What's the most probable diagnosis?

Spoiler

BPH

On DRE what are the features suggesting a prostate cancer?

Spoiler

Hard
Nodular
Fixed to rectal wall
Obliterated median sulcus

Mention 3 investigations to be performed in the outpatient clinic?

Spoiler

PSA
Mid-Stream Urine analysis
U&Es and creatinine

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

Spoiler

Transrectal ultrasonography guided biopsy

How is it done?

Spoiler

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?

Spoiler

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?

Spoiler

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?

Spoiler

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?

Spoiler

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?

Spoiler

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?

Spoiler

Gleason score

How is it calculated?

Spoiler

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?

Spoiler

TNM

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

Spoiler

Lumbar spine metastasis

Mention one laboratory test to exclude bony metastasis?

Spoiler

Alkaline phosphatase

What's the type of these metastasis? Why?

Spoiler

Sclerotic
Due to increased bone deposition due to increased osteoblastic activity

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

Spoiler

UTI

Which investigations would you request?

Spoiler

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?

Spoiler

1000=UTI, 100,000=Sepsis

Which of the blood components would rise?

Spoiler

WBC's – neutrophils

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

Spoiler

Androgen

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

Spoiler

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?

Spoiler

TURP and medication of androgen deprivation

Do we still have orchidectomy for treating prostate cancer?

Spoiler

Yes, we have medical orchidectomy.