Prostate Cancer [Symptoms And Diagnosis]

Question 1

Epidemiology of Prostate Cancer

Answer 1

Incidence: Most common cancer in men following Skin cancer [melanoma and non-melanoma combined]

Mortality: Second leading cause of death in men after Lung cancer

Question 2

Risk Factors of Prostate Cancer

Answer 2

1. Advanced Age [> 50 years old]
2. Family History [especially if a first degree relative has had Prostate Cancer]
3. African-American descent [in USA]
4. Genetic predispositions like BRCA2 mutation (increase the risk of aggressive prostate cancer), Lynch Syndrome (Mismatch repair genes defect)
5. Dietary factors [diet rich in Saturated fats, well-done meats and calcium]

BPH and Sexual activity frequency are NOT risk factors of Prostate Cancer

Question 3

Symptoms of Prostate Cancer [Clinical]

Answer 3

Symptoms of porstate cancer can vary depending on the stage and location of the cancer. 75% of Prostate cancers occur in the Posterior Peripheral zone of Prostate and all take an indolent course because they require Androgen for growth and are restricted in their own organs

Typically Asymptomatic in early stages
- Detected usually via DRE screening in 35-40 year old males and older
- Caught incidentally after BPH-related resection surgery

Symptoms can be of complicated LUTS type
- Change in urinary frequency/Urinary retention
- Hematuria [especially terminal hematuria]
- Urge incontinence [from bladder wall infiltration complication]
- Flank pain [from hydronephrosis complication]

Symptoms can also be of Consituitional or Metastatic type
- Fever/Chills/Change in appetite/clinically significant unintentional weight loss (> 5% change in weight in the last 6-12 months not in association to drugs or excerices or new diet)
- Bone pain/Neurologic deficits/Lymphedema

Question 4

Symptoms of Prostate Cancer [DRE]

Answer 4

During a routine Digital Rectal Exam, the following findings could indicate necessary further evaluation for Prostate Cancer:
- Localized indurated nodules [on an otherwise smooth surface]
- Prostatomegaly
- Lobar asymmetry
- Obliteration of sulcus [that divides the two lobes of prostate]
- Hard, nontender nodules

Pain during palpation usually not present unlike in Prostatitis

Question 5

with regards to its use in routine or evaluative Dx

How is DRE useful in the Dx of Prostate Cancer

Answer 5

DRE should be performed in anyone presenting with elevated PSA levels and complicated LUTS.

DRE is not the primary or sole DX evaluator/screening test as it has a low PPV.

DRE may be normal [Location of tumour in Anterior peripheral zone not palpable properly via DRE]. DRE even normal in patients with advanced Prostate Cancer

Normal DRE findings are smooth, symmetric, nontender bilobed gland with a palpable sulcus between the lobes

Thus DRE only performed in adjunction to Clinical suspecion [like complicated LUTS and PSA level elevation] and further Dx is required

Question 6

General Approach to suspected Prostate Cancer

For those with Positive Screening test or Symptomatic patients

Answer 6

1. Suspect Prostate cancer in elevated PSA levels > 2,5 ng/mL [usually no cut off but 15% of cancers also occur in PSA levels < 4 ng/mL] AND/OR abnormal DRE findings
2. Consider other PSA level tests in patients with PSA between 4-10 ng/mL [Free PSA:Total PSA; PSA density; Urinary PCA3 levels]
3. Imaging studies, like Transrectal US or multiparametric MRI [high-definition, three-dimensional image of the target organ]
4. Confirm Dx using TRUS or MRI guided biopsy [fine needle, or some cases, resected]
5. Stage cancer based on biopsy AND/OR mpMRI/other imaging studies [PET-CT]

Question 7

6 causes

Mention Ddx for elevated PSA levels

Answer 7

1. Prostate Cancer
2. UTI
3. Prostatitis
4. Prostate trauma
5. Post-DRE elevation
6. Benign Prostatic Hyperplasia

PSA is organ specific but not Tumour specific

Question 8

Things to do in order to rule in/out Prostate Cancer in symptomatic patients

Answer 8

1. DRE
2. PSA level examination
3. Free PSA:Total PSA | PSA density | Urinary PCA3 level [all three to be considered when PSA between 4-10 ng/mL]
4. Urinalysis [to rule out UTIs and Prostatitis in patients with LUTS]
5. mpMRI/TRUS

In addition to a good Patient History taking

Free PSA:Total PSA LOW: likely to be Prostate Cancer

PSA density LOW: clinically significant Prostate Cancer unlikely

Urinary PCA3 levels INCREASED: High probability of Prostate Cancer

PCA - Prostate Cancer Antigen 3 gene

Question 9

Imaging studies

Prefered methods for Local tumour extent and metastatic disease evaluation respectively?

Answer 9

mpMRI for local tumour extent
PET-CT for metastatic disease evaluation

Question 10

Histologic pattern

99% of Prostate cancer are of ____________ type

Answer 10

Adenocarcinoma

Question 11

TNM staging of Prostate Cancer

Histologic Grading done via Gleason Score and Grade

Risk stratification done to Localizaed Prostate Cancers

Answer 11

T1-T2: Tumour localized to Prostate AND INSIDE the capsule
T3a: Extracapsular involvement of Tumour
T3b: Extracapsular and extension to Seminal Vessicles
T4: Extracapsular and involvement of adjacent tissues* [rectum, bladder, levator ani, and lateral pelvic wall]*

N0: NO lymph node involvement
N1: Regional Lymph node involvement [pelvic, hypogastric, obturator, iliac, and sacral lymph node groups]

M0: No evidence of distant metastases
M1a: Lymph node involvement OUTSIDE true pelvis
M1b: Non-nodal spread to bone, especially vertebrae
M1c: Non-nodal spread to Lungs/Live/Adrenal glands [later stages of Cancer]