85 y/o with back pain and constipation x 7 days
Patient will present as → a 65-year-old man who presents to the office with slowly progressive trouble urinating. He is still able to urinate but claims that his, "stream is weak." On physical exam, external genitalia have no notable abnormalities. On digital rectal exam, you note several rock-hard nodules on the patient's prostate.
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 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
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
Periodic rectal exams
Many prostate carcinomas are contained within the gland, making it difficult to assess progression with a digital examination alone.
Ultrasonography is used largely for staging disease, not monitoring disease progression.
Measurements of serum acid phosphatase
Serum acid phosphatase is more predictive of metastatic disease than PSA measurement, but its use has largely been replaced by PSA.
Measurements of prostate-specific antigen
Squamous cell carcinoma found in the peripheral zone
Squamous cell carcinomas constitute less than 1% of all prostate carcinomas
Squamous cell carcinoma found in the central zone
15%-20% arise in the central zone
Acinar adenocarcinoma found in the peripheral zone
Sarcoma found in the transitional zone
10%-15% arise in the transitional zone
Routine prostate-specific antigen (PSA) testing in men older than 75 years
Repeat PSA testing every 1-2 years in men aged 50-70 years with normal digital rectal examination (DRE) findings and PSA level below 3 ng/mL
Annual retesting in patients with a PSA level 0.5-0.7
Prostate biopsy at a PSA level of 2 ng/mL
MRI and CT
Ultrasonography and CT
MRI and ultrasonography
PET and ultrasonography
External-beam radiation therapy
Total androgen deprivation