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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?
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?
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?
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?
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?
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?