Prostate Cancer

Question 1

Stem: A 65- year- old male paient with poor urine stream, urgency and nocturia. PR examination revealed an enlarged, firm, rounded prostate with a preserved median sulcus.

Q1: What’s the most probable diagnosis?

Answer 1

BPH

Question 2

On DRE what are the features suggesting a prostate cancer?

Answer 2

Hard, irregular, attached to rectum and obliteration of median salcus

Question 3

Q2: Mention 3 investigations to be performed in the outpatient clinic?

Answer 3

PSA, U&E, Urine analysis

Question 4

What’s the most important investigation to confirm or exclude malignancy? How it’s done?

Answer 4

Transrectal US guided biopsy of prostate
Multiple sample are taken from apex, base bilaterally and midlobe of the gland

Question 5

Q3: Why there is a need for multiple biopsies to diagnose prostate cancer?

Answer 5

As it’s multiofocal tumor that could be present in more than one locations so it’s better to have samples from different sites

Question 6

Q4: Biopsy showed high grade prostatic neoplastic tissue admixed with rectal glandular tissue, how can prostatic cells be differentiated from rectal cells during pathological analysis?

Answer 6

IHC for CEA will be positive and PSA will be negative

Question 7

Q5 : What are the gene mutations involved in the pathogenesis of prostate cancer?

Answer 7

TPRSS2-ETS fusion genes and mutations or deletions that activate the PI3K/AKT signaling pathway

Question 8

Q6: Patient underwent TURP for prostate cancer and 6 months later PSA was still raised. What does this signify?

Answer 8

Suspicion of recurrence

Question 9

Q7: Is PSA testing is reliable? Why?

Answer 9

No, because it’s specific to oragan not ot cancer
as it could raise in different conditions likeinstrumentation, ejaculation, Prostatitis and noduar hyperplasia

Question 10

Q8: What’s the name of the grading system for prostate cancer? How it’ calculated?

Answer 10

Gleason score
It grades prostate tumors from 2 – 10, 10 being the most abnormal and therefore the most likely to spread. The pathologist allocates a number from 1 - 5 for the most common histological pattern in the specimen, then does the same for the second most common pattern. The sum of these two numbers gives the Gleason score
Staging System is TNM

Question 11

Q9: If a patient with prostate cancer developed back pain and CT showed increased density in the lumbar spine, what’s your diagnosis?

Answer 11

Lumbar spine mets

Question 12

Mention one laboratory test to exclude bony metastasis?

Answer 12

ALP

Question 13

What’s the type of these metastasis? Why?

Answer 13

Sclerotic, as it increases activity of osteoplast and increase density of bone

Question 14

Q10: Post TURP the patient developed fever, confusion, dysuria and dusky red urine. Why?

Answer 14

UTI.

Question 15

Which investigations would you request?

Answer 15

FBC, Urine analysis, C&S, Inflamm. Markers

Question 16

What’s the colonies number in urine analysis indicating sepsis?

Answer 16

1000

Question 17

Q11: Which of the blood components would rise?

Answer 17

Neutrophils of WBCs

Question 18

Q12: What’s the primary stimulus of prostate growth during life?

Question 19

Q13: In the past bilateral orchidectomy was used as a treatment for cancer prostate. What was the rationale behind that?

Answer 19

As growth and survival of prostate cancer mainly depends on androgen released form testis. By doing Bilat Orichdectomy we will deprive cancer form androgens that leading to regression of it.

Question 20

Q14: apart from surgery, what are the other treament modalities of prostatic cancer?

Answer 20

TURP, Medical orchidectomy (hormonal), Radiotherpay. Radical prostatectomy. Brachytherapy.