| How is epidemiology of prostate cancer? | Most common cancer in men >50 yrs, exceptional <40 yrs, second cause of mortality after broncho cancer, incidence in autopsy in pt >90 is 70%.
highest in US lowest in china, mostly blacks.
Incidence increasing due to screening and PSA assays. |
| What are risk factors for prostate cancer? | There are 2 groups at risk:
● Patients with a family history of prostate cancer (8%) especially with at least 2 collateral relatives or cancer in a parent under 55 years of age.
● Afro-Caribbean patients. (africo antillais in french) |
| How is screening for prostate cancer? | Screening in asymptomatic population
Based on DRE and PSA dose, recommended age 50-75 if life expectancy <10 years
Not recommended for men w/ life expectancy <10 years
If PSA>4ng/ml uro consult is imp, for indication of US-guided biopsy |
| When is dx of prostate usually done? | In asymptomatic phase usually |
| How is the DRE findings for prostate cancer dx? | Systematically performed even if PSA normal, suspect cancer in peripheral zone
Search for: hard irregular non-painful nodule (not necessarily cancer) or invasion of capsule,seminal vesicles or neighboring organs
Any anomaly indicates biopsy |
| What are functional signs of prostate cancer? | Irritative/Obstructive urinary disorders (invasion of bladder trigone by prostate cancer)
Hemospermia/hematuria
General state alteration
Bone pain (bone metastasis)
Neurological signs (paresthesia, leg muscle deficit, cauda equina syndrome suggest spinal metastasis and compression. |
| What are clinical exam findings in prostate cancer? | ● Palpation of lumbar fossa.
● Edema of one of the lower limbs.
● neurological exam. |
| What is assay of serum PSA in prostate cancer? | Normal value is <4, Endourethral maneuvers, prostate biopsies and surgery lead to rise in PSA, while DRE, prostate massage, endorectal US or ejactulation lowers levels of PSA <1.
Pt w/prostate hyperplasia taking 5a reductase inhibitors drugs should be taken into account when assessing PSA level |
| What is free PSA/total PSA report use in prostate cancer dx? | In prostate cancer free PSA is less elevated than in prostate hyperplasia, if ration >20% more in favor of hyperplasia and if <10% in favor of cancer/prostatitis |
| What are other markers used in prostate cancer? | PSA densities (for biopsies), PSA kinetics (for tx monitoring) |
| What is the usual location of prostate adenocarcinoma? | 70% of cancers sit in the peripheral zone of the prostate, accessible to rectal examination starting from a certain volume.
10% in the central area.
20% sit in the transition zone (which is the area of development of benign prostatic hyperplasia). |
| How is the extension of prostate adenocarcinoma? | Extends to periprostatic fat by capsular penetration, then to seminal vesicles by continguity (direct extension along ejaculatory ducts or from neighboring fat)
Very rare rectal involvment in large tumors only, bladder neck/trigone/ureters involvement in locally evolved tumors.
Ganglionic extension is pelvic first then retroperitoneal lumbar-aortic, or supra-diaphragmatic.
Most frequent metastasis are ganglionic and bony, osteblastic lesions predominate in axial skeleton |
| How is tumor grading? | Gleason's classification, 5 subgroups from 1 (well-differentiated) to 5 (undifferentiated) according to tumor architecture.
Prognostic value of gleason's classification is well-established much more unfavorable in less differentiated.
Score 2-4 well-differentiated, 5-6 moderate, 8-10 little or no differentiation. |
| What are the indications for prostate biopsy? | Only affirmative exam, indicated in sus case on DRE or elevation of PSA, give dx, Gleason score, number of + biopsies, invasion, inflitration of capsule. |
| What is the modality of realization in prostate biopsy? | The biopsies are performed by ultrasonography, transrectally, under local anesthesia (or rarely general), under antibiotic prophylaxis and after rectal enema. The average number of biopsies is 12 samples. |
| What are complications associated with prostate biopsy? | The patient must be informed of the risks involved in performing biopsies:
● urine retention.
● perineal pain.
● vagal discomfort, hypotension.
● acute prostatitis (2% of biopsies), septicemia, septic shock, death.
● haemorrhagic complications (urethrorrhagia, rectorrhagia, hemospermia, hematuria) especially in patients on anticoagulants or antiplatelet agents. |
| How is endorectal echography used as imaging dx of prostate cancer? | Ultrasound of the prostate has no place in the diagnosis of prostate cancer. Its only use in prostate cancer is guiding biopsies. |
| How is MRI used in dx of prostate cancer? | Test for dx and prognosis, see diffusion and hypervascularization.
recommended in cancer of intermediate/high risks to assess site, infiltration and seminal vesicles invasion.
Can dx, can guide biopsy, can reveal pelvic lymphadenopathy or bone lesions. |
| How is use of abdominal CT in prostate cancer? | Abdominopelvic CT is one of the recommended tests in prostate cancer extension assessment. It may reveal pelvic and retroperitoneal lymphadenopathy or osteoconductive lesions. It can also highlight other tumoral pathologies. |
| How is the use of bone scintigraphy in prostate cancer? | Scintigraphy remains the reference examination for the search for bone metastases by the presence of foci of hyperfixation. Its limit remains its low specificity.
In high and intermediate risks D'Amico cancer classification (3 classes low [PSA<10, score <6 T1] intermediate [PSA 10-20, score 7] and high risk [PSA >20, score >8 T2c]) |
| How is use of PET scan w/choline in prostate cancer? | It remains inferior to bone scintigraphy for the diagnosis or follow-up of bone metastases. It is not currently recommended, except in case of biological progression of the cancer after treatment. |
| How is TNM classification of prostate cancer? | . |
| How is active monitoring in tx of prostate cancer? | The indication for active surveillance is therefore a clinically localized prostate cancer with a low risk of progression for patients whose life expectancy is greater than 10 years.
And for :
- Patients in the low risk group Amico (PSA <10 ng / mL and Gleason ≤ 6 and T1c or T2a).
- 1 to 2 biopsy cores positive on at least 10 samples.
- Tumor length <3 mm in total on the sample. |
| What is surgery done for prostate cancer? | Classically, the intervention is performed abdominal retropubic. In the absence of metastases, enlarged total prostatectomy is performed, with monoblock removal of the prostate and seminal vesicles followed by vesico-urethral anastomosis. Ganglion dissection of Prostate Cancer involves removal of the external iliac-iliac, iliac, and lateral iliac nerves to the iliac bifurcation. |
| What are surgical complications associated w/prostate cancer removal surgery? | Urinary incontinence (Mostly transient and recovery aided by perineosphincteritic reeducation, majority are continent w/in 3-6 months)
Stenosis of Vesico-urethral anastomosis (0.5-9% of cases favored by prior transurethral resection, intraop bleeding or fistulas, may require one or several dilatations)
Erectile dysfunction (always if no conservation of neurovascular pedicles of erection)
Infertility and Anejaculation (cst after this surgery) |
| How is hormone therapy medical tx of prostate cancer? | The hormonal treatment of prostate cancer, in case of locally advanced or metastatic disease, aims to reduce circulating testosterone.
Castration, whether medical or surgical, is the standard treatment. In cases of chemical castration by LH-RH analogues, the treatment is uninterrupted. Its usual side effects are low libido and erectile insufficiency, hot flashes and sometimes gynecomastia. In the long term, castration can be responsible for osteoporosis with risk of fractures, but also of amyotrophy, anemia or depression. |
| How is complete androgenic blockage as medical therapy for prostate cancer? | Complete androgen blockade (BAC) combines the Luteinizing Hormone-Releasing Hormone (LHRH) agonist with the peripheral antiandrogen.
LHRH Antagonist or Agonist The LHRH antagonist allows faster castration than LHRH agonists and does not expose to a peak of testosterone (flare-up). |
| How is radiotherapy in prostate cancer? | Radiotherapy consists of image-guided irradiation of the prostatic lodge at a dose of 76-78 Gy. It is also a curative treatment. It is now used according to a three-dimensional conformational technique, and aims to reduce the side effects related to the irradiation of adjacent organs.
However, patients may complain about:
- Radiation cystitis;
- Radiation rectitis;
- Urethral stenosis;
- erectile dysfunction;
- Radiation-induced tumor with a relative risk of 1.5 for cancer of the rectum or bladder. |
| What are CI of radiotherapy in prostate cancer? | Contraindications include antecedents of anterior pelvic irradiation or rectal inflammatory disease.
Radiation therapy may be associated with short-term hormonal therapy of 6 months for cancers at intermediate risk or long-term 3 years for cancers at high risk of progression. |
| How is brachytherapy in prostate cancer? | Interstitial prostate brachytherapy involves the placement of transperineal radioelements under ultrasound, endorectal and general anesthesia control. Most often, it involves the implantation of 125 I iodine grains.
The indication to date of brachytherapy is mainly for patients with localized prostate cancer and low risk D'Amico having a life expectancy of more than 10 years.
The risks are the same as those of external irradiation. |
| How is focused US/crytherapy (HIFU) in tx of prostate cancer? | This treatment has the purpose of destroying by focused ultrasound the prostatic tissue produced under general anesthesia and associated with a prostatic resection.
The ideal indication is the treatment of recurrent cancers locally after radiotherapy.
The risks are the risks associated with anesthesia, transfusion, infection, stenosis, urethrectal or prostatectal fistula, incontinence and erectile dysfunction. Cryotherapy is the only indication of local recurrence after radiotherapy |
| How is chemotherapy in tx of prostate cancer? | Chemotherapy has a recognized place in metastatic prostate cancer resistant to castration and symptomatic. |
| What is the all-in-all therapeutic strategy in prostate cancer? | ● localized prostate cancer: active surveillance or curative treatment (by surgery or radiotherapy).
● locally advanced prostate cancer: curative treatment by surgery in young subjects or hormone-radiotherapy.
● metastatic prostate cancer: hormone therapy.
● prostate cancer in the castration resistance phase: hormonal manipulation with little symptomatic symptoms (androgenic withdrawal syndrome, DistilbeneR, new hormonal therapies) or
so symptomatic chemotherapy (bone pain ...).
● and do not forget: 100% care, comfort care (treatment of pain, urinary disorders ...). Surveillance of at least 10 years based on clinical (TR) and biology (PSA level, testosteronemia) is recommended |
