INFORMATION FOR CANDIDATE:

You recently referred a 68 year old Mr. Higgins who initially

presented with frequency, urgency and pain when passing urine to a
urologist because you found on the pr examination an enlarged
prostate.
The urologist sends you a letter with the results of a range of
investigations he has initiated:
1. MSU showed growths of e.coli
2. PSA 6 ng/ml ( <4ng/ml normal, 4-6 ng/ml intermediate, >10
ng/ml high)
3. The core biopsy with 8 samples from the prostate was
positive for adenocarcinoma (Gleason grade 5)
4. A cystoscopy did not reveal a bladder neck obstruction
5. the whole body radioisotope scan did not show metastases
6. CT pelvis and spine did not show any tumour outside the
prostate capsule (stage T2)
The urologist mentions that he explained to Mr. Higgins that there
was cancer but he suggested to Mr. Higgins to see you for further
counseling.
Mr. Higgins comes today for explanations.
YOUR TASK IS TO:
Explain the results
Discuss the diagnosis and management options with the
patient

HOPC: As above. Mr. Higgins also tells you that he is still sexually active. His main
problem is that he got quite a shock when the urologist mentioned cancer and he really did
not understand anything else at the time and would like to get information from you.
PHx,: unremarkable
FHx.:NAD
SHx: married, retired accountant although still engaged in family business activities, non
drinker, non smoker, NKA, no medication.
DIAGNOSIS:
1. UTI
2. PROSTATE CANCER

Understanding the Prostate:

The prostate is a walnut-sized gland that
forms part of the male
reproductive system. The prostate secretes
fluid that carries sperm. It
surrounds the urethra, the canal which carries urine from the bladder out of the body.
With age and time, the prostate enlarges causing pressure on the urethra, similar to a
clamp on a garden hose. This causes problems with urination.

Prostate cancer is the most common cancer in men and constitutes a significant health
issue. Even though the saying more men die with prostate cancer than from it is still
valid, there is considerable morbidity! Rare before the age of 50 and increasing incidence
with age. There is a family connection similar to breast cancer, i.e. the younger a family
was when diagnosed with prostate cancer, the higher the risk for the patient. However, it
is considered to be a slow growing carcinoma and can be asymptomatic even when it has
extended beyond the prostate! Although, if a patient develops symptoms (lower urinary
tract obstruction, bladder outlet obstruction (BOO), back pain, haematuria, uraemia,
tiredness, weight loss and perineal pain) it usually is at a stage where the carcinoma has
already metastasized (bone!)! There a no early symptoms!
The prevention is therefore a must with regular digital rectal examination (DRE) and
prostate specific antigen (PSA) blood testing, although its usefulness as a screening test is
still debated because it is neither sensitive or specific enough. It is more useful as a test
over time as well a ratio of free to total PSA. PSA serves as a very sensitive indicator of
progress of disease and response to treatment!!!

Signs of abnormal prostate on DRE:

Hard lump
Asymmetry
Induration
Loss of median sulcus
BIOPSY: usually if DRE is suspicious or PSA elevated under transrectal ultrasound
(TRUS) guidance taking several core biopsy samples (6-12) for histological evaluation
using the Gleason score. A score from 1 to 5 is given based on the appearance of the
cancer cells, where 5 indicates a very abnormal and aggressive cell type. By grading the
appearance of the two most common cell types and adding the scores together, a total
rating from 2 to 10 is given. The Gleason score determines if the tumour is aggressive or
slow-growing, which in turn is important for management decisions. Fast-growing
cancers which are more likely to affect a mans health and lifespan are called high-grade
cancers with a Gleason score of 7 to 10. High grade cancers usually need to be treated
more radically, either by surgery or radiotherapy, since they grow more quickly and may
spread to other parts of the body. (Gleason score: 26 Low, 7 Intermediate, 810 High!)
The radionuclide bone scan is used for staging purposes looking for bone metastases.
In addition the normal TNM staging system is used:
T1 The tumour is found only in the prostate. It cannot be felt during a digital rectal
examination.
T2 The tumour is located within the prostate only. It can be felt during a digital rectal
examination.
T3 The tumour has spread from the prostate to nearby tissues such as the seminal vesicle
glands, which produce semen.
T4 The tumour has spread beyond the prostate to the bones or lymph nodes.
N1-3 means the cancer has spread to the lymph nodes (glands) near the prostate. N0
means the cancer has not spread to any lymph nodes.
M followed by 1a, b or c shows that the cancer has spread to the bones or other organs of
the body.
MANAGEMENT:
The management options should really be discussed with a specialist but include:
1. WATCHFUL WAITING recommended for patients over 70 years with no
symptoms
2. TOTAL (RADICAL) PROSTATECTOMY: one of the two potentially curative
therapies (radiotherapy being the other one) for tumours confined to the prostate.
Usually recommended for patients under 70 years with a PSA <20ng/ml. It offers
90% 10 year disease-specific survival for organ-confined tumours. Incontinence
rate is about 7% and impotence rate at least 30% or up to 70% (different authors).

3. RADIOTHERAPY: perhaps slightly less survival but also less mortality and
incontinence and impotence rates. Other side effects are diarrhoea and urinary
frequency.
4. BRACHYTHERAPY: another form of radiotherapy with tiny radioactive seeds
inserted directly into the tumour. Probably less side effects!
5. ANDROGEN SUPPRESSION: the mainstay for metastatic or locally advanced
disease. This methods can include bilateral orchidectomy, depot injections of lonacting luteinising hormone-releasing hormone (LHRH) analogues (goserelin =
Zoladex, leuprorelin acetate = Lucrin) and anti-androgens ( cyproterone acetate =
Androcur, flutamide = Eulexin, bicalutamide = Cosudex). All these have
significant side effects ranging from an initial testosterone surge to loss of muscle
mass, osteoporosis, anaemia, hot flushes and adverse cognitive changes.
Specifically in this patient the PSA is only slightly elevated and the biopsy has
confirmed a cancer with low aggressiveness and there is no further spread of the
tumour. At this stage in the AMC exam it is not necessary to come up with a definite
treatment rather to put the options to the patient!!!!
;
However one also has to deal with the UTI which should be treated with empiric
antibiotics or in accordance with the MSU result (sensitivity).