Lecture
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.
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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:
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- 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:
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- 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 |
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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?
Periodic rectal exams Hint: Many prostate carcinomas are contained within the gland, making it difficult to assess progression with a digital examination alone. | |
Transrectal ultrasonography Hint: Ultrasonography is used largely for staging disease, not monitoring disease progression. | |
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. | |
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?
Squamous cell carcinoma found in the peripheral zone Hint: Squamous cell carcinomas constitute less than 1% of all prostate carcinomas | |
Squamous cell carcinoma found in the central zone Hint: 15%-20% arise in the central zone | |
Acinar adenocarcinoma found in the peripheral zone | |
Sarcoma found in the transitional zone Hint: 10%-15% arise in the transitional zone |
Question 2 Explanation:
Most prostate cancers (95%) are adenocarcinomas. Approximately 4% of cases of prostate cancer have transitional cell morphology and are thought to arise from the urothelial lining of the prostatic urethra. The few cases that have neuroendocrine morphology are believed to arise from the neuroendocrine stem cells normally present in the prostate or from aberrant differentiation programs during cell transformation. Squamous cell carcinomas constitute less than 1% of all prostate carcinomas. In many cases, prostate carcinomas with squamous differentiation arise after radiation or hormone treatment. Of prostate cancer cases, 70% arise in the peripheral zone, 15%-20% arise in the central zone, and 10%-15% arise in the transitional zone. Most prostate cancers are multifocal, with synchronous involvement of multiple zones of the prostate, which may be due to clonal and nonclonal tumors.
Question 3 |
"Distinctly infiltrative margins" indicates what Gleason grade?
1 | |
2 | |
3 | |
5 |
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.
Question 4 |
Which of the following is recommended according to guidelines from the National Comprehensive Cancer Network (NCCN)?
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 |
Question 4 Explanation:
The NCCN issued revised guidelines on prostate cancer screening; the guidelines are based on recommendations by the majority of panel members rather than consensus. 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 (the age-specific median) 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.
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?
MRI and CT | |
Ultrasonography and CT | |
MRI and ultrasonography | |
PET and ultrasonography |
Question 5 Explanation:
MRI fusion biopsies under ultrasonographic guidance have produced higher yields of prostate cancer by targeting the abnormal areas on MRI and overlaying them onto the ultrasonographic images during transrectal prostate biopsy.
Question 6 |
Which of the following is not typically recommended as a treatment option for locally confined, medium-risk prostate cancer in a 69-year-old healthy man?
External-beam radiation therapy | |
Robotic prostatectomy | |
Total androgen deprivation | |
Watchful waiting |
Question 6 Explanation:
Hormone therapy for prostate cancer is also known as "androgen deprivation therapy." It may consist of surgical castration (orchiectomy) or medical castration. Agents used for medical castration include luteinizing hormone-releasing hormone analogues or antagonists, antiandrogens, and other androgen suppressants. This treatment is reserved for advanced disease or prostate cancer that is poorly differentiated in a patient who is unable to receive other treatment.
There are 6 questions to complete.
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References: Merck Manual · UpToDate
