Case Studies

Chapter 15 Case 2: Raised PSA

A 62-year-old man undergoes an annual ‘well man’ screen from his employer. He is otherwise fit and healthy with mild hypertension controlled by bisoprolol and is a keen cyclist. His PSA is elevated (6.4 ng/dL) but all other tests including routine bloods are normal. He denies lower urinary tract symptoms. On examination he has a smooth, mildly enlarged prostate. Urinalysis reveals trace of protein only.

• 1. What does PSA stand for and what is it?

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  Correct answer:

  Prostate-specific antigen. A glycoprotein enzyme which liquefies semen allowing sperm to swim and liquefies cervical mucous allowing sperm entry into the uterus. It is produced by the epithelial cells in the prostate.

• 2. What are the causes of a raised PSA?

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  Correct answer:

  • Tumour: prostate cancer and benign prostatic enlargement
  • Infection: prostatitis, cystitis
  • Inflammation: prostatitis
  • Iatrogenic: following any instrumentation including catheterisation
  • Ejaculation
  • Exercise: particularly cycling.

  Digital rectal examination can mildly elevate a PSA but this is not a clinically significant change. PSA has a half-life of approximately 2 weeks so avoid taking a PSA blood test within 4 weeks of urinary retention or instrumentation (including catheterisation) or infection.

• 3. What investigations does he require?

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  Correct answer:

  PSA should be repeated as it varies physiologically. A full history should exclude transient causes of a raised PSA (cycling large distances can significantly elevate a man’s PSA). If it remains elevated on a second blood test then further investigations should be performed.

• 4. How is a prostate biopsy performed and what are the risks?

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  Correct answer:

  A prostate biopsy is most commonly performed under local anaesthesia with transrectal ultrasound (TRUS) guidance using a core biopsy needle. Risks include infection (sepsis (approximately 1%) and death are possible but uncommon), bleeding (per rectum, per urethra and haematospermia) and urinary retention (approximately 1%). Antibiotic prophylaxis is typically given.

  Transperineal biopsy can also be performed, typically under general anaesthesia, with TRUS guidance. Most prostate biopsies are ‘random sampling’, but MRI-directed or fusion biopsies can be used to target lesions detected on MRI scanning as ultrasound is not sensitive for prostate cancer.

  His TRUS biopsies show Gleason 4+3 cancer in <10% of biopsy material on the left and no significant abnormality on the right. His MRI scan demonstrates organ confined disease (T2aN0M0).

• 5. What is a Gleason score?

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  Correct answer:

  Gleason scoring is the grade of prostate cancer; a measure of its aggressive nature. Scores range 3–5 (5 being aggressive, poorer prognosis disease) and both the most frequent (primary) and next most frequent (secondary) patterns listed to give a grade (primary +secondary) of 6–10 (i.e. he has a most prominent pattern of 4 with some grade 3 disease, giving a total score of 7).

• 6. What treatment strategies should be discussed with this man?

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  Correct answer:

  • Active surveillance: no active treatment can be chosen by men with small volume low grade (typically Gleason 6) disease who wish to avoid the side effects of radical treatments. Active surveillance typically includes regular PSA monitoring (e.g. 3-monthly initially) followed by repeat biopsies (e.g. at 1 and 4 years) which carries a significant anxiety factor for some patients. NB: active surveillance should be differentiated from watchful waiting which is a policy adopted for men not fit for radical treatment because of other co-morbidities (radical treatments are only offered to men with a life expectancy of ≥10 years).
  • Radical treatment:
    • Radical prostatectomy (open, laparoscopic or robotic-assisted laparoscopic via the trans- or extraperitoneal routes). This has high risk of impotence and a small but significant risk of incontinence persisting after 1 year. Men will not ejaculate after a radical prostatectomy as the vasa deferentia and seminal vesicles are also removed en bloc.
    • Radical radiotherapy: a 6-week course of external beam radiotherapy (EBRT) which can cause impotence, lower urinary tract symptoms (LUTS) and bowel symptoms. Hormone treatment (androgen deprivation therapy) can also be given for a limited time (e.g. 1–2 years).
    • Brachytherapy: insertion of radio-active iodine ‘seeds’ throughout the prostate gland. This typically causes LUTS and bowel symptoms for the first year because of inflammation so is typically only offered to men with a low IPSS (see Chapter 6).
  • Experimental treatments include high-intensity focused ultrasound (HIFU).