Most common cancer in men in the UK
26% of all male cancer diagnoses
Widely agreed that growth of prostate cancer is influenced by androgens like testosterone and DHT
Type of prostate cancer
>95% are adenocarcinomas
Over 75% of prostate adenocarcinomas arise from the peripheral zone
20% from the transitional zone
5% in the central zone
Prostate cancers are often multifocal
Subtypes of prostate adenocarcinomas
Acinar adenocarcinoma originating in the glandular cells that line the prostate and is the most common form
Ductal adenocarcinoma that comes from cell lining of the duct. They tend to grow and metastasis faster.
Ethnicity - Black african or Carribean ethnicity twice as likely.
FH of prostate cancer
BRCA2 or BRCA1 gene
Obesity, DM, smoking, degree of exercise
Usually presents with LUTS with a weak urinary stream, increased urinary frequency and urgency.
More advanced localised disease can also cause haemturia, dysuria, incontinence, haematospermia, suprapubic pain, loin pain and even rectal tenesmus.
Metastatic disease can also cause bone pain, lethargy, anorexia and unexplained wieght loss
DRE is essential
Most arise from posterior peripheral zone so check for asymmetry, nodularity or fixed irregular mass.
Bladder cancer, urinary stones, UTI and pyelonephritis
A serum protein produced both by malignant and normal healthy cells in the prostate which can be elevated
When else might PSA be elevated?
Further calculations using PSA
Free:Total PSA ratio
A low ratio is associated with increased chance of diagnosig prostate cancer
Explain PSA density
Serum PSA level divided by the prostate volume which is determined on imaging.
High PSA densitiies = increased likelihood of prostate cancer
Current standard method for diagnosis is through biopsies of prostatic tissue
Potential methods of biopsy
Transperineal Template Biopsy
TransRectal Ultrasound guided (TRUS) biopsy
Explain Transperineal Template Biopsy
Sampling of biopsy transperineally.
This is done as a day case under general anaesthetics.
Transperineal approach allows for better access to the anterior part of the prostate and has a lower risk of infection.
Explain TransRectal UltraSound-guided TRUS biopsy
Sampling transrectally under local anaesthetics
12 cores are taken bilaterally in equal distribution from base to apex
1-2 % risk of sepsis.
Repeat prostate biopsy after previous negative biopse is recommended if there is a rise in PSA or peristently elevated.
What grading system is used for prostate cancer?
Gleason Grading System
Explain Gleason Grading System
Sample is assigned a score according to differentiation
Score is then calculated as the sum of the most common growth pattern + the second most common growth pattern seen.
Higher score = Less favourable prognosis
Imaging in prostate cancer
Multiparametic magnetic resonance imaging mp-MRI is increasinly used to aid diagnosis.
It can identify abnormal areas which can then be targetted for biopsy by MRI-ultrasound fusion or cognitive-guidance techniques.
This means that mp-MRI is sometimes being used earlier in the diagnostic pathway prior to initial biopsy.
When is staging of prostate cancer done?
Staging is typically done in intermediate and high-risk disease via CT-abdo-pelvic scan and bone scan.
Specialist prostate cancer MDT meeting
PSA levels, Gleason score and T staging decides further management.
Low risk disease management
Radical treatment only offered to those who show evidence of disease progression
Intermediate and high risk management
Radical treatment options should be discussed.
Intermediate risk can also be offered active surveillane.
Metastatic disease management
Chemotherapy agents and anti-hormonal agents
Castrate-resistant disease management (Hormone-relapse prostate cancer)
Further chemotherapy like Docetaxel.
Corticosteroids can also be given as third line after androgen deprivation therapy and anti-androgen therapy.
Explain the Watchful waiting and active surveillance management.
Symptom guided approach
Monitoring of patients with 3-monthly PSA
6 month to yearly DRE
Re-biopsy at 1-3 yearly intervals assessing for progression
mpMRI is also being used.
Radical prostatectomy removing prostate gland, resection of the seminal vesicles + any surrounding tissue.
This can be done open approach, laparoscopically or robotically
Complications of prostatectomy
Bladder neck stenosis
When is radiotherapy done?
External-beam radiotherapy and brachytherapy are both commonly used as alternatives to curative intervention of localised prostate cancer.
Transperineal implantation of radioactive seeds of Iodine-125 directly into prostate gland