Prostate Investigations and Diagnosis

Question 1

What is PSA?

Answer 1

Prostate specific antigen is a protein produced by normal and malignant prostate cells

Question 2

What is PSA secreted by?

Answer 2

Secreted by the epithelial cells within the prostate into the prostatic fluid, allowing sperm to move more freely

Question 3

How does PSA indicate prostate cancer?

Answer 3

When cancer arises in the prostate, the changes to the structure of the gland allows more PSA to leak out into the blood, resulting in a higher circulating PSA

Question 4

What are some of the reasons linked to a high PSA?

Answer 4

Urinary tract infection (weeks later)
Recent ejaculation/stimulation of the gland or anal sex (last 48 hours)
Vigorous exercise such as cycling (last 48 hours)
Medications
DRE before PSA
Prostate biopsy (last 6 weeks)
Enlarged prostate

Question 5

What is benign prostate hyperplasia?

Answer 5

Increase in the number of cells

Question 6

What is benign prostate enlargement?

Answer 6

Increase in the size of the gland

Question 7

Can both BPH and BPE affect urination?

Answer 7

Yes, they both can due to the pressure on the urethra

Question 8

What does TURP stand for?

Answer 8

Transurethral Resection of the Prostate

Question 9

Advantages of PSA testing?

Answer 9

Early detection - earlier stage
Treatment options available

Question 10

Disadvantages of PSA testing?

Answer 10

False negatives > 15%may have prostate cancer, 2%have high-grade cancer
False positives > 75% negative biopsy
Unnecessary investigations > Biopsy – invasive, infection risk
Unnecessary treatment?
Cancer may never become clinically evident/cause morbidity.
Treatment = side effects
Stress/anxiety

Question 11

How will the prostate feel in DRE?

Answer 11

Normal, enlarged (BPE/BPH, Prostatitis) or hard/lumpy (Indicative of possible cancer)

Question 12

Limitations of DRE?

Answer 12

There is a posterior aspect of the prostate - what if the tumour is somewhere it cannot be felt?

Question 13

When should a GP urgently refer (2-week pathway) a patient?

Answer 13

Abnormal DRE AND high/rising PSA

Question 14

What is the first-line investigation for people with suspected clinically localised prostate cancer?

Answer 14

Multiparametric MRI

Question 15

Would palliative patients be offered mpMRI?

Answer 15

No, only patients who are able to radical treatment

Question 16

What should patient be offered if mpMRI Likert score is 3 or more?

Answer 16

Multiparametic MRI-influenced prostate biopsy

Question 17

What should a patient be offered if mpMRI Likert score is 1 or 2?

Answer 17

Consider omitting a prostate biopsy but only after discussing risks and benefits. If patient opts to have biopsy, offer systematic prostate biopsy (Transrectal ultrasound-guided biopsy or transperineal biopsy following mpMRI but needle placement not influenced by scan information

Question 18

What happens in a transrectal ultrasound-guided biopsy (TRUS)?

Answer 18

Ultrasound probe inserted into rectum
Local anaesthetic to numb the area
Needle placed alongside the probe and inserted through the rectal wall into the prostate
10-12 samples taken

Question 19

Advantages of TRUS?

Answer 19

Detects prostate cancer - If aggressive (fast growing) cancer is detected at an earlier stage, treatment may prevent spread

Question 20

Disadvantages of TRUS?

Answer 20

Biopsies find <50% of cancer MRI misses
1 in 100 people develop sepsis after TRUS

Question 21

What happens in a transperineal prostate biopsy?

Answer 21

Ultrasound probe inserted into rectum
Needle inserted through perineum (skin between the scrotum and anus)
Template biopsy: general anaesthetic, grid placed over skin and 2-3 cores sampled from 8 sites
Local Anaesthetic Transperineal Biopsy (LATP): Grid or freehand

Question 22

Advantages of transperineal prostate biopsy?

Answer 22

Risk of sepsis greatly reduced
Easier access to anterior and apex of the prostate - may improve detection

Question 23

If Likert score is 3 or more and biopsy is negative what happens?

Answer 23

Discussed at MDT to consider repeat biopsy

Question 24

For men with a raised PSA, mpMRI Likert 1-2 (or contraindication to MRI) and negative biopsy what happens?

Answer 24

Repeat PSA test 3-6 months and offer repeat biopsy if suspicion of cancer is high. If low, discharge to primary care and repeat PSA testing every 2 years

Question 25

How are prostate cancers graded?

Answer 25

Using the Gleason score

Question 26

What is the Gleason score?

Answer 26

The most common grade + the highest other grade in the samples

Question 27

What does a Gleason score of 6 (3+3) indicate?

Answer 27

Grade group 1 - cells look similar to normal prostate cells, cancer is likely to grow very slowly

Question 28

What does a Gleason score of 7 (3+4) indicate?

Answer 28

Grade group 2 - most cells look similar to normal prostate cells, cancer is likely to slowly grow

Question 29

What does a Gleason score of 7 (4+3) indicate?

Answer 29

Grade group 3 - cells look less like prostate cells, cancer is likely to grow at a moderate rate

Question 30

What does a Gleason score of 8 (4+4) indicate?

Answer 30

Grade 4 - some cells look abnormal, cancer might grow quickly or at a moderate rate

Question 31

What does a Gleason score of 9 or 10 (4+5=9, 5+4=9 or 5+5=10) indicate?

Answer 31

Grade group 5 - cells look very abnormal, cancer is likely to grow very quickly