PANCE Blueprint Genitourinary (5%)

Prostate cancer (ReelDx + Lecture)

REEL-DX-ENHANCED-PAID-MEMBERS-ONLY

85 y/o with back pain and constipation x 7 days

Patient will present as → a 68-year-old man presetns to the clinic for a regular check-up. His PSA levels have been gradually increasing over the last few years and are now 11 ng/mL. A digital rectal examination reveals an asymmetrically enlarged prostate with an irregular, nodular consistency on the left side. A transrectal ultrasound-guided biopsy is performed, which confirms the diagnosis of prostate adenocarcinoma with a Gleason score of 7. The patient has no symptoms of urinary obstruction or bone pain.

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When should men get a PSA-level check?

USPSTF recommendations for prostate cancer screening:

    • All men aged 55 to 69 years – the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one.
    • Men 70 years and older – The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older.

What are the indications for transrectal biopsy with normal rectal examination?
PSA > 10 or abnormal transrectal ultrasound

May present with urinary retention, decrease in urine stream strength, or back pain (metastatic disease)

  • Urinary retention is more likely a sign of BPH
  • Digital rectal exam: hard, nodular, enlarged and asymmetrical prostate
  • PSA > 4 warrants further workup
  • PSA > 10 suggestive of cancer

Risk factor:

  • Risk factors include old age (most men > 80 have a focus of prostate cancer) and family history

PSA > 4 get an ultrasound with needle biopsy

PSA > 10 get a bone scan to r/o METS

Prostate cancer screening (lots of debate here)

USPSTF recommendations for prostate cancer screening:

    • All men aged 55 to 69 years – the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one.
    • Men 70 years and older – The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older.

The NCCN issued revised guidelines on prostate cancer screening:

    • The NCCN recommends performing a baseline history (including family history, medications, and any history of prostate screening and disease) and physical examination
    • The clinician should then discuss the risks and benefits of a baseline PSA test with the patient, and consider a baseline DRE to identify high-risk cancers associated with a seemingly normal PSA.
    • In patients with a normal DRE result, the NCCN recommends baseline PSA testing at age 45-49 years, with retesting at age 50 years in patients with a level below 0.7 ng/mL and annual or biannual retesting in those with a level of 1.0 ng/mL or higher.
  • For patients aged 50-70 years with a normal DRE and a PSA below 3 ng/mL, the NCCN recommends retesting every 1-2 years.
  • NCCN panel members were divided on the question of PSA thresholds that would prompt prostate biopsy: 2.5 ng/mL has been used, whereas 3 ng/mL is evidence-based and reduces the risk for overdetection; however, some panel members recommended considering the PSA level in the context of other risk factors rather than using a specific PSA cutoff.
  • In selected cases, risk calculators could be used to stratify risk.

Radical Prostatectomy - The complication is erectile dysfunction!

  • Patients with metastases will need androgen deprivation therapy (leuprolide) if there are no meds, then castration
  • Monitor PSA should be less < 0.1

osmosis Osmosis
Picmonic
Prostate cancer

Prostate cancer is the most common cancer among men, and typically occurs in men over the age of 65. It can initially present with symptoms similar to those seen in BPH, like dysuria, dribbling, urgency, hesitancy, and hematuria. Prostate cancer can metastasize, and often does so to bone, and a common site is the lumbosacral vertebrae. Patients can display fatigue and lower back pain. There are diagnostic tests if there is a clinical suspicion of malignancy, such as PSA, PAP, and digital rectal exam. The only definitive diagnostic test is via ultrasound-guided needle biopsy.

Prostate cancer assessment
Play Video + Quiz
Leuprolide
Play Video + Quiz

Question 1
A patient with prostate cancer has a nonpalpable, focal lesion, and the patient is reluctant to have surgery at this time. Which of the following would best monitor disease progression?
A
Periodic rectal exams
Hint:
Many prostate carcinomas are contained within the gland, making it difficult to assess progression with a digital examination alone.
B
Transrectal ultrasonography
Hint:
Ultrasonography is used largely for staging disease, not monitoring disease progression.
C
Measurements of serum acid phosphatase
Hint:
Serum acid phosphatase is more predictive of metastatic disease than PSA measurement, but its use has largely been replaced by PSA.
D
Measurements of prostate-specific antigen
Question 1 Explanation: 
PSA measurement correlates well with volume and stage of disease and is the recommended examination for monitoring disease progression.
Question 2
Which of the following presentations of prostate cancer is most common?
A
Squamous cell carcinoma found in the peripheral zone
Hint:
Squamous cell carcinomas constitute less than 1% of all prostate carcinomas
B
Squamous cell carcinoma found in the central zone
Hint:
15%-20% arise in the central zone
C
Acinar adenocarcinoma found in the peripheral zone
D
Sarcoma found in the transitional zone
Hint:
10%-15% arise in the transitional zone
E
Adenocarcinoma located in the transitional zone
Hint:
While adenocarcinomas are the most common type of prostate cancer, they are most commonly found in the peripheral zone, not the transitional zone, making this option less accurate than option C.
Question 2 Explanation: 
The vast majority of prostate cancers, approximately 95%, are classified as adenocarcinomas. Around 4% of prostate cancer cases exhibit transitional cell characteristics, believed to originate from the urothelial cells lining the prostatic urethra. A small fraction of prostate cancers display neuroendocrine features, which are thought to develop either from the prostate's inherent neuroendocrine stem cells or through unusual differentiation pathways during the transformation of cells. Squamous cell carcinomas are exceedingly rare in the prostate, making up less than 1% of cases. Often, squamous differentiation in prostate carcinomas is observed following treatments like radiation or hormone therapy. Regarding the anatomical origin within the prostate, about 70% of cancers are found in the peripheral zone, while the central and transitional zones account for 15%-20% and 10%-15% of cases, respectively. It's also noted that prostate cancers frequently present as multifocal diseases, involving several zones simultaneously. This multifocality could be attributed to both clonal and nonclonal tumor growths within different prostate regions.
Question 3
"Distinctly infiltrative margins" are characteristic of which Gleason grade?
A
Grade 1
Hint:
Small, uniform glands
B
Grade 2
Hint:
More stroma between glands
C
Grade 3
D
Grade 4
Hint:
Irregular masses of neoplastic glands
E
Grade 5
Hint:
Only occasional gland formation
Question 3 Explanation: 
The standard approach for grading prostate cancer depends on a Gleason score, which is based on pathologic evaluation of a prostatectomy specimen and is commonly estimated from prostate biopsy tissue. Prostate cancer patterns are assigned a grade from 1 to 5; the score is created by adding the most common pattern and the highest-grade patterns. Grade 3 is indicated by distinctly infiltrative margins.
Gleasonscore small

Image by public domain

Question 4
Which of the following prostate cancer screening guidelines is recommended by the US Preventive Services Task Force (USPSTF)?
A
Routine PSA screening for all men over age 50
Hint:
This statement does not accurately reflect the USPSTF guidelines, which recommend against a one-size-fits-all approach and instead advocate for individualized decision-making for men aged 55 to 69 years.
B
PSA screening for men aged 55 to 69 years should be an individual decision
C
Annual PSA screening for men starting at age 40
Hint:
The USPSTF does not recommend routine annual PSA screening starting at age 40 for all men. Screening decisions should be individualized, particularly for those in the 55 to 69-year age group.
D
PSA screening is not recommended at any age
Hint:
This statement is too broad and does not accurately represent the nuanced approach of the USPSTF, which suggests individualized decision-making for men aged 55 to 69 years and recommends against PSA-based screening for prostate cancer in men 70 years and older.
E
PSA screening for men aged 70 and older should be performed annually
Hint:
The USPSTF recommends against PSA-based screening for prostate cancer in men aged 70 years and older due to the potential harms outweighing the benefits in this age group.
Question 4 Explanation: 
The USPSTF recommends that the decision to undergo periodic prostate-specific antigen (PSA) screening for prostate cancer in men aged 55 to 69 years should be an individual one. This recommendation acknowledges the potential benefits of reducing the risk of death from prostate cancer but also considers the potential harms of overdiagnosis and overtreatment. Men in this age group are encouraged to discuss the potential benefits and harms of PSA screening with their healthcare provider to make an informed decision based on their values and preferences.
Question 5
Which of the following combinations of imaging studies provide good imaging of the prostate and increase the yield of positive biopsies by targeting abnormal areas?
A
MRI and CT
Hint:
While MRI is excellent for imaging the prostate and identifying suspicious areas, CT does not provide the same level of detail for prostate tissue and is generally not used for guiding prostate biopsies.
B
Ultrasonography and CT
Hint:
Ultrasonography is commonly used in guiding needle biopsies of the prostate, but CT does not offer significant advantages in imaging the prostate or targeting biopsies and is not typically combined with ultrasonography for this purpose.
C
MRI and ultrasonography
D
PET and ultrasonography
Hint:
PET scans are used in certain contexts for imaging prostate cancer, particularly for detecting metastatic disease rather than for guiding biopsies of the prostate itself. Ultrasonography is used for biopsy guidance but does not benefit significantly from combination with PET for targeting biopsies in the prostate.
E
CT and PET
Hint:
Both CT and PET scans are more relevant for staging advanced prostate cancer and assessing for metastasis rather than for guiding initial biopsies of the prostate based on imaging of the gland itself.
Question 5 Explanation: 
The combination of MRI and ultrasonography, particularly through the use of MRI/ultrasound fusion-guided biopsy, has been shown to improve the imaging of the prostate and increase the yield of positive biopsies by accurately targeting abnormal areas. MRI provides detailed images of the prostate, identifying regions that may harbor cancer, while real-time ultrasonography guides the biopsy needle to these specific areas during the procedure. This approach allows for more precise sampling of suspicious lesions compared to traditional methods, enhancing the detection of clinically significant prostate cancer.
Question 6
For a 69-year-old man in good health with locally confined, medium-risk prostate cancer, which of the following treatment options is generally not advised?
A
External-beam radiation therapy
Hint:
This is a common treatment for localized prostate cancer, including medium-risk cases, and can be an effective option for controlling the disease.
B
Robotic prostatectomy
Hint:
Surgical removal of the prostate using robotic assistance is another viable treatment for localized prostate cancer, offering precise removal of cancerous tissue.
C
Total androgen deprivation
D
Watchful waiting
Hint:
For some men, especially those with medium-risk, localized prostate cancer, watchful waiting or active surveillance may be recommended to monitor the cancer closely without immediate treatment.
E
Cryotherapy
Hint:
While not as commonly recommended as radiation therapy or prostatectomy for medium-risk, localized prostate cancer, cryotherapy is a treatment option that involves freezing cancer cells. It's less commonly chosen but still considered a viable option for some patients.
Question 6 Explanation: 
Total androgen deprivation therapy is not typically the first-line treatment for a healthy 69-year-old man with locally confined, medium-risk prostate cancer. This approach is more commonly reserved for advanced or high-risk cases due to its significant side effects and the potential impact on quality of life. Androgen deprivation therapy (ADT) aims to reduce testosterone levels, which can slow the growth of prostate cancer cells but may not be necessary for medium-risk, localized disease in a patient who might be effectively managed with other, less invasive options.
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References: Merck Manual · UpToDate

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