Prostate and UT Cancers

Question 1

What are the 3 Zones of the Prostate Gland?

Answer 1

Transitional
Central
Peripheral

Question 2

Why are the prostate gland zones important?

Answer 2

The Prostate Gland Zones are important as they have implications of the disease pathway and different propensities to disease

The reason being that each zone is derived from different embryological layers i.e. Transitional Zone is derived from Mesoderm and Peripheral Zone is derived from the Endoderm.

Question 3

What disease pathways affect which zones of the prostate gland?

Answer 3

The transitional zone tends to be more prone to benign prostate enlargement/hyperplasia (BPE/BPH) which causes an inability to pee (retention).

The peripheral zone tends to be more prone to cancers

Question 4

Can prostate hyperplasia be normal?

Answer 4

Yes.

As the male increases in age, the prostate gland tends to increase in size due to the influence of the androgen hormones, which affect predominantly the transitional and central zones of the prostate.

Question 5

What is the issue with BPH?

Answer 5

Affected zones border the urethra and so, can obstruct urinary flow, causing the LUT symptoms associated with it.

Generally, the Central Zone is more affected and obstructions can be fixed via Trans-Urethral Resection.

Question 6

What are symptoms of prostate cancer?

Answer 6

THE MAJORITY OF PATIENTS ARE ASYMPTOMATIC ON PRESENTATION.

LUT Symptoms (if the Transitional Zone affected)
Haematuria/Haematospermia
Bone pain (consider mets)
Anorexia
Weight loss
On DRE; a hard, firm prostate with an asymmetry, singular nodules, fixed craggy mass which indicates abnormality (one possibility is abnormal prostate due to tumour growth in cancer)

Question 7

What are investigations for prostate cancer?

Answer 7

PSA

DRE

Question 8

What is important to remember with PSA?

Answer 8

Note that PSA is not a prostate cancer specific antigen but is prostate specific. Therefore, it highlights anything that is wrong with prostate as any prostate abnormality can cause PSA increase e.g. infection, enlargement, prostatitis, retention, catheterisation, abnormal DRE

Question 9

Why is there no screening for prostate cancer in the UK?

Answer 9

It is extremely slow growing

Question 10

What is PSA?

Answer 10

A protein that causes liquefication of semen

ALL PATIENTS WITH HIGH PSA WARRANT FURTHER INVESTIGATION
Generally, patients with PSA in their 1000s tend to have cancer
.

Question 11

What is important to remember when it comes to measuring PSA levels?

Answer 11

The extremely high-grade (nasty) cancers do NOT produce PSA as the higher the grade of cancer, the more abnormal the cell is and therefore, the less likely they are to behave like normal cells.

NEVER DO A PSA SCREEN AFTER A DRE/PR EXAM AS RUBBING THE PROSTATE DURING THE EXAM CAUSES A PSA INCREASE.

Increasing PSA during/after treatment can indicate Recurrence of Cancer

Question 12

When is trans-rectal biopsy for prostate cancer indicated?

Answer 12

Men with abnormal DRE
Previous biopsies with Prostatic Intraepithelial Neoplasia
Normal biopsy but rising PSA

Question 13

How many biopsies are taken from the prostate gland and why?

Answer 13

10 biopsies are taken from the prostate (5 from each lobe) or sometimes, more

The majority of prostate cancers are multifocal adenocarcinomas

Question 14

What grading is used for prostate cancer and how does it work?

Answer 14

Gleason’s Scoring

2 most abundant cell features are assessed and added together to make a combined score i.e. The Gleason’s Score.

1-5 is Microscopic
6 = Low Grade
7 = Immediate Risk
>7 = High Risk

Question 15

How is staging for prostate cancer done?

Answer 15

TMN Staging

Question 16

What is the management of organ-confined prostate cancer?

Answer 16

1. Watchful waiting/deferred treatment
2. Active surveillance/monitoring
3. Radical surgery
4. Radical radiotherapy for high/intermediate risk

Question 17

What is management of locally advanced prostate cancer?

Answer 17

1. Radiotherapy with neo-adjuvant hormonal (testosterone cutting) therapy
2. Watchful waiting
3. Hormonal therapy

Question 18

What is management of metastatic prostate cancer?

Answer 18

1. Androgen deprivation therapy
2. Diethylstilboestrol/ Steroids
3. Cytotoxic chemo

Question 19

What are the 2 major types of urinary tract (UT) cancer?

Answer 19

1. Non-Muscle Invasive Cancer, which requires lifelong monitoring
2. Muscle Invasive Cancer, which requires the bladder to be taken out (Cystectomy)

Question 20

Describe the progression of UT cancer?

Answer 20

The cancer starts from the transitional epithelium and moves into the submucosa.
If muscle invasive, it then moves into the muscles and finally, into the fat

Question 21

What are the 3 subtypes of UT cancer (cell type)?

Answer 21

Transitional cell cancer (Most common)
Squamous cell
Adenocarcinoma etc. (Least common)

Question 22

Which of the 3 cell type UT cancers is most associated with calcification?

Answer 22

TCC

Question 23

How are UT cancers categorised according to morphology?

Answer 23

1. Papillary (50% are infiltrative and a stippled appearance)
2. Non-Papillary (Flat) are the Worst of the 2 types as they tend to Grow into the Bladder Wall and are ALL MALIGNANT

Question 24

Describe features of TCC

Answer 24

Multicentric
Bilateral in up to 10% of Patients (Synchronous or Metachronous)
Up to 50% of Patients with a cancerous ureter/pelvis will develop carcinoma
Papillary Transitional Cell Carcinomas tend to be more common than their ‘Carcinoma In-Situ’ Flat counterparts.
Have Fibrovascular Cores

Question 25

Why is biopsy needed in flat TCC?

Answer 25

Flat TCCs tend to present as a Bright Red Patch on pathology and so, a Biopsy is needed to differentiated between possible inflammation and cancer. Biopsy is done, even in the most obvious patient histories for inflammation/infection to be able to 100% exclude the possibility of Flat TCC.

Question 26

What are TCC risk factors?

Answer 26

Cyclophosphamide | Smoking

Question 27

What is important to remember with UT cancer potential?

Answer 27

THE ENTIRE URINARY TRACT IS EXPOSED TO THE SAME RISK FACTORS. Therefore, if the patient's urine indicates cancer but the bladder is fine, the cancer must be higher up in the urinary tract.

Question 28

What makes adenocarcinoma difficult to diagnose?

Answer 28

Adenocarcinoma can occur on a background of metaplasia and also, can be difficult to distinguish from colon cancer that has invaded through the bladder. Radiology is often needed to distinguish the origin of the adenocarcinoma.

Question 29

What particular structure can adenocarcinomas arise from?

Answer 29

Urechus

Question 30

What are symptoms of UT Cancer?

Answer 30

Haematuria, which presents in 75-85% of patients Retention of Urine Urinary Irritative Symptoms Loin Pain PATIENTS >40 WITH HAEMATURIA HAVE TO BE INVESTIGATED

Question 31

What are investigations for UT cancer?

Answer 31

Flexible Cystoscopy CT Scan (MRI in those allergic to contrast) USS Halo Sign (imaging characteristic sign) is a filling defect of bladder due to the tumour being close to the wall.

Question 32

What is the management of UT cancer?

Answer 32

If tumours are Superficial, then treatment is via Endoscopy. Otherwise, treatment is Cystectomy with a Piece of the Bowel and Stoma used to create a New Bladder with the Ureters attached i.e. Radical Cystectomy Bladder Reconstruction As the most common region of urinary bladder cancer metastases is the Lymph Nodes, do a Lymph Node Dissection to reduce Recurrence chances