Prostate Cancer case

Case History:

A 56-yr-old man was referred to me with a prostate-specific antigen (PSA) level of 6.5 ng/ml. The patient had mild lower urinary tract symptoms (International Prostate Symptom Score of 4) not requiring treatment. He is sexually active (International Index of Erectile Function-5 score of 24). His family history includes his father, who was diagnosed with intermediate-risk prostate cancer (aged 72 yr) and underwent surgery with a radical prostatectomy. No other medical concerns and he has had no previous surgery. A digital rectal examination revealed a moderately enlarged benign feeling prostate. Renal tract ultrasound revealed normal kidneys, bladder had a prevoid volume of 356ML and a residual of 45ML, prostate measuring 56g.

Prostate MRI criteria were met (positive family history and elevated PSA). Prostate MRI showed a PIRAD 4 lesion on the right side of the prostate.

What are the patient Medicare eligibility requirements for a Prostate MRI?

These items are only for scans of patients with specified indications. The request form must list the relevant clinical indications.

The patient must be suspected of having prostate cancer based on:

1. a digital rectal examination (DRE) which is suspicious for prostate cancer; or
2. in a person aged less than 70 years, at least two prostate specific antigen (PSA) tests performed within an interval of 1- 3 months are greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25% or the repeat PSA exceeds 5.5 ng/ml: or
3. in a person aged less than 70 years, whose risk of developing prostate cancer based on family history is at least double the average risk , at least two PSA tests performed within an interval of 1- 3 months are greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25%: or
4. in a person aged 70 years or older, at least two PSA tests performed within an interval of 1- 3 months are greater than 5.5ng/ml and the free/total PSA ratio is less than 25%.

Note: Relevant family history is a first degree relative with prostate cancer or suspected of carrying a BRCA 1, BRCA 2 mutation.

Patient undergoing active surveillance the below clinical criteria must be met:

1. the patient is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and
2. the patient is not planning or undergoing treatment for prostate cancer.

Transperineal Prostate Biopsy under general anaesthesia was recommended after the prostate MRI results were discussed. This allows multiple biopsies to be taken throughout the prostate for histological examination. Possible complications explained can include: infection (prophylactic antibiotics given), haematuria, haematospermia, PR bleeding (mainly with transrectal biopsies), urinary retention, perineal bruising.

Histopathology results confirmed a Grade 2 (ISUP Grading 2014) equivalent to a Gleason Score 3 + 4 = 7, in 5 of 42 cores.

Prostate biopsy results discussed with patient and partner. Metastatic evaluation with bone scan and CT scan were normal. PSMA PET scan not performed – criteria not met.

Treatment with curative intent was recommended which incudes surgery (robotically assisted radical prostatectomy) or radiotherapy. Known possible complications were discussed with the main relevant ones being urinary incontinence and erectile dysfunction. Prior to undergoing definitive treatment counselling with my nurse where pelvic floor exercises and penile rehabilitation were discussed and recommended these be commenced prior to treatment. Radiotherapy consultation arranged and discussed. Decision made by patient to proceed to surgery with a Robotically Assisted Radical Prostatectomy. Written information about prostate cancer and treatment options provided.

Robotically Assisted Radical Prostatectomy: less invasive, less blood loss. less pain, shorter hospital stays, faster recovery times (although catheter needs to remain in bladder for same amount of time after robotic or open procedure).

Histopathology results from the prostatic removal were discussed in detail with the patient (Grade Group 2 with no extracapsular disease and clear surgical margins).

Initial Post-operative PSA at 2 months was undetectable (<0.01). Recommended that a PSA be performed 6 monthly.

Post operative recovery: Almost full continence at 2 months (pad only used for confidence reasons and not wet), penile rehabilitation effective and partial erections returning at 3 months without the need for PDF-5 inhibitors.

(important to be aware that most pathology collecting companies record a PSA reference range, but this is not calibrated to a post operative or treatment related PSA value – the reference range refers to an individual who has not had treatment for prostate cancer).

Take home messages:

1. Consider an annual PSA for men 50 years and over or 40 years and over with a positive family history. If a man enquires at an earlier age, then appropriate counselling should be given. Men in their forties with no family history can still be diagnosed with prostate cancer – in my opinion, don’t deny them of a PSA.
2. Prostate MRI – ordered by specialist (urologist, oncologist) – gives further information and may minimise the need for unnecessary prostate biopsies.
3. PSMA PET scan in select cases to evaluate for metastatic disease. Arranged by Urologist / oncologist.
4. Treatment options need to be carefully discussed with potential short- and long-term complications outlined. Counselling from allied staff should be provided.
5. Six monthly post-operative PSA readings – should continue long term. Any change in the PSA from an undetectable level (<0.01) should be referred to Urologist.

Dr Nestor Lalak is the region's most experienced Urological Surgeon based in South West Sydney. He has ana interest in a wide range of urology procedures including Robotic, Laparoscopic, Endoscopic and Open Surgery of the prostate, kidney, bladder and testis.

P: 1300 224 355
F: 02 4623 5561
E: admin@swsurology.com.au
Dr Nestor Lalak - Urological Surgeon - South West Sydney Urology (swsurology.com.au)

South West Sydney Urology,
Suite 10, 70 Bowral Street
Bowral, NSW, 2576