## Clinical Presentation of Prostate Cancer This patient has **red flags for prostate cancer**: - Hard, irregular, asymmetric nodule on DRE - Elevated PSA (18 ng/mL, normal <4) - Hypoechoic lesion on TRUS (suspicious for malignancy) - Gross hematuria and dysuria (local invasion or obstruction) ## Diagnostic Algorithm for Suspected Prostate Cancer ```mermaid flowchart TD A[Elevated PSA + abnormal DRE]:::outcome --> B[TRUS-guided biopsy]:::action B --> C{Histology}:::decision C -->|Benign| D[Surveillance or repeat biopsy]:::outcome C -->|Malignant| E[Gleason score & staging]:::outcome E --> F[MRI + bone scan for staging]:::action F --> G{Stage & grade}:::decision G -->|Localized, low-grade| H[Active surveillance or EBRT]:::action G -->|Localized, high-grade| I[Radical prostatectomy ± ADT]:::action G -->|Metastatic| J[ADT ± chemotherapy]:::action ``` ## Why Biopsy First? **Key Point:** **Histological diagnosis is mandatory before any definitive treatment** in suspected prostate cancer. TRUS-guided biopsy is the gold standard. **High-Yield:** Biopsy provides: 1. **Confirmation of malignancy** (rules out benign mimics like prostatitis, BPH) 2. **Gleason grading** (prognostic significance; guides treatment intensity) 3. **Extent of involvement** (number of cores positive, percentage involvement) 4. **Risk stratification** (low, intermediate, high-risk disease) **Clinical Pearl:** Gleason score is the single most important prognostic factor in prostate cancer. Treatment decisions (watchful waiting, EBRT, radical prostatectomy, ADT) depend critically on Gleason grade and stage. ## Why Not the Other Options? | Option | Reason for Rejection | |--------|---------------------| | ADT immediately | ADT is a systemic therapy for advanced/metastatic disease or high-risk localized disease. It cannot be started without histological proof of cancer and staging. | | Radical prostatectomy without investigation | Surgery is only offered after biopsy confirmation, Gleason grading, and staging. Proceeding without histology is unethical and may expose the patient to unnecessary morbidity. | | MRI + bone scan before biopsy | Staging investigations are performed AFTER biopsy confirms malignancy and Gleason score is known. Staging before diagnosis is illogical and wasteful. | ## Biopsy Technique - **Route:** Transrectal (TRUS-guided) is standard; transperineal is alternative - **Cores:** Minimum 10–12 cores; saturation biopsy (20–24 cores) if high suspicion - **Anesthesia:** Local periprostatic block or general anesthesia - **Complications:** Hematuria (common, self-limited), hematospermia, rectal bleeding, infection (prophylactic antibiotics given) [cite:Harrison 21e Ch 305; Robbins 10e Ch 20]
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