Diagnosis

Question 1

Multiparametric MRI components

Answer 1

T2 weighted image - appears abnormal low signal
Diffusion weighted- restricted diffusion shows as bright area
DCE- faster wash in and washout due to increased vascularity of tumour

Question 2

Complications TRUS biopsy

Answer 2

Sepsis 1%
light headedness 3%
Pain 44%
Blood in sperm 90%
Haematuria 66%
Rectal bleeding 37%
Missing significant cancer 
Need repeat biopsy
Retention 
Clot retention

Question 3

PSA secreted by

Encoded on

Answer 3

Prostate ductal epithelial cells

Chromosome 19

Question 4

PSA bound to

Answer 4

ACT

Alpha 1 antichymotrypsin

Question 5

PSA measurement technique

Answer 5

Monoclonal antibody assay technique

Question 6

Osterling PSA ranges

Answer 6

1993 Jama
40-50 = 2.5
50-60 = 3.5
60-70 = 4.5
70-80 = 6.5

Question 7

PSA and risk prostate cancer

Answer 7

<0.5 = 6.6% (risk of ISUP grade ≥2 Pca = 0.8%)
0.6-1.0 = 10% (1.0%)
1.1-2.0 = 17% (2.0%)
2.1-3.0 = 24% (4.6%)
3.1-4.0 = 27% (6.7%)
Thompson IM et al NEJM 2004, PCPT prostate cancer prevention trial
Criticism of this trial is high proportion of Pca diagnosed, in PCPT trial cancer was diagnosed in 24% of patients, whereas man’s lifetime risk of developing Pca is 16%

Question 8

PPV PSA for prostate cancer

Answer 8

20-29 = 74%
30-39= 90%
50-99 = 100%
>20 = 87%

Question 9

PCPT trial
Number
Arms
Years
Biopsy threshold
RRR %
Higher incidence gleason 7
Criticism

Answer 9

NEJM 2003
18000 men
7 years
Finasteride 5 mg vs placebo
Bx if PSA over 4
RRR  24%
Higher incidence Gleason 7 and above in finasteride arm 6.4% vs 5.1%
Overdiagnosis prostate cancer 24% whereas lifetime risk 16%

Question 10

Post RP high risk and very high risk relapse patients

Answer 10

2/3 very high risk T3 , R1 , Gleason 8-10

High risk
ISUP > 2
Positive margin
T3b> T3a

Question 11

Free PSA

Answer 11

Prostate cancer lower free/T PSA value
In the range 4-10
Cut off greater than 25% suggests benign disease

Question 12

PSA post RP predicts BCR

Answer 12

PSA nadir less than 0.01 then BCR occurred in only 3% compared to 75% if not attained

Question 13

Screening Cochran’s meta analysis

Answer 13

5 RCTs

No significant difference

Question 14

Screening ERSPC trial

Answer 14

16 years fu
Number needed to screen 570
Number needed to treat 18

Question 15

NICE PSA testing

Answer 15

Men over 50 who ask for it

Men over 45 with risk factors race and family history

Question 16

MRI
Sens Spec
Cancer risk with PSAD and negative MRI
False negative rate

Answer 16

Sens 90% Spec 40%
PSAD 0.15 to 0.20 risk 27-40% of prostate cancer with negative MRI
5-25%

Question 17

Risk CS prostate cancer with PIRAD 1-2

Risk insignificant cancer on biopsy with negative MRI

Answer 17

11-28%

18-23%

Question 18

Bone scan positive rates
PSA 20-50
PSA 10-20

Answer 18

15%

5%

Question 19

Equation for PSA velocity

Answer 19

ideally 3 PSA required to produce result PSAV = 0.5 x (PSA 2-PSA 1 pSA/time 1 in years + PSA3 - PSA2/time 2 in years)

Question 20

REDUCE trial

Answer 20

dutasteride
negative biopsy within 6 months entry
PSA 2.5 to 10 50-60 years
PSA 3-10 in above 60 years
repeat biopsy at 2 and 4 years
RRR in PCa on bippsuy with dutasteride of 22% over 4 years
also increased numbers of higher grade cancers detected in dutasteride group

Question 21

Transperineal biopsy complications

Answer 21

haematuria can last 10 days almost everybody
haematospermia can last 6 weeks almost everybody
retention 5%
temporyr effect on erections due to bruising 5%
clot retention 2%
bruising 10-50%
no cancer detected that is CS 2-10%
repeat procedure 2-10%
1% admission for haemturia
1% infection requiring abx
<1% risk sepsis

Question 22

Which Criteria of WHO screening not met 2
Which met 4
Which partially met 4

Answer 22

Not met
Costs
Workload

Partially met
Treatment early beneficial
Risks of treatment against benefits and psychological
Understand natural history 
Policy on who to treat

Met
Important disease
Suitable test, acceptable to population
Early detection beneficial, latent early stage
Interval of testing known - case finding on continuous basis

Question 23

DWI in MRI benefits

ADC vs b value

Answer 23

DWI improves specificity of MRI vs T2 alone
High b value bright
Low signal on ADC

Question 24

PROMIS study
PSA limit
Tests 
Men
Primary endpoint 
Definition of csPC

Answer 24

576 men
Biopsy naive 
PSA up to 15
MRI and TRUS and Template
Gleason 4+3 or higher 
Sens 90%
Spec 40%

But lower with less stringent cs PC definition

Question 25

Precision study

Answer 25

MRI scan first fewer patients required biopsy

Number of CS PC also increased if MRI first

Question 26

histology feature of prostate cancer

Answer 26

ductal epithelium
absence of basal cell layers, absence staining basal cell makers of P63 and cytokeratin 34BE
BM breached by malignant cells

Question 27

BAUS trus biopsy complications 10

Answer 27

Almost all
blood urine
blood sperm six weeks
blood stools

10-50%
dicomfort prostate

<10%
infection requiring abx

5%
temporary problem erections
2%
clot retention

1-2% sepsis
1% risk emergency admission
<1% risk need repeat biopsy if inconclusive or psa rises further

Question 28

PSA NHS test sensitivity

Answer 28

The PSA test can miss prostate cancer. For example, one major study showed that 1 in 7 men (15 per cent) with a normal PSA level may have prostate cancer, and 1 in 50 men (two per cent) with a normal PSA level may have a fast-growing cancer.
About 3 in 4 men with a raised PSA level will not have cancer. The PSA test can also miss about 15% of cancers.