will start to grow around nerves yet is still inside the prostate.


Describe the prostatic nerves?

The run between the prostate and the rectum. These are the nerves that innervate the penis and the erectile tissue. Sometimes in removing the prostate the nerves can get damaged (and cause impotence).


Describe TNM staging?

T1 - clinically inapparent tumour (not palpable or visible by imaging).
T2 - palpable tumour is confined within the prostate.
T3 - tumour extends through the prostatic capsule.
T4 - tumour is fixed or invades adjacent structures other than seminal vesicles.


Describe the management of prostate cancer?

There are three categories:
1. Small low grade tumours - no treatment (active surveillance).
2. Significant tumours - radical treatment.
3. Advanced tumours - palliative treatment.


Describe radical treatment of prostate cancer?

Radical treatment is used when the tumour is significant. There are two types of radical treatment:
1. Radical prostatectomy - the whole prostate is removed with the seminal vesicles, the bladder is anastomosed onto the urethra.
2. Radical radiotherapy - radiotherapy aimed at the prostate with curative intent.
Both of these don't come in pure form, it all depends on the stage of the tumour. Often androgen deprivation therapy is given before the radical treatment, it is also given after as well.


Describe palliation treatment?

1. Anti-androgen treatment - actual removal of the testes (castration - use less and less), usually the first stage is anti-androgen drugs. However, sometimes the tumour does escape the anti-androgen treatment.
2. Palliative radiotherapy - can be used locally if there is a recurrence of tumour in the pelvis and is used frequently for metastatic disease.


Describe the pathology of the bladder?

1. Congenital abnormalities.
2. Diverticula.
3. Stones.
4. Inflammations.
5. Tumour-like conditions.
6. Tumours: carcinoma, some papilloma, connective tissue tumours as well.


Describe carcinoma of the bladder?

It is more common in men (M:F = 3:1). smoking and industrial chemicals (dyes) have a high cause of this carcinoma. The carcinoma arises from urothelial cell CIS. Often multifocal, may affect other parts of the urothelium (renal, pelvis and ureter).


Describe the morphology of carcinoma's of the bladder?

Macro - most are papillary, may become invasive and grow into underlying tissues.
Micro - most are urothelial (transitional), some squamous and some adenocarcinoma.


Describe the treatment of carcinoma's of the bladder?

1. Superficial - local therapy: BCG (attenuated TB). This will cause a very intense inflammatory resposne which helps to make the bladder tumour to disappear.
2. Into detrusor muscle - cystectomy. This is because the tumours have a tendency to metastasise quite widely. The chances of impotence increase.
3. Radiation therapy is generally only used in a palliative setting.


What are the clincial features of carcinoma's of the bladder?

1. Present with haematuria.
2. Often recurrent or new tumours.
3. Follow by urine cytology, cystoscopy.


Describe a grade 1 papillary urothelial carcinoma of the bladder?

This is a low grade tumour. The nuclei are pretty uniform.


Describe a grade 3 papillary urothelial carcinoma of the bladder?

This is a high grade tumour. The nuclei are ugly, irregular and large.


What is the incidence of renal cell carcinoma?

This will account for 90% of renal cancer. The M:F ratio is 2:1. It occurs in peak 6th decade (60yo).


What is the aetiolgoy of RCC?

1. Smoking.
2. Genetic - von Hippel-Lindau disease (sporadic cases also have 3p abnormalities).


Describe the macroscopic appearance of RCC?

It is a well circumscribed mass that appears mottled red, yellow and brown. It is part cystic. RCC may invade the renal vein (invade into the blood vessels within the tumour and permeate through to the blood vessels outside the tumour, and sometimes they go into the IVC and even into the right ventricle.


Describe the microscopic appearance of RCC?

Adenocarcinoma - clear cell variant is the most common. They are graded dependending on their nuclear features. A low grade tumour has an increasing survival rate.


Describe the spread and survival rate of RCC?

Local spread of RCC is not common it is mainly blood-borne metases (lung, bones, liver, adrenals and brain). The survival rate overall is 40% at 5 years time.


What are the clinical features of RCC?

1. Symptoms will occur late.
2. Haematuria.
3. Flank pain.
4. Palpable abdominal mass.
5. Ectopic hormone production - polycythemia, hypertension, hypercalcaemia, Cushing's syndrome and either feminisation or masculinisation.