The document discusses prostate cancer, including that it is the most common malignancy of the male urogenital tract, with about 10,000 cases per year in the UK. It is rare before age 50 and found in 80% of men older than 80 upon autopsy. Prostate cancer arises in the prostate gland and can spread through the capsule, lymph nodes, bones, and other sites. Risk factors include family history and diet. Screening includes digital rectal exam and PSA testing, while diagnosis involves biopsy. Staging uses the TNM system and Gleason grading provides a prognosis. Treatment depends on stage and includes surgery, radiation, hormone therapy, and active surveillance.

1. Mr Rahul Mistry
Urology Special Registrar
Mersey Deanery

3.  Prostate cancer
 Testicular cancer
 Bladder cancer

4.  Commonest malignancy of male urogenital tract
 There are about 10,000 cases per year in the United
Kingdom
 Rare before the age of 50 years
 Found at post-mortem in 80% of men older than 80
years
 5-10% of operation for benign disease reveal
unsuspected prostate cancer

6.  Adenocarcinomas
 Arise in the posterior / periphery
 Spread through capsule into perineural
spaces, bladder neck, pelvic wall and
rectum
 Lymphatic spread - common
 Haematogenous spread occurs to axial
skeleton
 Graded by Gleason classification

7.  Not well known
 First-line relative - risk is at least doubled
 If two or more first-line relatives - the risk increases 5- to 11-fold
 Incidence high in the USA and Northern Europe and low in South-
East Asia
 However, if Japanese men move from Japan to Hawaii, their risk of
CaP increases, and if they move to California their risk increases
even more and approaches that of American men
 High content of animal fat in the diet may be important in
increasing the risk of developing CaP
 Low intakes of vitamin E, selenium, lignans and isoflavenoids
(soybeans)
 Sunlight might be protective againstCaP due to an increase in
vitamin D levels

9.  60% symptoms of bladder outflow
obstruction
 10% incidental findings atTURP
 Bone pain, cord compression or leuco-
erythroblastic anaemia
 Renal failure can occur due to bilateral
ureteric obstruction

10.  DRE:
 Hard nodule
 Loss of central sulcus
 Transrectal biopsy
 Pelvic MRI - staging
 Bone scans – metastasis
 Unlikely to be abnormal if asymptomatic and PSA
< 10 ng/ml

11.  Prostate specific antigen
 Kallikrein-like protein produced by prostatic epithelial cells
 Age matched:
 40-50:2.5
 50-60: 3.5
 60-70: 4.5
 70-80: 6.5
 >10 ng/ml is highly suggestive of prostatic carcinoma
 Can be significantly raised in BPH, UTI’s or secondary to
retention
 Monitoring response to treatment

12. PPV = positive predictive value
PSA ng/mL PPV for cancer
0 - 1 2.8-5%
1 - 2.5 10.5-14%
2.5 - 4 22-30%
4 - 10 41%
> 10 69%

13. Gleason score Risk of cancer death Cancer-specific
mortality
2 – 4 4 – 7% 8%
5 6 – 11% 14%
6 18 – 30% 44%
7 42 – 70% 76%
8 – 10 60 – 87% 93%

14.  Grading score
 Score: 2 – 10
 2 - least aggressive
 10 -most aggressive.
 Total score = the sum of the two most common
patterns (grades 1-5) of tumour growth found
 TRUS prostate biopsy
 TURP

15.  TX Primary tumour cannot be assessed
 T0 No evidence of primary tumour
 T1 Clinically inapparent tumour not palpable or visible by imaging
 T1a Incidental histological finding in 5% or less of tissue resected
 T1b Incidental histological finding in more than 5% of tissue resected
 T1c Tumour identified by needle biopsy (e.g., because of elevated PSA)
 T2 Tumour confined within the prostate
 T2a Tumour involves one half of one lobe or less
 T2b Tumour involves more than half of one lobe, but not both lobes
 T2c Tumour involves both lobes
 T3 Tumour extends through the prostatic capsule
 T3a Extracapsular extension (unilateral or bilateral)
 T3b Tumour invades seminal vesicle(s)
 T4 Tumour is fixed or invades adjacent structures other than seminal vesicles:
bladder neck, external sphincter, rectum, levator muscles, or pelvic wall

16.  More men die with than from prostate cancer
 Treatment depends on stage of disease, patient's age
and general fitness
 Local disease –
 Observation
 Radical radiotherapy / brachythrapy
 Radical prostatectomy
 Locally advanced disease
 Radical radiotherapy
 Hormonal therapy
 Metastatic disease
 Hormonal therapy

17.  80% of prostate cancers are androgen dependent for growth
 Hormonal therapy involves androgen depletion
 Produces good palliation until tumours 'escape' from
hormonal control
 Androgen depletion can be achieved by:
 Bilateral subcapsular orchidectomy
 LHRH agonists - goseraline (Zoladex)
 Anti-androgens - cyproterone acetate, bicalutamide
 Complete androgen blockade
 Oestrogens - stilbeostrol

18.  Regulated by the hypothalamic-pituitary-gonadal axis.
 LHRH stimulates the anterior pituitary to release LH and FSH
 LH stimulates the Leydig cells of the testes to secrete testosterone
 In Prostate cells, testosterone is converted by the enzyme 5-α -reductase
into 5-α -dihydrotestosterone (DHT), which is an androgenic stimulant
approximately 10 times more powerful than the parent molecule
 Circulating testosterone is peripherally aromatized and converted into
oestrogens which, together with the circulating androgens, exert a
negative feedback control on the hypothalamic LH secretion
 If prostate cells are deprived of androgenic stimulation, they undergo
apoptosis (programmed cell death)
 Any treatment ultimately resulting in the suppression of androgen activity
is referred to as androgen deprivation therapy

21.  Commonest solid malignancy in young men
 1% - 1.5% of male neoplasms
 5% of urological tumours
 3-6 new cases occurring per 100,000 males per year
inWestern society
 Only 1-2% of cases are bilateral
 Incidence high in caucasians in northern Europe and
USA
 1400 new cases per year in UK
 95% 5 year survival testis localised disease
 Peak incidence
 Third decade of life for non-seminoma
 Fourth decade for pure seminoma

22.  History of cryptorchidism
 x4-13 increased risk
 7-10% tumours in undecended testis
 Klinefelter’s syndrome
 FHx
 Father/brother: x6-8 increased risk
 Presence of a contralateral tumour
 5-10% risk
 HIV
 seminoma

23.  Unilateral testicular mass
 20% scrotal pain
 27% local pain
 Trauma
 Reduction in testis size
 Gynaecomastia 7% (beta HCG) more common in non-
seminomatous tumours
 Symptoms of metastatic disease
 Seminomas metastasize to para-aortic nodes back pain – 11%
 Teratomas – spread to para-aortic nodes, liver, lung, bone and
brain
 10% of cases can mimic an epididymo-orchitis
 Supraclavicular / distant metastases
 Palpable abdominal mass

24.  Staging and response to treatment
 Alpha-fetoprotein
 Produced by yolk sac elements
 Not produced by seminomas
 Beta-human chorionic gonadotrophin
 Produced by trophoblastic elements
 Elevated levels seen in both teratomas and seminoma
 Lactate Dehydrogenase
 Less specific marker
 Concentration is proportional to tumour volume
 Elevated in 80% of patients with advanced testicular cancer
 It should be noted that negative markers levels do not exclude the diagnosis of a
germ cell tumour

25.  Ultrasound
 Sensitivity almost 100%: intra- or extratesticular
 Inexpensive test
 Screening test of the contralateral testis in the follow-up
 Elevated serum beta-hCG or AFP
 MRI
 Higher sensitivity and specificity than ultrasound
 May differentiate seminomatous from non-seminomatous tumours
 Sensitivity of 100% and a specificity of 95-100%
 High cost
 Thoraco-abdominalCT scanning for staging

26. Radical Orchidectomy

27.  Seminomas are radiosensitive
 Teratomas are not radiosensitive
 Surgery: Inguinal orchidectomy
 Radiotherapy
 Chemotherapy

29.  95% transitional cell carcinomas
 4% squamous / adenocarcinoma
 Superficial tumours are usually low grade and
associated with a good prognosis
 Muscle invasive tumours are of higher grade
and have a poorer prognosis

30.  TCCs should be regarded a 'field change' disease
with a spectrum of aggression
 80% ofTCCs are superficial and well differentiated
 Only 20% progress to muscle invasion
 Associated with good prognosis
 20% ofTCCs are high-grade and muscle invasive
 50% have muscle invasion at time of presentation
 Associated with poor prognosis

31.  Occupational exposure
 20% ofTCC are believed to result from occupational
factors
 Chemical implicated - aniline dyes, chlorinated
hydrocarbons
 Cigarette smoking
 Pelvic irradiation - for carcinoma of the cervix
 Schistosoma haematobium associated with
increased risk of squamous carcinoma

32.  Requires
bladder
muscle to be
included in
specimen
 Staged
according to
depth of
tumour
invasion
 Grade of
tumour
differentiation
Tis In-situ disease
Ta Epithelium only
T1 Lamina propria invasion
T2 Superficial muscle invasion
T3a Deep muscle invasion
T3b Perivesical fat invasion
T4 Prostate or contiguous muscle
G1 Well differentiated
G2 Moderately well differentiated
G3 Poorly differentiated

33.  80% present with painless haematuria
 Also present with treatment-resistant infection or bladder
irritability and sterile pyuria
Haematuria clinic involves:
 Urinalysis
 Mid stream urine
 Serum urea and creatinine
 Ultrasound - bladder and kidneys
 KUB xray - to exclude urinary tract calcification
 Flexible cystoscopy
 Consider IVU / CT urography if no pathology identified

34.  RequiresTURT follow-up
 Consider prophylactic chemotherapy (mitomycin-C)
if risk factor for recurrence or invasion (e.g. high
grade)
 Consider immunotherapy
 BCG = attenuated strain of Mycobacterium bovis
 Reduces risk of recurrence and progression
 50-70% response rate recorded
 Occasionally associated with development of
systemic mycobacterial infection

36.  Carcinoma-in-situ is an aggressive disease
 Often associated with positive cytology
 50% patients progress to muscle invasion
 Consider immunotherapy - BCG
 If fails patient may need radical cystectomy

37.  Choices are between radical cystectomy and radiotherapy
 Radical cystectomy has an operative mortality of about 5%
 Urinary diversion achieved by:
 Ileal conduit
 Neo-bladder
 Local recurrence rates after surgery are approximately 15%
and after radiotherapy alone 50%
 Pre-operative radiotherapy is no better than surgery alone
 Adjuvant chemotherapy may have a role

38.  Prostate_Exam.pps
Prostate cancer is a disease that can affect men as they
older. The sooner it’s detected, the better the prognosis.
Urologia
O n l i n e