Prostate cancer✅

Related Subjects: | Urothelial Tumours | Haematuria | Acute Urinary Retention | Anuria and Oliguria | Bladder Cancer |Penile Cancer | Renal Cell Carcinoma | Benign Prostatic Hyperplasia | IgA Nephropathy | Prostate Cancer | Henoch-Schonlein Purpura | Glomerulonephritis

🧪 PSA (Prostate-Specific Antigen) is a protein produced by epithelial cells of the prostate gland. ⚗️ It is a 34 kDa serine protease glycoprotein that helps liquefy semen.

• 📈 PSA can rise in prostate cancer, benign prostatic hyperplasia (BPH), prostatitis, urinary retention, and increasing age.
• ⏱️ PSA velocity refers to the rate of PSA change over time and may suggest malignancy if rapidly rising.
• 🦴 Very high PSA levels (often >100 ng/mL) strongly suggest metastatic disease, particularly bone metastases.
• ✋ Digital rectal examination (DRE) does not significantly elevate PSA.
• ⚠️ PSA is not cancer-specific; interpretation requires clinical context.

📌 About Prostate Cancer

• 🧓 Most common cancer in men in the UK.
• 📈 Incidence increases sharply with age.
• 🔍 Many tumours are slow growing and may never cause symptoms.
• ⚖️ The clinical challenge is balancing early detection with avoiding overtreatment.
• 💉 Tumour growth is typically androgen-dependent (driven by testosterone).

📊 Epidemiology

• 🇬🇧 Around 52,000 new cases per year in the UK.
• 👨 Rare before age 50.
• 🏿 Risk is significantly higher in Black African and Caribbean men.
• 👨‍👦 Family history increases risk (≈2–3×).
• ⚖️ Obesity and smoking are associated with more aggressive disease.

🧫 Pathology

• 🧬 ~95% are acinar adenocarcinomas arising from glandular epithelium.
• 📍 Most tumours arise in the peripheral zone of the prostate.
• 🧪 Prostatic intraepithelial neoplasia (PIN) is a recognised precursor lesion.
• 🧬 Tumour aggressiveness is graded using the Gleason scoring system.

🩺 Clinical Presentation

• 💧 Lower urinary tract symptoms (LUTS) frequency, nocturia, weak stream, hesitancy
• 🩸 Haematuria or haematospermia
• 🦴 Bone pain → may indicate metastatic disease
• ⚠️ Many patients are asymptomatic at diagnosis

🧩 Common Clinical Findings

• 📈 Raised PSA on blood testing
• ✋ DRE findings: hard, irregular or nodular prostate
• 🚽 Bladder outflow obstruction → possible renal impairment
• 🦴 Osteosclerotic bone metastases causing pain or pathological fracture

📐 PSA Reference Ranges (Age-Adjusted)

• 👨 40–49 yrs: <2.5 ng/mL
• 👨 50–59 yrs: <3.5 ng/mL
• 👨 60–69 yrs: <4.5 ng/mL
• 👨 ≥70 yrs: <6.5 ng/mL
• 📊 PSA 4–10 ng/mL → cancer risk ≈25%
• 📊 PSA >10 ng/mL → higher risk of malignancy

🔍 Investigations

• 🩸 Blood tests: U&E, FBC, ALP (may rise with bone metastases)
• 📡 Multiparametric MRI (mpMRI) is now performed before biopsy in suspected prostate cancer.
• 🧪 Targeted prostate biopsy (usually transperineal) guided by MRI findings.
• 📊 Gleason score / Grade Group used to determine tumour aggressiveness.
• 🦴 Bone scan or PSMA-PET if high PSA, high Gleason score, or symptoms suggesting metastases.

📊 Risk Stratification (Localised Disease)

🛠️ Management (UK Practice – NICE NG131)

📌 Initial Assessment

• Risk stratification using PSA, MRI findings, Gleason score, and stage.
• All cases discussed at specialist multidisciplinary team (MDT).

🏥 Localised Disease (T1–T2)

• 👀 Active surveillance is often preferred.
• Definitive treatment if progression occurs.

• 🔪 Radical prostatectomy
• 🎯 External beam radiotherapy ± short-course androgen deprivation therapy
• ⚡ Brachytherapy in selected patients

• 🎯 Radiotherapy + long-term androgen deprivation therapy (ADT)
• 🔪 Surgery considered in selected patients in specialist centres

📍 Locally Advanced Disease (T3–T4)

• 🎯 External beam radiotherapy + long-term ADT
• Multimodal treatment often required

🌍 Metastatic Disease

• 💉 Androgen deprivation therapy (ADT) (LHRH agonist or antagonist)
• ➕ Treatment intensification with docetaxel, abiraterone, enzalutamide, or apalutamide

• Continue ADT
• ➕ novel hormonal therapies or chemotherapy
• 🦴 Radium-223 for symptomatic bone metastases
• 🧬 PARP inhibitors (e.g. olaparib) for BRCA-mutated cancers

🤝 Supportive Care

• 🦴 Bone protection: bisphosphonates or denosumab
• 💪 Manage ADT complications (osteoporosis, metabolic syndrome, fatigue)
• 🎯 Palliative radiotherapy for painful bone metastases

🇬🇧 UK Practice Points

• Follow NICE NG131 guidance.
• mpMRI is recommended before biopsy.
• All treatment decisions made via MDT discussion.
• 📊 Long-term PSA monitoring after treatment is essential.

🩺 Case 1 – Low-risk Prostate Cancer

A 62-year-old man has PSA 6.1 ng/mL detected in primary care. MRI shows a small PIRADS-3 lesion and biopsy confirms Gleason 3+3 disease. Management: Active surveillance with regular PSA monitoring, MRI follow-up, and repeat biopsy if disease progression is suspected.

🩺 Case 2 – Intermediate-risk Disease

A 68-year-old man presents with PSA 12.8 ng/mL and MRI showing a PIRADS-5 lesion. Biopsy confirms Gleason 4+3 cancer. Management: Radical prostatectomy or external beam radiotherapy with short-term androgen deprivation therapy.

🩺 Case 3 – Metastatic Prostate Cancer

A 74-year-old man presents with back pain and PSA 186 ng/mL. Imaging confirms multiple bone metastases. Management: Androgen deprivation therapy combined with systemic therapy (e.g. abiraterone or docetaxel), with palliative radiotherapy for symptomatic bone metastases.