Mock18 Prostate Cancer

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A 65-year-old male patient with poor urine stream, urgency and nocturia. DRE revealed an enlarged, firm, rounded prostate with a preserved median sulcus.

What's the most probable diagnosis?

BPH

On DRE what are the features suggesting a prostate cancer?

Hard
Nodular
Fixed to rectal wall
Obliterated median sulcus

Mention 3 investigations to be performed in the outpatient clinic?

PSA
Mid-Stream Urine analysis
U&Es and creatinine

What's the most important investigation to confirm or exclude malignancy?

Transrectal ultrasonography guided biopsy

How is it done?

TRUS guided from: mid lobe parasagittal plane at: the apex, the mid gland, and the base, bilaterally and should take more than 10 biopsies

Why there is a need for multiple biopsies to diagnose prostate cancer?

Prostatic cancer can be focal, so it's important to take samples from different sites

Biopsy showed high grade prostatic neoplastic tissue admixed with rectal glandular tissue, how can prostatic cells be differentiated from rectal cells during pathological analysis?

Using immunohistochemical marker
In rectal cells, CEA is +ve and PSA is -ve

What are the gene mutations involved in the pathogenesis of prostate cancer?

TMPRSS2 (transmembrane protease, serine 2)
BRCA2, BRCA1, ATM, HOXB13, CHEK2, MSH2, MLH1

Patient underwent TURP for prostate cancer and 6 months later PSA was still raised. What does this signify?

Fall in the level of PSA below detectable levels within 4-6 weeks
High PSA after prostatectomy → recurrence should be considered

Why PSA is not very reliable?

PSA is organ specific, but not cancer specific.
Although serum levels of PSA are elevated to a lesser extent in BPH than in prostatic carcinomas, there is considerable overlap.
Other factors such as prostatitis, infarction of nodular hyperplasia, instrumentation of the prostate, and ejaculation also increase serum PSA levels.

What's the name of the grading system for prostate cancer?

Gleason score

How is it calculated?

2 biopsies are taken from the prostate cancer
Then the pathologist allocates them a number from 1-5 for the most common histological pattern in the specimen, then does the same for the second most common pattern.
The sum of these two numbers gives the Gleason score.
It grades prostate tumours from 2-10 (2 is well differentiated and 10 being the most abnormal and therefore the most likely to spread)

Name of staging system of prostate cancer?

TNM

If a patient with prostate cancer developed back pain and CT showed increased density in the lumbar spine, what's your diagnosis?

Lumbar spine metastasis

Mention one laboratory test to exclude bony metastasis?

Alkaline phosphatase

What's the type of these metastasis? Why?

Sclerotic
Due to increased bone deposition due to increased osteoblastic activity

Post TURP the patient developed fever, confusion, dysuria and dusky red urine. Why?

UTI

Which investigations would you request?

Blood investigation [CBC, Inflammatory markers (ESR and CRP)]
Urine analysis
Culture and sensitivity for urine

What's the colonies number in urine analysis indicating sepsis?

1000=UTI, 100,000=Sepsis

Which of the blood components would rise?

WBC's – neutrophils

What's the primary stimulus of prostate growth during life?

Androgen

In the past bilateral orchidectomy was used as a treatment for cancer prostate. What was the rationale behind that?

Androgen deprivation, reducing the rate of cancer growth.
The growth and survival of prostate cancer cells depends on androgens, which bind to the androgen receptor (AR) and induce the expression of pro-growth and pro-survival genes.

Apart from open surgery, what are the other treatment modalities of prostatic cancer?

TURP and medication of androgen deprivation

Do we still have orchidectomy for treating prostate cancer?

Yes, we have medical orchidectomy.

isurg

Mock18 Prostate Cancer