What is the prostate covered by?
*What kind of epithelium*
Transitional Epithelium
Where is the apex of the prostate?
Where is the base?
Apex = Inferior part that is continous with the striated sphincter
Base = Superior part, continious with bladder neck
Describe the zones of the prostate?
Transitional Zone - Surronds Urethra
Central Zone - Cone shaped region that surronds ejaculatory ducts
Peripheral Zone - Posterior/lateral part of prostate
What part of the prostate is most commonly affected in prostate adenocarcinoma?
Peripheral Zone
Is prostate cancer commmon or rare?
High or low mortality?
Do people die of prostate cancer or with prostate cancer?
Very Common
2nd Highest mortality from cancer
Has a long course and is slow growing - most people die with prostate cancer
Peak age range for prostate cancer?
What group is it rare in?
Elderly (>70)
Rare in anyone under 50
Who has a higher risk for prostate cancer:
- Asians or Americans?
- Caucasians or Blacks?
- West or East?
Americans have a high risk, asians have a low risk
Blacks have a higher risk than caucasians
Prostate cancer common in west but not in east (Eg Common in America, Scandinavia but not Asia)
Prostate cancer is caused by mutations of what chromosomes/genes?
1q
8p
Xp
BRCA 2
Describe family history and risk of developing prostate cancer?
If you have one 1st degree relative, risk doubles
if you have two 1st degree relatives, risk quadruples
How are the majority of prostate cancers found? (What is the presentation)?
Most found due to PSA tests and abnormal DRE (Digital Rectal Exam)
Describe some of the symptoms of prostate cancer?
Urinary Symptoms - Nocturia, Frequency
Haematuria
Haematospermia
Bone pain
Weight Loss
75% of prostate cancers arise in the PERIPHERAL/CENTRAL zone?
75% of prostate cancers arise in the peripheral zone
Describe what you would feel on an abnormal digital rectal exam?
Asymmetrical
Nodule
Fixed Craggy Mass
True or false?
- 50% of abnormal PR exams are associated with cancer of the prostate
True
50% of abnormal PR exams are associated with cancer of the prostate
True or False:
The majority of patients with prostate cancer who have an abnormal PR exam will have organ confined disease?
False
40% of patients who have an abnormal PR will have organ confined disease
This means 60% who have an abnormal PR will have metastatic disease
What is PSA?
Where is it produced?
Prostate Specific Antigen
Enzyme produced by the secretory epithelial cells of the prostate
Describe the serum and semen levels of PSA in a:
- Healthy patient?
- Patient with prostate cancer?
Healthy:
- High SEMEN PSA
- Low SERUM PSA
Cancer:
- High SEMEN PSA
- High SERUM PSA
Describe PSA sensitivity and specificity in prostate cancer?
Sensitivty = 90% (PSA is raised in 90% of cancers)
Specificity = 40% (Can be raised by many other causes so doesn’t definitly diagnose cancer)
Name some conditions that cause elevated PSA?
- Benign Prostatic Hyperplasia
- Prostatism/ UTI
- Retention
- Catherization
Describe PSA testing in
- Symptomatic Patients?
- Asymptomatic Patients?
Symptomatic: Good test for prostate cancer, should be used
Asymptomatic: Can be used however must be counselled (Eg; May not be cancer, explain how it’s non-specific)
Explain how you would counsell for PSA testing?
Must be done in asymptomatic patients
Very sensitive - 90%
Specific - 40%
Patient must be invovled in decision
If raised PSA is found, then you will have to do a biopsy and then treatment
May not be necessary or curative
When would you carry out a trans-rectal ultrasound guided biopsy of the prostate?
- Men with abnormal PR exam and raised PSA
- Previous biopsy showing PIN or ASAP (pre-cancerous changes)
- Normal biopsy but rising PSA
Risks of rectal biopsy?
Sepsis
Rectal Bleeding
Haematuria and haematospermia for 3 weeks after
The majority of prostate cancers are …?
Multifocal Adenocarcinomas
Describe the bone lesions seen following prostatic metastases?
Sclerotic Lesions
How are prostate cancers graded?
Gleason’s Scoring
Based on architectural appearance
Apart from Gleason’s scoring, how else can prostate cancer be staged?
TNM Scoring
T = Tumour (Size/Invasion)
N = Nodes (Regional lymph nodes metastases)
M = Metastases
What imaging is used to stage prostate cancer?
Bone Scans
MRI
CT Scan
Give the TNM stage for:
- Organ confined disease?
- Locally advanced disease (not local lymph nodes)
- Metastatic disease
Organ Confised: T1-2/N0/M0
Locally Advanced: T3/T4/N0/M0
Metastatic: T3/4/N1/M1
Management of organ confined prostate cancer?
Watchful Waiting
Active Monitoring
Radical Surgery
Radical Radiotherapy
Management of locally advanced disease?
Radiotherapy
Watchful Waiting
Hormonal Therapy
Management of metastatic disease?
Androgen Deprivation Therapy
Steroids
Chemotherapy
What hormone controls the prostate?
Where is this from?
Testosterone
From testis and adrenal gland
Explain how androgen deprivation therapy works?
Starves the prostate cells from androgens (Testosterone)
This causes apoptosis
Helps treat symptoms
What is used for hormone therapy in prostate cancer?
How do they work?
LRHR Agonists (luteinizing-hormone releasing hormone agonists)
Long term use causes down-regulation of LRHR receptors and then suppression of pituitary LH and FSH leading to drop in testerone
Describe the flare up of LRHR agonists?
How do you prevent this?
When they are first given, they cause increased LRHR receptors, increased LH and FSH and increased testerone
In 20% of patients, this causes catastrophic spinal cord compression
Anti-Androgen is given 1 week before and 2 weeks after the LHRH agonist injection
Side effects of LHRH agonists?
Loss of libido
Erectile Dysfunction
Hot flushes and sweats
Weight Gain
Gynaecomastia
Anaemia
Cognitive Changes
Osteoporosis
Describe how anti-androgens work?
Compete with testoerone and DHT for binding sites
This promotes apoptosis and inhibits prostate cancer growth
Describe the two types of anti-androgens and their side effects?
Steroid (Eg: Cyproterone Acetate)
- Loss of libido, erectile dysfunction, gynaecomastia, cardiovascular toxicity and hepatotoxicity
Non-Steroidal (Nilutamide, Flutamide, Bicalutamide)
Sexual interest and libido maintained
Gynaecomastia, hot flushes, breast pain, sweating, hepatotoxicity
What are the types of transitional cell cancer?
Papillary (80%)
Non Papillary (20%)
Risk factors for bladder cancer?
Chemical exposure (Factory workers, hairdressers, etc.)
Smoking
Symptoms of bladder cancer?
Painless Haematuria *MOST COMMON SYMPTOM
Also increased frequency
Urge
Dysuria
Imaging in bladder cancer?
Cystoscopy
CT
MRI
Is urinary bladder cancer more common in:
- Males or females?
- Elderly or young?
More common in males
More common after 5th decade of life
What two epithelium of the bladder can cancer occur in?
Transitional (Most common)
Squamous