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A 73-year-old patient presents to his GP with hesitancy and poor urinary flow worsening over the last 6 months. Over the last few weeks he has also noticed blood in both urine and semen. His brother has previously been treated for prostate problems. This patient reports that his father died in his early sixties of prostate cancer. Digital rectal examination revealed a nodule on the right lobe. Blood tests show normal FBC and renal function, PSA 13 ng/mL.
1. Where is the pathology likely to be located in this patient?
Potential differential diagnoses in this case include benign prostatic hyperplasia (BPH), urinary tract infection, bladder cancer or prostate cancer. Given the patient’s worsening urinary flow symptoms, but no associated dysuria or risk factors for infection such as indwelling catheter or associated sexually transmitted infection (STI), this can rule out these differential diagnoses. The patient’s family history, examination findings and elevated PSA point towards prostate cancer in this case.
2. What are the next steps in further investigating this patient’s symptoms?
This patient should be referred for urological investigations. This patient requires an MRI of the pelvis to identify localised prostate tumour, bone scan +/– choline positive emission tomography (PET) CT to identify any distant metastatic disease and a prostate biopsy. MRI of the pelvis will also be able to identify if there any lesions within the bladder that may be cause for visible haematuria. The prostate can also be measured to see if there is any enlargement that may also be a cause for the symptoms and elevated PSA. If there is no suspicious lesion on MRI and biopsy is negative, BPH could be the cause of the patient’s symptoms.
MRI revealed a suspicious tumour in the right lobe of the prostate. Distant bone scans did not reveal any metastatic disease. Prostate biopsy revealed right-sided Gleason 3+4 maximum cancer core length 4 mm.
3. How should this patient be managed?
This patient has intermediate risk cancer – T2bM0N0 disease. This patient has the option of whole gland treatment such as radical prostatectomy or external beam radiotherapy (EBRT) with hormones. Newer options such as focal therapy can also be considered. This can include either high-intensity focused ultrasound or cryotherapy, directed to the area of cancer alone. In this case it could be delivered in a hemi-ablative manner treating the right-hand side only. The patient can then be followed up with regular 3-monthly PSA and annual MRI to review any sign of recurrence.
The patient opts to have EBRT and hormones. He does well post treatment and achieves a PSA nadir <0.5 ng/mL 6 months later. The patient continues to have his PSA monitored for the next year but is unfortunately lost to follow-up. He presents to his GP 2 years later with worsening back pain and weight loss. His PSA is repeated and found to be 9 ng/mL.
4. What should be the next steps in this patient’s management?
The patient should be re-investigated for localised and distant disease as above. He should also have repeat prostate biopsy.
MRI revealed suspicious tumour extending into the bladder. Bone scan revealed likely bony metastases in L4 and L5 lumbar vertebrae. Prostate biopsy revealed Gleason 4+5, maximum cancer core length 12 mm.
5. What should be the next steps in this patient’s management?
Recurrence post primary treatment for prostate cancer can occur in approximately one-third of men. Sadly, this patient has now developed metastatic prostate cancer and will have to be managed with hormones. Metastases from prostate cancer most likely develop in the bone, spine, pelvis, femur ribs and liver and lung due to circulating tumour cells via the bloodstream. Para-aortic and pelvic lymph node metastases can also occur. Hormones tend to control disease for approximately 3–5 years before castrate resistance develops. The patient can be then be started on palliative chemotherapy.