BEST PRACTICE IN PROSTATE

CANCER DIAGNOSIS

Miss Elizabeth Waine

MD FRCS(Urol)Ed

Consultant Urologist

Royal Devon and Exeter NHS Foundation Trust

Overview

• Where we all are now

• Techniques available in places

• What would be the ideal situation

What we all have now

• PSA

• Transrectal ultrasound and prostate biopsy

• MRI of Prostate

• Bone Scan

PSA

• Simple blood test offered to men by their GP

• Indications

• Pts wish to be screened after counseling

• Lower urinary tract symptoms

• Abnormal digital rectal examination

• Bone pain

• Anorexia, weight loss

• Spontaneous DVT

• Sensitivity of 80%, Specificity of 40-50%

• Huge variety of reasons for a raised PSA

PSA variables to help predict prostate

cancer • PSA age specific range

• By using these the sensitivity is improved in younger men but

specificity is improved in older men

• PSA Density

• DSA-D=Total serum PSA /TRUS volume

• If >0.3ng/ml increased likelihood of cancer

• But measuring operator dependent

• PSA Free: total ratio

• Assay availability is low and sample must be delivered to lab fresh

• Prostate cancer more likely if ratio is low that is less free and more

complexed PSA

• Prostatitis can alter ratio

PSA variables to help predict prostate

cancer • PSA velocity

• Requires multiple readings over a 2 year period

• If >0.3ng/ml/yr then increased risk of CaP

• PSA doubling time PSA-DT

• Requires several measurements over 2 years

• PSA-DT < 5 years should trigger further investigation

Trans-rectal ultrasound and Prostate biopsy

• Standard method of achieving tissue diagnosis

• Advantages

• Can be done in the outpatient setting under LA

• Takes 10-20 mins to perform

• Disadvantages

• Complications

• Missed cancers

Sextant Biopsy

Para sagittal plane

Misses 10-30% cancer when patients undergo a second biopsy

10 core biopsy

•Adding 4 lateral biopsies of the peripheral zone:

• Mid & base of prostate

•Presti et al (J Urol 2000): (n=483)

•10 core biopsies (& lesion directed & 6 TZ biopsies)

•Overall 42% had cancer detected

•Sextant detected 80% of the cancers

•Combination of sextant & lateral detected 96% of the cancers

•(4% lesion directed or extra TZ biopsies)

Completing staging investigations

• MRI

• For patients with grade 4

disease

• assessment of lymph

node status

• Assessment of local

disease

• Can have false positive

rate particularly if

performed after prostate

biopsy

• Bone Scan

• Any pattern 4 disease

• PSA>10ng/ml

• Any history to suggest

bone pain

What is available

• PCA-3

• Not yet available on the NHS

• Gives a prediction of prostate cancer which is more accurate when

used in conjunction with PSA, DRE and if possible a F:TPSA

• Patients require a digital rectal examination and a prostatic

massage and then provide a urine specimen the initial catch of this

urine is analysed

• A score is obtained correlating to the probability of a cancer

• Prostate size does not affect PCA3 levels

What is available?

• Multi-parametric MRI

• Scoring system which determines the likelihood of clinically

significant disease

• Combination of standard high resolution T2 weighted MRI with at

least 2 functional MRI techniques.

• Takes 30-45 minutes to acquire the series of imaging depending

upon the indication

Multi-parametric MRI

• Advantages

• Reduces unnecessary biopsies

• Localisation of tumours for improved biopsy yield

• Determine clinically significant tumours

• Disadvantages

• Some false positives can be generated

• Long scan times- claustrophobic patients

• THR and other metallic implants can limit its usefulness

Multi-parametric MRI

• Indications

• Detection of high risk tumours where biopsy high risk/not easy

• For men who have a raised PSA with multiple negative biopsies

• For men with a very high PSA and low grade disease on biopsy

• Planning treatments

• HDR Brachy boost- localisation of tumour

• Surgery- To nerve spare or not?

• Focal therapy mapping

• Categorising patients risk if active surveillance is treatment of

choice

• Ensures no significant peripheral, apical or anterior tumours that have

not been biopsied

MRI Template map

Audit tool

What is available?

• Targeted Biopsy

• Transrectal or Transperineal

• After MRI or with newer USS possible to see the abnormalities

• Send 10 core biopsy and targeted biopsies separately

• Advantages

• Reduces false negative biopsies

• By using MP-MRI target clinically significant lesions

• Disadvantages

• Small lesions are difficult to hit

• Quality of USS images may be insufficient

What do we have available at the RD&E

• MP-MRI

• High suspicion of CaP but normal DRE & who are likely to require

radical treatment

• High risk prostate biopsies

• Patients for AS

• Monitoring AS

• Targeted prostate biopsies

• Transperineal prostate biopsy

The ideal prostate diagnosis pathway

• Patient referred to a one stop service with at least 2 PSA

results

• Have full information about medical history and symptoms

before patient entered hospital doors to enable the

optimum pathway instigated.

• Arrange a pre-biopsy Multi-parametric MRI according to

indications to determine areas for targeted biopsy, if

anterior arrange a trans-perineal prostate biopsy.

• If a candidate for radical treatment appropriate biopsy

and/or stage according to clinical findings, biopsy result,

PSA and co-morbidity can be determined

• Pts with some understanding of the forthcoming process

Thank you