Diagnosis Flashcards
Multiparametric MRI components
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
Complications TRUS biopsy
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
PSA secreted by
Encoded on
Prostate ductal epithelial cells
Chromosome 19
PSA bound to
ACT
Alpha 1 antichymotrypsin
PSA measurement technique
Monoclonal antibody assay technique
Osterling PSA ranges
1993 Jama 40-50 = 2.5 50-60 = 3.5 60-70 = 4.5 70-80 = 6.5
PSA and risk prostate cancer
<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%
PPV PSA for prostate cancer
20-29 = 74% 30-39= 90% 50-99 = 100% >20 = 87%
PCPT trial Number Arms Years Biopsy threshold RRR % Higher incidence gleason 7 Criticism
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%
Post RP high risk and very high risk relapse patients
2/3 very high risk T3 , R1 , Gleason 8-10
High risk
ISUP > 2
Positive margin
T3b> T3a
Free PSA
Prostate cancer lower free/T PSA value
In the range 4-10
Cut off greater than 25% suggests benign disease
PSA post RP predicts BCR
PSA nadir less than 0.01 then BCR occurred in only 3% compared to 75% if not attained
Screening Cochran’s meta analysis
5 RCTs
No significant difference
Screening ERSPC trial
16 years fu
Number needed to screen 570
Number needed to treat 18
NICE PSA testing
Men over 50 who ask for it
Men over 45 with risk factors race and family history
MRI
Sens Spec
Cancer risk with PSAD and negative MRI
False negative rate
Sens 90% Spec 40%
PSAD 0.15 to 0.20 risk 27-40% of prostate cancer with negative MRI
5-25%
Risk CS prostate cancer with PIRAD 1-2
Risk insignificant cancer on biopsy with negative MRI
11-28%
18-23%
Bone scan positive rates
PSA 20-50
PSA 10-20
15%
5%
Equation for PSA velocity
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)
REDUCE trial
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
Transperineal biopsy complications
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
Which Criteria of WHO screening not met 2
Which met 4
Which partially met 4
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
DWI in MRI benefits
ADC vs b value
DWI improves specificity of MRI vs T2 alone
High b value bright
Low signal on ADC
PROMIS study PSA limit Tests Men Primary endpoint Definition of csPC
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
Precision study
MRI scan first fewer patients required biopsy
Number of CS PC also increased if MRI first
histology feature of prostate cancer
ductal epithelium
absence of basal cell layers, absence staining basal cell makers of P63 and cytokeratin 34BE
BM breached by malignant cells
BAUS trus biopsy complications 10
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
PSA NHS test sensitivity
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.
