Prostate 20 20Bladder 20Cancer 20 20Iain 20McIntyre 20 Nov 2009 by y18a5zKA

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									Prostate and Bladder Cancer


           Iain McIntyre
   Consultant Urological Surgeon
    Manchester Royal Infirmary
          Prostate - incidence
•   27 000 new cases per year in UK
•   10 000 deaths
•   8% of men will be diagnosed
•   3% will die from prostate cancer

• Latent cancer present in 25% of screened
  patients and 50% of post-mortem patients
               Aetiology
• Age – much more common in over 70s
• Race – especially African Americans
• Genetics – 1st degree relative with Ca
  prostate diagnosed <60 yrs quadruples risk
• Familial Ca prostate gene – Chr 1 (few
  cases though)
• Smoking – NOT a factor
                 Pathology
•   95% adenocarcinomas
•   70% peripheral zone
•   25% central zone
•   5% transition zone (good prosgnosis)
                Precursor
• PIN – Prostatic Intraepithelial Neoplasia

• Starts 10 years before prostate cancer
• Often found next to cancer
• If you find PIN alone chance of cancer is
  25%
             Presentation
• Lower urinary tract symptoms
• Family history
• Opportunistic screening

• No plans for population screening in uk
PROSTATE CANCER DIAGNOSIS
     Prostate Specific Antigen
• Protein released by prostate into ejaculate
• Some leaks into blood – more in cancer
• Normal range 0-4 ng/ml
• PSA 4-10 = 25% chance of cancer
• PSA>50 = >50% chance metastatic
  cancer
• Next step is prostate needle biopsy
    Digital Rectal Examination
• Used in conjunction with PSA test
• Sensitivity only 50% at detecting cancers
• Far less with screened cancers
     Prostate needle biopsies
• Carried out via trans rectal ultrasound
  scan
• Scan is mainly to aim biopsy needle into
  appropriate part of prostate
• Local anaesthetic used
• 2% risk major sepsis despite ciprofloxacin
  prophylaxis
          Gleason grade
• Depends on architecture, not cellular
  appearance
• Gleason 2-5 - rare
• Gleason 6 – commonest – good prognosis
• Gleason 7 – moderate prognosis
• Gleason 8-10 – poor prognosis
STAGING/PROGNOSIS
                Prognosis
• Localised disease – good
  – Gleason 6 – 75% alive after 15 years


• Metastatic disease – poor
  – Median survival 2 years
    At the first consultation . . .
You will know
• PSA
  – Mets likely if over 50. NB Some men with
    PSA<4 have mets
• Gleason grade
  – The higher the Gleason the more likely he is
    to have mets
• Clinical stage
                  Stage
• T1 – impalpable
• T2 – palpable, confined to prostate
• T3 – locally advanced, through prostate
  capsule – not curable by radical surgery
• T4 – Adjacent organs involved

• M+ - distant metastases – usually bone
            Staging tests
• DRE – for local staging
• MR scans used routinely but not perfect
  for detecting extra-prostatic spread
• CT – little role
• Radionuclide bone scans – for bone mets
• All patients with PSA>10 or Gleason >7
      Treatment – localised CaP
•   Radical Prostatectomy
•   Radical external beam radiotherapy
•   Brachytherapy (interstitial radioactive seed implants)
•   Active surveillance

• Only one study has shown that surgery better than
  surveillance at cancer “cure”
• None have compared surgery with radiotherapy
• Patients given free choice
        Radical prostatectomy
•   Big operation
•   Whole prostate removed
•   Open vs laparoscopic vs robotic
•   Bladder anastomosed to urethra
•   60% chance impotence
•   5% incontinence
•   35% “positive margin”
•   >80% PSA eradication ie biochemical cure
            Radiotherapies
• External beam
  – 15 daily treatments
  – Good cancer cure
  – Can be used for T3 disease
  – Causes transient bowel side effects
• Brachytherapy
  – Seed therapy – single treatment
  – Low risk T2 only
  – Causes some urinary frequency/dysuria
        NICE guidelines 2008
Localised prostate cancer risk stratification
Low risk
  PSA< 10 and Gleason 6 and T1/T2

Medium risk
   PSA 10-20 and Gleason 7 and T2

High Risk
   PSA>20 and Gleason 8-10 and T3/T4
    Recommended treatments
Low risk – active surveillance (ie regular
  PSA monitoring and treat if PSA rises)

Medium risk – surgery or radiotherapy

High risk – radiotherapy usually with
  neoadjuvant hormone therapy
  Surgery in few selected patients
             Older patients
• Radical treatment reserved for fit patients
  aged <70
• ie those with >10 year life expectancy
• Older patients treated with watchful
  waiting or hormone treatment (if PSA>20)
         Metastatic disease
• Complications
  – Bone pain
  – Anaemia
  – Pathological Fracture
  – Spinal cord compression
    Metastatic CaP - treatment
• LHRH analogues – zoladex/prostap
• 3-monthly injection
• Decrease serum testosterone
• Essentially palliative
• Use 2nd line antiandrogen or oestrogen
  treatment when they fail (ie PSA rises)
• Radiotherapy to painful discrete bony mets
• Chemotherapy - docetaxel has recently been
  shown to increase survival - slightly
         Prostate screening
• Controversial – not recommended in UK
• 2009 European Screening study showed
  small survival advantage at 9 years
• Need to treat 48 patients to save one life
• May unmask many latent cancers
• Little survival benefit shown to date
    Prostate cancer - summary
• Commonest male cancer
• Usually localised and very slow growing
• Some are metastatic – poor progress
• Wide choice of treatments for localised
  disease – including surveillance
• Screening still not recommended
• Check PSA or do DRE if patient has
  symptoms/family history/is worried
• Rarely treat localised cancer in the over 80s
           Bladder cancer
• 13 000 new cases per year in UK
• Male:female 2.5:1
• More common in the elderly
                Aetiology
• Smoking – 4x increased risk
  – Causes 50% of cases


• Occupational – rubber/dye industry
  – Napthylamine, benzidine


• Schistosomiasis, chronic infection
               Pathology
• Transitional cell carcinoma 90%
• Squamous carcinoma – 5%
• Adenocarcinoma – 2%

• Superficial 75%
• Invasive 25%
      Presentation/diagnosis
• Classically painless frank haematuria
• 25% serious cause for this in over 65s
• All should have cystoscopy, IVU, renal
  USS and urine cytology
• Cystoscopy is mandatory
• Cytology can be only 60% sensitive
• Some present with microscopic
  haematuria (5% serious causes)
                     Grade
• Grade 1 – well differentiated – good prognosis
• Grade 2 – moderately differentiated
• Grade 3 – poorly differentiated
  – Least common
  – Most progress to invasive disease
                    Stage
• Ta – confined to the epithelium, no invasion
  through basement membrane – common
• Tis – carcinoma in situ – aggressive (grade 3)
  cells confined to epithelium – 50% progression
  risk
• T1 – invades lamina propria
• T2 – invades bladder muscle
• T3 – outside bladder
• T4 – adjacent organs involved
              Treatment
• Diagnosed at flexible cystoscopy
• Urgent TURBT (trans-urethral resection of
  bladder tumour) booked
• CXR
• IVU (5% chance upper tract involvement)
• Bimanual examination carried out at
  TURBT
• Intravesical mitomycin reduces risk of
  recurrence
          Superficial TCC
• ie pTa
• Flexible check cystoscopy booked for 4
  months
• 50% chance recurrence
• Course of 6 weekly mitomycin treatments
  given for persistent Ta tumours
                T1, Cis
• Both have 50% chance of progressing to
  muscle invasive disease
• Do early check cystoscopy and rebiopsy
• Treat with intravesical BCG
  immunotherapy – effective in 50%
• Course of 6 weekly instillations then
  further cystoscopy/biopsy
• Cystectomy of treatment fails
               Invasive TCC
•   ie T2-4
•   Require radical therapy
•   ie radical cystectomy or radiotherapy
•   Both equally effective
•   Radiotherapy poor if multifocal disease or
    widespread cis or small bladder capacity
        Radical cystectomy
• Bladder and prostate/uterus removed
• Urine diverted into an ileal conduit or
  (rarely) an orthotopic neobladder made
  from ileum
• Complex surgery – avoid in over 75s
• Mortality 2%
• Sometimes required after radiotherapy
  failure “salvage cystectomy”
            Metastatic disease
•   Relatively uncommon
•   Often pulmonary – always need CXR
•   Treat with chemotherapy
•   Classic M-VAC
    – Methotrexate, vinblastine, doxorubicin,
      cisplatin
    – Highly toxic
    Bladder cancer summary
• Classic presentation is haematuria
• Take haematuria seriously in the over 50s
• Mostly superficial cancer – treat with
  TURBT
• Muscle invasive cancer needs radical
  cystectomy or radiotherapy
• Mets are relatively rare at presentation

								
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