Prostate Ca

• Most common malignancy amongst men. 5 year survival rate is 98%.
• Prostatic urethra runs directly through the prostate, emerging as the membranous and penile urethra
• 4 main zones of the prostate:

  • Peripheral zone - posterior, where most malignancies originate
  • Fibromuscular zone - anteriorly
  • Central zone
  • Transitional zone surrounds the urethra
• Prostate is supplied by:

  • Primary and middle rectal arteries
  • Internal pudendal arteries
• Prostate drains into the internal iliac veins
• Lymph drains into internal iliac and sacral lymph nodes
• Risk factors:

  • Age >50
  • Black ethnicity
  • Family history of prostate cancer
  • Family history of other heritable cancers e.g. breast or colorectal cancer - BRCA 2 gene associated with prostate cancer
  • High levels of dietary fat
• The most common presenting symptoms of prostate cancer include:

  • Lower urinary tract symptoms (LUTS) including frequency, urgency, nocturia, hesitancy, dysuria and post-void dribbling.
• Other symptoms can include:

  • Haematuria
  • Haematospermia
  • Systemic symptoms: weight loss, weakness, fatigue
  • Bone pain (associated with metastatic prostate cancer)
• Other important areas to cover in the history include:

  • Past medical history: previous hospitalisations, surgical procedures and history of pelvic radiation.
  • Medication history
  • Family history: prostate cancer in a first-degree relative less than 65 years old and breast cancer (BRCA2 gene is associated with prostate cancer).
  • Social history: alcohol intake, smoking history (affects prostate cancer prognosis) and recreational drug use.
• Typical clinical findings on examination include:

  • Asymmetrical prostate
  • Nodular prostate
  • Indurated prostate
• A digital rectal exam should always be accompanied by a PSA test
• Lab tests:

  • PSA - normal levels are age specific and can be raised by prostatitis, BPH or UTI. May need to repeat to confirm trending elevation
  • U&Es - may be obstructing ureters, leading to hydronephrosis and kidney dysfunction
  • FBC - anaemia
• Normal PSA levels are age-specific. In the UK, Public Health England recommends 2-week referral for men aged 50-69 years old with a PSA ≥3ng/ml and for men aged 70+ with a PSA >5ng/ml.
• The majority of prostate cancers (95%) are adenocarcinomas. Other, much rarer, forms include transitional cell, squamous cell and neuroendocrine cancers.
• Before testing PSA men should not have:

  • Active or recent UTI (last 6 weeks)
  • Recent ejaculation, anal sex or prostate stimulation
  • Engaged vigorous exercise for 48 hours
  • Had a urological intervention in the past 6 weeks
• Multiparametric MRI is now commonly the first line investigation in the diagnosis of prostate cancer. The Likert score is used based upon the radiologist's impression of the scan - how likely cancer is
• A guided biopsy is offered to patients with a Likert score of 3 or greater. 
• The Gleason score is a histological grade assigned to prostate cancers. From the biopsy, the most common and second most common tumour pattern is assigned a score of 1 to 5 (5 being the highest grade) to give a combined score of 2 to 10.
• Common sites of metastasis:

  • bones
  • Lymph nodes
  • Liver
  • Lungs
• Management:

  • Low risk - watchful waiting or active surveillance
  • Intermediate risk - active surveillance, radical prostatectomy or radiotherapy
  • High risk - surgery, radiotherapy +/- hormone treatment
  • Hormone treatment aims to block testosterone (growth is androgen driven)
• Testosterone levels should be measures as androgen deprivation may be a treatment
• LFTs should be monitored - risk of hepatitis with treatment
• To investigate potential metastases a CT CAP may be used
• Treatment complications of radical treatment for prostate cancer include:

  • Dysuria
  • Urinary frequency
  • Urinary incontinence
  • Rectal bleeding/proctitis (mainly associated with radiotherapy)
  • Erectile dysfunction (may be caused by surgery or androgen deprivation therapy)