Prostate: Investigations, Diagnosis, Staging and Grading Flashcards
What is PSA testing?
- Prostate specific antigen
- All men have some PSA but high levels can indicate cancer
- PSA is secreted by epithelial cells when turn cancerous more PSA leaks out
What is considered raised PSA?
- 3ng/mL or above is considered high
What does high PSA levels mean? How can PSA levels be raised?
- Could be vigorous exercise (cycling e.g.)
- Recent ejaculation or stimulation of the prostate gland via anal sex
- Medications
- UTI
- DRE before a PSA could lead to increased PSA levels
- A prostate biopsy can raise PSA level for up to 6 weeks
What does an enlarged prostate mean for diagnosis?
- Prostate naturally enlarges with age
- Benign prostatic hyperplasia= increased number of cells
- Benign prostatic enlargement = increased size of the gland
- Both might lead to similar symptoms as prostate cancer but are benign
- TURP = a resection of the prostate to relieve symptoms
What are the advantages of PSA testing?
- Early diagnosis
- Treatment options are available earlier (e.g less area for RT)
What are disadvantages of PSA testing?
- False negatives -> 15% false negatives
- False positives -> 75% negative biopsy
- Could lead to unnecessary investigations, e.g. biopsies are invasive
- Could it lead to unnecessary treatment, some cancers are never significant
- Causes stress and anxiety
What are the issues with screening?
- Conflicting opinions
- Unnecessary diagnosis
- Risk management is a form of screening?
What is a DRE?
- Following a high PSA test a DRE will be performed
- Digital Rectal Examination
- Prostate nay feel, normal, enlarged, hard or lumpy
What are limitations of a DRE?
- if tumour is located anteriorly or centrally it may not be felt
- Some patients may find uncomfortable
What did the PROMIS study do?
- determine if the mpMRI can identify men with clinically significant prostate cancer
- Is it more accurate than a biopsy
- Can patients be triaged via mpMRI
- It reduced over diagnosis and unnecessary biopsies
What do mpMRI gradings mean?
- 3+ = needly placement is guided by the mpMRI and ultrasound biopsy will be given
- 1 or 2 it is a discussion with the patient, cannot be ultrasound guided.
What is a TRUS biopsy?
- TRUS = transrectal ultrasound biopsy
- Ultrasound probe inserted
- sometiemes general anaesthetic
- 10-12 samples taken
What are advantages of a prostate biopsy?
- 11-28 in every 100 people with low risk mpMRI actually have prostate cancer
- If aggressive cancer can be detected at early stage
What are disadvantages of a prostate biopsy?
- Still miss a lot of cancers
- Insignificant cancers identified
- 1 in 100 people develop sepsis
What is a transperineal prostate biopsy?
- Ultrasound into rectum
- Needle through perimeum
- Template biopsy placed over the skin and 2-3 cores are samples
- LATP adopted throughout pandemic
What are the advantages of transperineal prostate biopsy?
- Sepsis risk greatly decreased
- Easier access to anterior and apex which may lead to better detection
What is the NICE guidance for a negative biopsy after an mpMRI?
- If mpMRI Likert score is 3+ they will be offered a repeat
- Men with a raised PSA but lower Likert and a negative biopsy they will have another PSA at 3-6 months
- If low suspicion they will have repeat PSA tests every 2 years
What do the biopsy histology look at?
- Look at how abnormal the cells look
- How many samples contain the abnormal cells
- Can be used to determine grade, aggression and spread
How do gleason scores work?
- Gleason score = most common grade + highest other grade in the samples
How are T1 prostate cancers staged?
- T1 are too small to be seen on a scan or felt during a DRE
- T1a = <5% of tissues found unexpectedly
- T1b in 5% or more found unexpectedly
- T1c are found in biopsies
How are T2 prostate cancers staged?
- T2a = half of one lobe
- T2b more than half but still one lobe
- T2c cancer in both lobes but still contained in the prostate
How is a T3 prostate cancer staged?
- T3 cancer expands through the prostate capsule
- 3b = spread to seminal vesicles
How is a T4 prostate cancer staged?
- Spread to nearby organs
