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Flashcards in Prostate cancer Deck (13):
1

Epidemiology of prostate cancer 

  • Commonest urological malignancy and male deaths
  • commonest cause of male cancer death - 3% of all men

2

Risk factors for prostate cancer 

  • Genetic – HPC1 gene
  • Hormones (increased dihydrosterterone, or increased 5 alpha reductase)
  • Obesity
  • Environmental – work environment
  • Diet – Vitamin D and E protective
  • Age > 65
  • Racial  

3

Symptoms of prostate cancer 

  • often none until advanced 
  • diffuclty voiding -catheter required 
  • prostate gland becomes hard 
  • pain 
  • spinal cord compression-  causing lower limb weakness, due to metastatic disease in the Lumbar spine

4

Signs of prostate cancer 

  • Local- confined to the prostate (66%)
    • Often asymptomatic
    • Can have lower urinary tract symptoms- haematuria or UTI
    • Urinary retention (anuria, uraemia)
  • Locally advanced- into rectal/pelvic wall or lymph nodes (27%)
    • Lymphoedema
    • Metastastic (7%)
    • Weight loss
    • Cachexia
    • Bone pain- most common mestasases
    • Renal failure-ureteric obstruction
  • *Raised PSA level- on suspicion or screening*

5

Diagnosis and screening of prostate cancer 

  • Digital Rectal Examination
  • Prostate-specific antigen--> require counselling as the test following this is TRUS:
  • Trans-Recal U/S biopsy- risk of complications-->retention, haematuria, sepsis (1-2% of severe sepsis)

6

Pathology of prostate cancers

  • Majority are adenocarcinoma

  • 2/3 arises in the peripheral zone of the prostate (back portion, felt on DRE)

7

How are renal cancers graded?

Gleason grading 

Graded using histological Gleason Grading cell pattern, a combined sum of numbers 1-5 

Pattern 1 - small, uniform 
Pattern 2 - More stoma between glasnds 
Pattern 3 - Distinctinly infiltrative margins 
Pattern 4 - Irregular masses of neoplastic glands 
Pattern 5 - Occasional gland formation 

The higher the Gleason score, the more likely it is that the cancer will grow and spread rapidly. Pathologists often identify the two most common patterns of cells in the tissue, assign a Gleason grade to each, and add the two grades. The result is a number between two and 10

8

Staging of prostate cancer

TMN 

  • Local - MRI/CT
  • Distant - bone scan 

9

Prostate specific antigen 

  • Serine protease that is secreted into seminal fluid
  • Role is to liquefy seminal coagulation, efficiently hydrolyses semenogelins - to allow for sperm release. Measured in serum, as a small proportion leaks into circulation
  • Tissue specific not Tumour specific – poor diagnostic test.
  • PSA- affected by:
    • Age- rises with age
    • Depends on prostate size (consider benign prostatic hypertrophy)
    • Can be increased by UTI (sharp rise)
    • Chronic prostatitis
    • Instrumentation can increase it (catheter etc.)
  • PSA>4mg/ml requires investigation

10

PSA advantages and disadvantages 

Advantages

  • More acceptable than DRE
  • Detects cancers
  • Predicable value
  • Reassurance if tests are normal

Disadvantages

  • Not specific for prostate cancer
  • Unnecessary patient stress
  • May not identify men with confined organ disease

11

Treatment for prostate cancer 

  1. watchful waiting 
  2. active surveillance 
  3. radical - surgery v DXT v Brachytherapy 
  4. palliative - DXT, radium or stontium 
  5. Hormone treatment - GnRH agaonist or antagonists 

12

Metastatic complications of prostate cancer 

  • Spinal cord compression: Urological emergency - Severe pain, off legs. Retention, Constipation.
    • Urgent MRI
    • Refer for radiotherapy/decompression surgery
    • LHRH agonist
  • Ureteric obstruction: Anorexia, Weight loss, Raised creatinine
    • To nephrostomize or not and then to stent or not
    • Temporary measure will not improve cancer progression

13

Hypothalamic-pituitary-testicular axis 

  • The hypothalamus releases CRH & GnRH
  • Act on the pituitary to release Luteinising hormone and follicle stimulating hormone
  • These act on the testes to create testosteroneàprostate and also act on the Adrenal glands
  • There is short loop and long loop negative feedback from all of this to reduce the hypothalamic activity
  • Adrenocorticotrophic hormone (ACTH) is released from the pituitary gland after stimulation by corticotrophin-releasing hormone (CRH) which is secreted from the hypothalamus.12  ACTH regulates secretion of adrenal androgens, some of which are converted to testosterone.
  • LHRH agonists-stimulate the testes at first, but due to negative feedback lead to the reduction in the testes and reduced testosterone
  • Antagonist-block the receptor, inhibit testosterone straight away-given for patients with spinal cord compression