Male Pelvic Malignancies

What four malignancies are covered in this lecture?

Prostate cancer; testicular cancer; penile cancer; male urethral cancer.

What is the prostate?

A gland found only in men.

Where is the prostate located?

Below the urinary bladder and in front of the rectum.

What is the normal size of the prostate gland?

About the size of a walnut.

What is the size of the prostate at birth?

About the size of a pea.

When does the prostate have its two growth spurts?

During puberty and around age 50.

What do prostate cells produce?

Fluid contained in seminal fluid that nourishes sperm.

What is the urethra?

The tube that carries urine and semen out of the body.

Where does the urethra run in relation to the prostate?

Through the center of the prostate.

What is the second leading cause of cancer death in American men, behind lung cancer?

Prostate cancer.

Is prostate cancer always fatal?

No. It can be serious depending on the stage, but most men diagnosed with it do not die from it.

Why is prostate cancer sometimes called a "watch and wait disease"?

Because some cases, particularly lower-grade disease, may be monitored rather than treated immediately.

How many men in the United States who have been diagnosed with prostate cancer are estimated to still be alive?

Approximately 3.1 million.

How does the incidence rate of prostate cancer change with age?

It increases with each decade of life.

At what age is prostate cancer rare?

Before age 40.

What percentage of prostate cancer cases occur in men over age 65, according to the slides?

65%.

Which racial group has a higher incidence of prostate cancer according to the slides?

African-American men.

In what geographic area is prostate cancer more common according to the slides?

North America.

How can a first-degree relative with prostate cancer affect a man's risk?

A father or brother with prostate cancer can double the risk; the risk is higher when the affected relative is a brother.

What are the main prostate cancer risk factors listed in the slides?

Age, race, geography, family history, and genetics.

Which dietary factor may be associated with a slightly higher chance of prostate cancer?

Increased dairy product consumption.

What does the lecture say about obesity and prostate cancer risk?

The relationship is unclear. Some studies show obese men may have a lower risk of low-grade disease but a higher risk of more aggressive disease.

What does the lecture say about smoking and prostate cancer?

The slide says there is no link between smoking and prostate cancer, but research is ongoing.

Which chemical exposures are mentioned as possible prostate cancer risk factors?

Agent Orange and possible chemical exposures among firefighters.

What other possible prostate cancer risk factor is listed?

Vasectomy.

What does DRE stand for?

Digital rectal examination.

What is the purpose of a digital rectal examination (DRE)?

To feel for nodules because many prostate cancers begin in the back part of the gland.

How often does the lecture say DRE should be performed in men over 50?

Annually.

What does PSA stand for?

Prostate-specific antigen.

Why does the normal PSA range depend on age?

The prostate enlarges as men age.

What PSA level do most men without prostate cancer have, according to the slides?

Under 4.

At what age should average-risk men begin prostate cancer screening according to the lecture?

Age 50, if they are expected to live at least 10 more years.

At what age should high-risk men begin prostate cancer screening according to the lecture?

Age 45.

Who is included in the high-risk screening group beginning at age 45?

African-American men and men with a first-degree relative diagnosed at age 65 or earlier.

At what age should men at even higher risk begin screening according to the lecture?

Age 40.

Who is included in the even-higher-risk group beginning at age 40?

Men with more than one first-degree relative with prostate cancer at any age.

What screening tests may be used for prostate cancer?

PSA testing, with or without a digital rectal examination (DRE).

When prostate cancer develops, what usually happens to PSA?

It usually rises above 4 ng/mL.

Does a PSA below 4 rule out prostate cancer?

No. About 15% of men with a PSA below 4 will have prostate cancer on biopsy.

What is the borderline PSA range?

Between 4 and 10.

What is the approximate chance of prostate cancer when PSA is between 4 and 10?

About 1 in 4.

What is the chance of prostate cancer when PSA is above 10?

Over 50%.

What are the urinary symptoms of prostate cancer?

Decreased urinary stream, urinary frequency, difficulty starting the urinary stream, and dysuria.

What does dysuria mean?

Painful or difficult urination.

What blood-related symptoms may occur with prostate cancer?

Occasional hematuria or blood in the semen.

What can bone pain indicate in prostate cancer?

More extensive disease.

What neurological or functional symptoms may occur with later-stage prostate cancer?

Lower-extremity numbness or weakness and bladder or bowel incontinence.

What are the main methods used to establish a diagnosis of prostate cancer?

DRE, PSA testing, transrectal ultrasound-guided biopsy, and transrectal MRI.

What is assessed during a DRE when diagnosing prostate cancer?

Abnormalities or enlargement of the prostate.

What percentage of prostatic nodules found during rectal examination are confirmed malignant at biopsy, according to the slides?

50%.

What biopsy method is listed for prostate cancer diagnosis?

Transrectal ultrasound-guided biopsy.

Why is a biopsy necessary to diagnose prostate cancer?

A histologic diagnosis is required.

What imaging method can be helpful for detecting smaller prostate tumors?

Transrectal MRI.

What is the purpose of the Gleason grading system?

It assigns a grade based on how much prostate cancer cells look like normal prostate tissue.

What is the Gleason grade range?

1 to 5.

What does Gleason grade 1 look like?

It looks a lot like normal prostate tissue.

What does Gleason grade 5 look like?

The tissue looks very abnormal.

How is the Gleason score calculated?

Two grades from the areas that make up most of the cancer are added together.

What is the possible Gleason score range?

2 to 10.

What Gleason score is considered low-grade?

6 or less.

What Gleason score is considered intermediate-grade?

7.

What Gleason scores are considered high-grade?

8 to 10.

What does a PSA below 10 suggest about detectable metastatic disease?

Detectable metastatic disease is rare when PSA is below 10, according to the slides.

What staging system is used for prostate cancer?

The TNM staging system.

What are the prognostic factors listed for prostate cancer?

Gleason grading/score, DNA analysis by flow cytometry, PSA level, and predictive models for organ-confined versus non-organ-confined disease.

What tests are listed under prostate cancer detection and diagnosis?

Abdominal and pelvic CT scans, chest X-ray, bone scan, liver function tests, and serum PSA.

When can observation be considered as a treatment for prostate cancer?

In lower-grade cases.

What are the treatment techniques listed for prostate cancer?

Observation, surgery, external beam radiation therapy (EBRT), brachytherapy, and hormonal therapy.

If a prostate tumor is limited to the prostate, how do radical prostatectomy and radiation therapy compare?

The slides state that they are equally effective treatments.

How does the Da Vinci robotic surgery system allow the surgeon to operate?

The surgeon operates from a console with a 3-D screen and uses grasp controls to manipulate surgical tools inside the patient.

How do the robotic arms of the Da Vinci system work?

They translate the surgeon's finger, hand, and wrist movements.

What is a key feature of the Da Vinci robotic surgery system?

Very high precision.

What is the goal of external beam radiation therapy (EBRT) for prostate cancer?

Maximize damage to the prostate while minimizing damage to surrounding tissues, such as the bladder and rectum.

When do most external beam radiation side effects occur?

During treatment; most subside after treatment is completed.

What gastrointestinal side effects can occur during prostate EBRT?

Diarrhea, abdominal cramping, rectal discomfort, and occasional rectal bleeding.

What other acute side effects can occur with prostate EBRT?

Fatigue, frequent and painful urination, and blood in the urine.

What are the late rectal side effects of prostate EBRT?

Persistent proctitis, rectal bleeding, and ulceration.

How does increasing radiation dose affect rectal side effects?

Rectal side effects can become worse with increased doses.

Why can urinary urgency and frequency occur after prostate radiation?

The urethra is located within the prostate.

How does erectile dysfunction after EBRT compare with erectile dysfunction after radical prostatectomy, according to the slides?

It is less common after radiation treatment than after radical prostatectomy, but recovery is slower.

What factors affect erectile function after prostate radiation?

The patient's age and function before treatment.

What does the word "brachy" mean?

Short.

What does the word "therapy" mean?

Treatment.

What is brachytherapy?

Radiotherapy in which radiation sources are placed close to or directly inside the target volume.

What are brachytherapy sources usually sealed inside?

A small metal structure, usually titanium or stainless-steel tubes welded shut at the end.

What is LDR brachytherapy?

Low-dose-rate brachytherapy with a dose rate under 2 Gy per hour.

What is medium-dose-rate brachytherapy?

Brachytherapy with a dose rate from 2 to 12 Gy per hour.

What is HDR brachytherapy?

High-dose-rate brachytherapy with a dose rate higher than 12 Gy per hour.

What four brachytherapy applications are listed in the slides?

Interstitial, intraluminal, intracavitary, and surface.

What is interstitial brachytherapy?

Placement of a radioactive source directly into a tumor or tumor bed.

What may be used to place interstitial sources?

Rigid needles or flexible tubes.

What are the common uses of interstitial brachytherapy listed in the slides?

Neck, breast, prostate, and soft tissue sarcomas.

What is intraluminal brachytherapy?

Placement of radiation sources within body tubes.

What devices may be used for intraluminal brachytherapy?

Catheters and various centering applicators.

What are common uses of intraluminal brachytherapy?

Esophagus, trachea, and bronchus.

What is intracavitary brachytherapy?

Placement of a radiation source directly inside a body cavity.

What body cavities are most commonly treated with intracavitary brachytherapy?

Uterus, cervix, and vagina.

What is surface brachytherapy?

Placement of radioactive sources on top of the area being treated.

What are common uses of surface brachytherapy listed in the slides?

Nonmelanoma skin cancer, oral cavity, nasal cavity, hard palate, orbital cavity, and eye plaque.

What is listed under intravascular brachytherapy examples in the slides?

No examples are listed.