prostatic neoplasia

RE: prostatic neoplasia

Sarah Keir — Wed, 20 Jun 2018 22:16:17 GMT

Clive Ansell I agree but some owners need time to come to the reality of the situation and if they go away and read Dr Google about it and ask why you didn't discuss the options, not just the options you feel are appropriate... I can see a letter the the RCVS. Oh, we're straying into ethics here.

RE: prostatic neoplasia

Clive Ansell — Wed, 20 Jun 2018 18:56:41 GMT

[quote user="Sarah Keir"]can buy more time.[/quote]

I would not want to buy more time.

With a definitive diagnosis of prostatic carcinoma, the known guarded prognosis, survival time despite any available treatment, my own experience (n=only 4 I know), and Gerry's post, I would be leaning towards PTS asap in respect of the patients welfare.

RE: prostatic neoplasia

Gerry Polton — Wed, 20 Jun 2018 15:10:04 GMT

Some very interesting discussions.

As a general point, prostate carcinoma is either a glandular tumour (PCA) or a tumour of the urothelium (TCC). Just like TCC of the urinary bladder, TCC of the prostate can respond favourably to NSAID therapy. There is also the tale of uncertain significance in relation to the threat of tumour seeding along the track of a needle biopsy; this applies to TCC, not to PCA as far as I know. Just like TCC of the bladder, patients can respond favourably to the combination of a NSAID and chemotherapy. There are now reports of improved life expectancies using radiotherapy but not the kinds of radiotherapy available currently in the UK. Surgery for PCA can be performed. Total prostatectomy does induce urinary incontinence. This can be managed. The bigger the dog, the more urine they produce and the regretful the owner will be that they took the decision to proceed. I have never managed a case that I felt was a good candidate for prostatectomy. If there are suitable cases, they will have small tumours, not big tumours. In my opinion, TCC cases are not candidates for surgery. The nature of TCC is that is spreads enthusiastically along mucosal surfaces and I would therefore not expect a TCC to be truly localised to the prostate. Relapse would be inevitable. Partial prostatectomy is reported for TCC/PCA. It does not achieve a sufficient benefit to justify its use in my opinion. Urethral stenting is an option for obstructed urethral TCC. To date, median life expectancies are approximately four months. 25% of cases develop significant urinary incontinence.

Complete bladder and prostate removal can be performed. This would then require some plumbing to be done to connect the ureters to the penis or the prepuce. Absolute urinary incontinence is inevitable. There are significant risks of peri-operative and post-operative complications and management of these patients following surgery is never straightforward.

There are non-neoplastic differential diagnoses as has been stated in this thread more than once. There are also non-PCA/TCC diagnoses. However, these occur rarely.

Have a lovely afternoon

Gerry

RE: prostatic neoplasia

Sarah Keir — Wed, 20 Jun 2018 14:50:49 GMT

I second all of the above, all good advice. If dysuria becomes a problem then urethral stenting can buy more time. Otherwise piroxicam (or another NSAID depending on the evidence of the day). Do any of the specialist centres even offer surgery for these?

RE: prostatic neoplasia

Clive Ansell — Wed, 20 Jun 2018 12:33:07 GMT

In response to the OP, +1 for getting a definitive diagnosis. Maybe further imaging; us or ct/mri?

At one of the last local cpd evenings I attended at a local referral centre, they had had a case in that day for CT imaging. Even though early in the progression of the disease, with the prostate not massively enlarged, individual mets could be seen within some of the vertebral bodies.

I've seen 4 cases over 22 years, all were fairly advanced by the time of presentation and diagnosis, and all had pulmonary metastases. Despite palliative care they all deteriorated quickly and were pts within a short space of time. Tend to advise pts for these.

RE: prostatic neoplasia

Kate Richardson — Wed, 20 Jun 2018 11:18:49 GMT

[quote user="Judith Archbold"]

I’d do a prostatic wash to try to get a diagnosis ( massage prostate first to aid cell shedding my etc). I thought prostrate removal in dogs was a definite no no from an anatomical point of view as will always end up with urinary incontinence. Can refer for radiotherapy : about 6-8 months prognosis if successful. Last dog I treated with a prostatic TCC was on Piroxicam and Dantrium . They don’t go on for very long sadly. Ended up draining his bladder daily with a catheter until the owner finally agreed to let him go.

[/quote]

Only ever seen 2 cases, but both were neutered dogs, both managed palliatively (analgesia)- prostate removal not recommended as per Judith's advice, poor prognosis regardless of treatment was my understanding at the time

RE: prostatic neoplasia

Dinu Catilina — Wed, 20 Jun 2018 09:12:39 GMT

[quote user="robloxley"]If it's a carcinoma, and you're not going to do surgery, how much does 'seeding' tumor cells matter (or happen)?[/quote]

I don't know but there were cases reported in bladder TCC with abdominal masses occurring after transabdominal aspirates. It probably matters more if owners change their mind 2 months down the line, want to see a specialist and there are secondary masses.

RE: prostatic neoplasia

Judith Archbold — Wed, 20 Jun 2018 08:48:38 GMT

I thought I had tried to give you a constructive answer!

RE: prostatic neoplasia

Rob Loxley — Wed, 20 Jun 2018 08:44:15 GMT

[quote user="Dinu Catilina"]If you suspect neoplasia from the scan (no cystic structure) then a wash is better, no risk of seeding tumour cells in the needle tract. [/quote]

If it's a carcinoma, and you're not going to do surgery, how much does 'seeding' tumor cells matter (or happen)?

[quote user="villagevet"]Does anybody have any constructive answers for if neoplasia is confirmed/cysts ruled out?[/quote]

Ultimately it's not good news. If they are interested in chemo we defer to an oncologist, otherwise meloxicam; if significant dysuria urethral stenting is possible

RE: prostatic neoplasia

Lindsey Edwards — Wed, 20 Jun 2018 07:49:04 GMT

Does anybody have any constructive answers for if neoplasia is confirmed/cysts ruled out?

RE: prostatic neoplasia

Dinu Catilina — Wed, 20 Jun 2018 00:02:39 GMT

I wouldn't rule out a prostate abscess which can occur in neutered dogs as well. Radiography is not great at evaluating prostate size, especially if there is a prostatic or paraprostatic cyst.

I would scan it first and if the content is anechoic or you can see a hyperechoic capsule I would chose an ultrasound guided aspiration. If it's a cyst or an abscess you might not get any relevant information from a wash.

If you suspect neoplasia from the scan (no cystic structure) then a wash is better, no risk of seeding tumour cells in the needle tract.

If it is a cyst or abscess then probably best is to do surgery, open it, flush it and omentalise it.

RE: prostatic neoplasia

Rob Loxley — Tue, 19 Jun 2018 18:44:53 GMT

Agree you need a diagnosis to progress much, scan sounds good. I've always had better results on direct FNA cytology than via prostatic wash

RE: prostatic neoplasia

Anthony Dennison — Tue, 19 Jun 2018 18:41:29 GMT

Agree with all above. Without imaging with ultrasound you won't know.

If it's just prostatic cysts there will be big anechoic circles present. If its a TCC there will be a very heterogenous appearance to the prostate, with hyperechoic patches surrounded by anechoic lesions.

Prostatic washes are easy to do. Remember to empty the bladder first via the catheter, and then flush it out to completely empty it. If the prostate is massive and you can feel the catheter push past it, you could try a catheter tip suction biopsy: when you feel resistance go a little further (think where the hole is on the tip), then use a 5ml syringe and create a decent amount of negative pressure and tug!

RE: prostatic neoplasia

Judith Archbold — Tue, 19 Jun 2018 17:34:29 GMT

RE: prostatic neoplasia

Elisabeth Knappett — Tue, 19 Jun 2018 17:12:51 GMT

[quote user="Jill Butterworth"]Stick a US probe on it. Cysts are very easy to diagnose and can be large. [/quote]

Second this and possibly attempt an FNA/prostatic wash to get cytology sample for confirmation? Both relatively straightforward and generally well tolerated.

If you want to discuss best current treatment, Iain Grant at Chemopet has been very helpful for me in the past and will supply individual doses +/- individual PPE and administration sets - you usually just need to provide a catheter! Can be more costly though.

RE: prostatic neoplasia

Lindsey Edwards — Tue, 19 Jun 2018 16:08:42 GMT

Thanks Jill - very helpful!

Was hoping to have some solutions to discuss with owner if it is not a cyst!

RE: prostatic neoplasia

Jill Butterworth — Tue, 19 Jun 2018 16:03:26 GMT

Stick a US probe on it. Cysts are very easy to diagnose and can be large.

RE: prostatic neoplasia

Martin Atkinson — Tue, 19 Jun 2018 15:46:06 GMT

Forgive me if I'm wrong but as I understand you've not actually made a diagnosis of prostatic neoplasia yet so a bit soon to be discussing chemo. It may be a prostatic cyst which is a lot easier to treat surgically. Have you done a cPSA even? - mind you the only prostatic cancer I've seen in recent years had a normal value!