Tumours of the Urinary System 1 (Prostate Cancer and Testicular Cancer)

Question 1

prostate cancer

Question 2

where is the prostate gland?

Answer 2

Question 3

what is the commonest cancer in men?

Answer 3

prostate

Question 4

what is the aetiology and risk factors of prostate cancer?

Answer 4

• Age

• Race/Ethnicity - African or Afro-Caribbean men living in Western countries vs East Asian or Asian men living in Western countries

• Geography - Northwest Europe/North America/Caribbean/ Australia vs Asia/Africa/Central & South America

• Family history - first degree relative 2x risk, HPC1; BRCA1 & 2

Question 5

where do most prostate cancers start?

Answer 5

Most prostate cancers start in the peripheral zone

Question 6

80% of newly diagnosed prostate cancers are __________

Answer 6

localised

Question 7

are most asymptomatic or symptomatic?

Answer 7

Mostly asymptomatic (i.e. do NOT have cancer-specific symptoms)

Question 8

How is prostate cancer diagnosed?

Answer 8

Diagnosed through opportunistic PSA testing (not screening!)

Diagnostic triad of PSA, digital rectal examination and TRUS-guided prostate biopsies

PSA is prostate specific but not necessarily cancer-specific

Question 9

localised prostate cancer:

what are the presenting symptoms in local disease?

Answer 9

weak stream

hesitancy

sensation of incomplete emptying

frequency

urgency

urge incontinence

UTI

Question 10

localised prostate cancer:

what are the presenting symptoms in locally invasive disease?

Answer 10

haematuria

perineal and suprapubic pain

impotence

incontinence

loin pain or anuria resulting from obstruction of the ureters

symptoms of renal failure

haemospermia

rectal symptoms including tenesmus

Question 11

metastatic prostate cancer:

presenting symptoms in distant metastases

Answer 11

bone pain or sciatica

paraplegia secondary to spinal cord compensation

lymph node enlargement

lymphoedema, particularly in the lower limbs

loin pain or anuria due to obstruction of the ureters by lymph nodes

Question 12

metastatic prostate cancer:

presenting symptoms in widespread metastases

Answer 12

lethargy (e.g. due to anaemia, uraemia)

weight loss and cachexia

Question 13

MCQ: 1. What is the commonest mode of presentation for prostate cancer?

a. Frank haematuria
b. Asymptomatic (i.e. incidentally noted)
c. Acute urinary retention
d. Symptoms of benign prostatic enlargement and obstruction
e. Bone pain

Answer 13

B

Question 14

Screening leads to ___________ and ____________ of harmless cancers

Answer 14

over-diagnosis

over-treatment

Question 15

How to avoid under-treatment of aggressive cancers?

Answer 15

Answer: Ad-hoc PSA testing!!

Question 16

what is PSA?

Answer 16

Prostate-specific antigen

• Kallikrein serine protease - liquifies semen
• Produced by glands of prostate - may leak into serum
• Normal serum range 0-4.0 mg/mL

Age-related range - Levels increase with age:

• < 50 years : 2.5 is upper limit
• 50-60 years : 3.5 is upper limit
• 60-70 years : 4.5 is upper limit
• >70 years : 6.5 is upper limit

Question 17

what may cause elevations in PSA?

Answer 17

• UTI
• chronic prostatitis
• instrumentation (e.g. catheterisation)
• physiological (e.g. ejaculation)
• recent urological procedure
• BPH
• prostate cancer

Question 18

what is PSAs half life?

Answer 18

2.2 days

Question 19

What is the probability of cancer based on PSA?

Answer 19

Levels of PSA and cancer probability (PPV):

0-1.0: 5%

1. 0-2.5: 15%
2. 5–4.0: 25%
3. 0-10: 40%

>10: 70%

Question 20

What is Gleason Grading of Prostate Cancer?

Answer 20

• Pathologist classifies grade of prostate cancer
• Score 3-5 (well to poorly differentiated)
• Summated to give Gleason SUM core
• e.g. 3 + 4 = 7

•Useful prognostically and guides treatment

Question 21

Grading system is changing to ISUP grade group

Answer 21

Question 22

what are the stages of prostate cancer?

Answer 22

• For purposes of treatment and prognosis, useful to divide prostate cancer into 4 stages :

• Localised stage
• Locally advanced stage
• Metastatic stage
• Hormone refractory stage

Question 23

how is staging of localised prostate cancer done?

Answer 23

• Digital rectal examination (local staging)
• PSA
• Transrectal US guided biopsies
• CT (regional and distant staging)
• MRI (local staging)

Question 24

what is the treatment of localised prostate cancer?

Answer 24

• Watchful waiting
• Radiotherapy - External-beam, Brachytherapy
• Radical prostatectomy - Open, Laparoscopic, Robotic
• Others under investigation - Cryotherapy, Thermotherapy

Question 25

what are the types of hormonal therapy for prostate cancer?

Answer 25

* Surgical castration (i.e. bilateral orchidectomy) * Chemical castration (i.e. LHRH analogue – goserelin, leuprorelin; or LHRH antagonists) - LHRH analogues eventually downregulates androgen receptors by negative feedback - tumour flare in first week of therapy (hence need anti-androgen during this period) - LHRH antagonists DO NOT cause tumour flare * Anti-androgens - inhibits androgen receptors * Oestrogens (i.e. diethylstilboestrol) - inhibits LHRH and testosterone secretion, inactivates androgens and has direct cytotoxic effect on prostatic epithelial cells

Question 26

how does each stage of cancer relate to its prognosis?

Answer 26

Question 27

what is the treamtent of localised disease?

Answer 27

Question 28

2. The following are reasonable treatment options for low-risk localised prostate cancer except: a. External beam radiotherapy b. Active surveillance c. Brachytherapy d. Radical prostatectomy e. Radical chemotherapy

Answer 28

e

Question 29

3. The following statements about screening for prostate cancer are true except: a. PSA is the best available screening test b. Compared with ad-hoc opportunistic PSA testing, screening for prostate cancer is beneficial because it saves lives c. If screening is advocated, it should be performed for men at risk of prostate cancer rather than the entire male population d. Screening for prostate cancer is not currently advocated e. For suspicious cases detected by screening, there is a need to undergo a definitive test to confirm or exclude presence of prostate cancer

Question 30

Testicular cancer

Question 31

what is the presentation of testicular cancer?

Answer 31

Presentation - Usually: • Painless lump Less often: * tender inflamed swelling * history of trauma (although trauma NOT a risk factor) * symptoms/signs from nodal or distant metastasis - para-aortic lymph nodes - chest - bone

Question 32

what is the incidence and aetiology of testicular cancer?

Answer 32

* One of the commonest cancers of young men * Peak incidence in third decade * Racial - higher risk in Caucasians * Risk higher in testicular maldescent; infertility; atrophic testis; and previous cancer in contralateral testis * Aetiology is unknown but Testicular Germ Cell Neoplasia In-Situ is a precursor lesion

Question 33

what are tumour marker sin testicular cancer?

Answer 33

* Blood for tumour markers is taken immediately before and serially after surgery * Types of tumour markers: - AFP (alpha-fetoprotein) (teratoma) - bHCG (Human Chorionic Gonadotrophin) (seminoma) - LDH (Lactate dehydrogenase) (non-specific marker of tumour burden)

Question 34

what is the diagnosis of testicular cancer?

Answer 34

* Lump in testis = testicular tumour until proven otherwise * MSSU * Testicular ultrasound scan and CXR * Tumour markers

Question 35

What are some differential diagnoses for testicular cancer?

Answer 35

• Differential diagnoses: - infection (i.e. epididymo-orchitis) - epididymal cyst - missed testicular torsion

Question 36

what is the treatment for testicular cancer?

Answer 36

* Radical orchidectomy is essential (surgery to remove your testicle and the spermatic cord) * Occasionally may need biopsy of ‘normal’ contralateral testis if high risk for tumour * Further treatment depends on tumour type, stage (TNM) and grade

Question 37

1. For testicular cancer, the main lymphatic spread to regional lymph nodes occurs in which group of lymph nodes? a. Scrotal lymph nodes b. Inguinal lymph nodes c. Pelvic lymph nodes (i.e. internal iliac chain) d. Mediastinal lymph nodes e. Para-aortic lymph nodes

Answer 37

i think c maybe e as says on first testicular cancer card

Question 38

2. When performing radical inguinal orchidectomy for testicular cancer: i. Where is the incision made? ii. Why is the incision made here?

Question 39

what are the different pathologies of testicular cancer?

Answer 39

* Germ cell tumour (GCT) (95%) vs Non-GCT (5%) * GCT: - Seminomatous GCT (classical, spermatocytic, or anaplastic) - Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT) • Non-GCT (sex cord/stromal): - Leydig - Sertoli - Lymphoma rare

Question 40

Seminoma and Non-seminomatous mainly affect who?

Answer 40

- Seminoma - Mainly affects 30-40 year olds • Non-seminomatous - Mainly affect 20-30 year-old - Often mixed

Question 41

what does grading of testicular cancer mean?

Answer 41

Grading = assessment of AGGRESSIVENESS

Question 42

what are the different grades of testicular cancer?

Answer 42

•Based on histological assessment of differentiation - Low grade = well differentiated - High grade = poorly differentiated

Question 43

what does stagig of testicular cancer mean?

Answer 43

Staging = assessment of SPREAD Stage using TNM system

Question 44

What ways can spread occur in?

Answer 44

•Spread occurs in 3 ways: - local spread (i.e. local invasion to adjacent structures) - regional spread (lymphatic invasion) - distant spread (lungs, bone, liver)

Question 45

how can you stage testicular cancer?

Answer 45

* Local staging (via pathological assessment of orchidectomy specimen) * Nodal staging (via CT scan) * Distant staging (chest, abdomen and pelvis) (via CT scan) * Tumour markers also provide staging and prognostic information

Question 46

what are the different stages of testicular cancer?

Answer 46

* Stage I - disease is confined to the testis * Stage II - Infradiaphragmatic nodes involved * Stage III - Supradiaphragmatic nodes involved * Stage IV - extralymphatic disease

Question 47

Further treatment following orchidectomy depends on tumour type, stage (TNM) and grade what are some futher treatments?

Answer 47

_Low stage, negative markers:_ - Orchidectomy, followed by: - Surveillance; or - Adjuvant radiotherapy (SGCT only); or - Prophylactic chemotherapy _Nodal disease, persistent tumour markers, or relapse on surveillance:_ - Combination chemotherapy (BEP); or - Lymph node dissection (NSGCT only) _Metastases:_ - First-line chemotherapy - Second-line chemotherapy

Question 48

Prognosis good if treated:

Answer 48

Stage 1: 5-year survival – 99% Stage 2/3: 5-year survival – 96% Stage 4: 5-year survival – 73%