Prostate cancer

Question 1

A 68-year-old man presents with difficulty passing urine and frequent nocturia. He has a general enlarged prostate with a small hard nodule on its surface. How would you assess and manage him?

Answer 1

Impression
Obstructive LUTS with nocturia and difficulties passing urine. with enlarged and nodular prostate and patient age demographic, I am most concerned about prostate adenocarcinoma of the peripheral zone (95%)

Ddx to consider;

• BPH
• Overactive bladder, UTI, prostatitis (nocturia causes)
• urolithiasis, strictures
• CRC given mass felt PR

Goals

• perform clinical assessment and confirm PDx with Trans-rectal ultrasound guided biopsy of the prostate, with subsequent gleason scoring histologically and staging interventions.
• MDT management, likely resection and adjuvant treatments

Question 2

Prostate cancer - History

Answer 2

History

• sx: obstructive luts; difficulty peeing; starting, maintaining, dribbling, poor stream, hesitancy, incomplete voiding, straining, frequency, nocturia vs irritative LUTS (indicative of infection). Haematuria and characterise/quantify. Other urinary changes. incontinence, erectile changes, other mass effect (bowel changes, changes in sensation, onset and timing.
• pain history (socrates)
• PC/REDS: weight loss, night sweats, fevers,
• Risks: age, black ethnicity, fam hx, high PSA, obesity
• PMHx, Meds, Allergies, PSHx

Question 3

Prostate cancer - Examination

Answer 3

Examination

• general appearance + vitals
• Abdo + PR examination: enlarged prostate, irregular nodular surface
• systems review, lymph nodes (femoral, inguinal), MSK, resp: metastasis

Question 4

Prostate cancer - Investigations

Answer 4

Investigations
Key/diagnostic
- PSA level, compare with previous test to observe trend (note things that falsely elevate)
- TRUS guided biopsy of prostate with histopathological tissue diagnosis - subsequent Gleason grading. Explain risks associated (erectile dysfunction, incontinence)
o Trans cutaneous
o trans urethral

• Bedside: UA
• Bloods: FBC, UEC, LFT (baseline, mets, ALP for bony disease), PSA trend, CMP, CRP/ESR
• Imaging: MRI pelvis, staging CT scan, (sclerotic bony lesions)

Question 5

Prostate cancer - Management

Answer 5

Management

• urology referral, MDT management is critical
• Mx depends on disease and patient factors, ultimately deciding treatment intent (curative, palliative)
• note limited benefit to regular PSA screening

Supportive

• Patient education about consequences and outcome
• MDT involvement
• other lifestyle factors (smoking, alcohol, etc) control
• input of palliative care if appropriate

Definitive
- Surgical (Radical or sub-total prostatectomy)
\+/- radiation
NO CHEMOTHERAPY options available.
\+/- pelvic nodes dissection
- consider androgen deprivation therapy

Patient also requires active surveillance and monitoring of PSA levels, DRE annually.