Outpatient- Raised PSA

Question 1

A 66M has been referred to urology with a PSA of 6.6. How would you proceed?

Answer 1

• See in urgent outpatient suspected cancer clinic, so within 2 weeks of GP referral. As them to provide urinalysis and fill out IPSS questionnaire
• Intro, wash hands, confirm patient name dob
• focussed urological Hx:
• –LUTs {storage/voiding]
• –Associated infection/trauma/catheterisation
• –Red flags [wt loss, bony pain, night sweats, neurological signs]
• –Fluid diet
• –PMHx, Dhx, Shx, FamHx
• focussed clinical exam with chaperone:
• –general appearance
• –abdominal exam-scars, palpable bladder
• –External gen- testicular lump, phimosis, lesions, meatal stenosis, Hypospadias
• –DRE- character, size mobility of prostate, anal tone
• –Neuro exam

Question 2

A 66M has been referred to urology with a PSA of 6.6.

What investigations would you perform?

Answer 2

Urinalysis- rule out infection, NVH, undiagnosed diabetes, proteinuria suggesting renal problems
Bloods- repeat PSA if standalone sample ideally 2 months apart or after infection. FBC, Coag, U&Es
Imaging- mpMRI, bone scan is suspect mets, CTCAP to assess lymphadenopathy
Biopsy- if imaging suggests lesions likely to be cancer- targeted biopsy [Artemis] or TRUS biopsy. Transperoneal biopsy has lower infection risk

Question 3

How would you consent for a TRUS biopsy?

Answer 3

Confirm patient name, DOB
Clarify understanding of indication of procedure as well as offering alternatives [PSA monitoring, tranperineal bx]
Ideally given BAUS leaflet prior to consent
Cover risks/ Cx:
-bleeding [VH, PR bleeding, haematospermia]
-infection [1-2% risk sepsis]
-temp erectile dysfunction
-dysuria
-pain

Question 4

How would you avoid the risk of infection but still obtain prostate tissue sample?

Answer 4

• Transperineal biospy

- Rectal swab prior to biopsy

Question 5

How would you avoid the risk of infection but still obtain prostate tissue sample?

Answer 5

• Transperineal biospy

- Rectal swab prior to biopsy

Question 6

What is the risk classification of prostate cancer?

Answer 6

NICE guidelines
Low risk: Gleason 3+3, PSA <10, T1- T2a
Intermediate: Gleason 3+4, 4+3, PSA 10-19, T2b-T2c
High Risk: Gleason 4+4, 4+5, 5+4, PSA >20, T3-T4

Question 7

What is the difference between Active surveillance and Watchful waiting?

Answer 7

AS= management option for men who wish to delay curative treatment to avoid complications from the treatment. Those that show progression of disease should be offered radical treatment. Royal Marsden criteria: age 50-80, fit for radical tx, PSA<15, <50% positive cores, T1-2,

Question 8

What are the possible treatment options of prostate Cancer?

Answer 8

Low Risk: AS, WW, Rad RTx, Rad Prostatectomy, Brachytx
Intermediate: AS, WW, Rad RTx, Rad Prostatectomy, Brachytx
High: Rad RTx, Rad Prostatectomy, ADT

Question 9

How would you follow up a patient on active surveillance?

Answer 9

According to NICE:

• initial mpMRI
• PSA 3-4 months for 1 yr then 6 monthly
• DRE every 6-12 months until year 4 then yearly
• TRUS at year 1 of AS

Triggers to treat:
>50% positive cores
primary Gleason >4
PSA velocity >1ng/ml/year
PSADT of <2 years

Question 10

How would you follow up a patient on active surveillance?

Answer 10

According to NICE:

• initial mpMRI
• PSA 3-4 months for 1 yr then 6 monthly
• DRE every 6-12 months until year 4 then yearly
• TRUS at year 1 of AS

Triggers to treat:
>50% positive cores
primary Gleason >4
PSA velocity >1ng/ml/year
PSADT of <2 years

Question 11

What types of radiation can be used for prostate cancer?

Answer 11

• External beam radiotherapy
• Low dose Brachyradiotherapy alone for low/intermediate risk, combine with EBRT for high risk
• High dose brachyradiotherapy

Question 12

How does radiotherapy work?

Answer 12

Rtx uses ionising radiation to achieve fatal damage to neoplastic cells. Rtx uses high energy photon which interact with outer atoms causing free radicals. This causes DNA damage and double strand breakage.

Question 13

What are the contraindications of brachytherapy?

Answer 13

• high risk disease
• previous TURP
• volume >50cc
• coag problem
• mod-severe LUTs
• previous pelvic radiation

Question 14

How does ADT work?

Answer 14

ADT= Androgen deprivation therapy and prevents the action of testosterone, the hormone required for function, growth and proliferation of prostate cells

Question 15

Outline androgren production

Answer 15

• Testosterone made in the leydig cells in testes
• GnTH from hypothalamus causes release of LH and FSH from ant pituitary gland.
• Testosterone [inactive] is converted to active DHT [dihydrotestosterone] using 5 alpha reductase enzyme
• DHT binds to androgen receptors and interacts with DNA, promoting cell growth and division

Question 16

What are the different types of ADT for prostate cancer

Answer 16

LHRH analogues= synthetic analogues of GnRH. Results in initial rise of LH and FSH but overtime causes negative feedback and eventual lower production of DHT
LHRH antagonist= blocks the GnRH receptors, directly stopping production of LH & FSH from ant pituitary
Anti-androgens= splits into non-steroidal or steroidal antiandrogens. Non-steroidal purely act on androgen receptors, often given to avoid testosterone flare, Steroidal acts on androgen receptor and on GnRH receptors.
Surgical castration= removal of leydig cells in its entirety.

Typical regimen:
=anti-androgen 1 week before LHRH analogue and 2 weeks after 1st dose LHRH analogue
=LHRH antagonist can be used in CES but has high risk significant effects of histamine release

Question 17

What is a multi-parametric MRI scan?

Answer 17

MRI scan with T1 and T2 weighted sequences with combination of function imaging [DWI-diffuse weighted imaging, and DCE- dynamic contrast enhancement]