Getting to Diagnosis. Debbie Victor Uro-Oncology CNS Royal Cornwall Hospitals Trust

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1 Getting to Diagnosis Debbie Victor Uro-Oncology CNS Royal Cornwall Hospitals Trust

2 GP Visit Symptoms Reduced urinary flow Difficulty starting/stopping Urgency Frequency Nocturia Because a friend/relative has been diagnosed Prostate cancer awareness event Advanced symptoms Bone pain Weight loss Erectile dysfunction Haematuria/haemospermia

3 What happens then? Patients presenting with symptoms suggesting prostate cancer should have a digital rectal examination (DRE) and prostate-specific antigen (PSA) test after counselling. Symptoms will be related to the lower urinary tract and may be inflammatory or obstructive. NICE 2005

4 Counselling before PSA test prostate-patient-info-sheet.pdf 65% men with raised PSA don t have cancer 20% of men with prostate cancer have normal PSA NHS Choices 2011

5 Age specific PSA normal ranges years years years Over 70 years 2.5 ng/ml 3.5 ng/ml 4.5 ng/ml 6.5 ng/ml

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7 PSA unreliable <6 weeks of urinary retention and UTI

8 Digital Rectal Examination Approximately 70% of prostate cancers are located in the peripheral zone and can be detected on DRE if tumour volume >0.2ml

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10 Urgent referral (2ww) YES Hard, irregular prostate Rising PSA, normal DRE, no symptoms Consider co-morbidities, if life expectancy <10years discuss with patient/carers Symptomatic with raised PSA NO Borderline PSA, normal DRE, asymptomatic? Repeat PSA after 1-3 months. NICE 2005

11 MRI or biopsy first? MRI Biopsy needle can miss significant cancers Less post biopsy artefact leading to over/under staging Cut down on unnecessary biopsies Biopsies can find slow growing, insignificant cancers over diagnosis Can allow targeting of lesion Speeds up investigation pathway Biopsy Only way of grading tumour Reduces burden on MRI scanners Reduces unnecessary scans What about claustrophobic patients? Currently gold standard Await results of PROMIS (PROstate Mri Imaging Study)

12 Standard MRI images

13 Confirm indications. Is TRUS feasible? Risks Transrectal Ultrasound: Take a history. - Drugs (anticoagulants) - Drug/Latex Allergy - Active UTI - High-risk prophylaxis e.g. mechanical heart valves

14 Transrectal Ultrasound: Patient Counselling. Explain the procedure and risks to the patient. 1-2% risk sepsis with return to hospital Small risk of urinary/clot retention Bleeding urine/semen/faeces Prostatitis, epididymitis False negative rate approx 15% Let them know that they can have a G.A. if they find TRUS too uncomfortable Consent Talk to the patient throughout

15 Transrectal Ultrasound: Antibiotic Prophylaxis Single dose v multiple dose, significantly greater risk of bacteriuria in single dose Short course (1 day) v Long course (3 days) beneficial reduction of bacteriuria with long course Antibiotics as per local guidelines BNF March 2012 recommends single dose cipro & metronidazole Zani et al 2011 Cochrane Database Syst Rev May 11;(5):CD

16 Transrectal Ultrasound: Enema? Many U.S. urologists advise self-admin phosphate enemas Complications (bleeding/infection) not less common in patients with enemas Imaging not benefited by enema No enema

17 Transrectal Ultrasound: needle guide in place

18 Transrectal Ultrasound: positioning Left lateral position, knees drawn up

19 Perform DRE first Transrectal Ultrasound: procedure This allows examination of prostate, relaxation of sphincter, and detection of any anal fissures or rectal tumours that may render TRUS-biopsy unsuitable. Insert ultrasound probe with gel filled condom and needle guide

20 Transrectal Ultrasound: Ultrasonic Appearance isoechoic (the same echogenicity as surrounding tissue), hyperechoic (brighter) hypoechoic (darker). Isoechoic area could be: normal tissue, tumour Hypoechoic area could be: cyst, abscess, tumour Hyperechoic area could be: calcification, tumour

21 Transrectal Ultrasound: Transverse

22 Transrectal Ultrasound: Sagittal

23 Transrectal Ultrasound: Anæsthesia Peri-prostatic lignocaine administered using spinal needle: Apical Superolateral Significant reduction in pain scores in blinded, control studies.

24 Biopsy needle

25 Biopsy: how many is right? On the first biopsy (baseline biopsy) the sample sites should be as far posterior and lateral in the peripheral zone as possible. Traditional sextant biopsies are no longer considered adequate. At volume ml at least 8 cores should be taken. More than twelve cores have not been shown to be significantly more conclusive. (Level of evidence: 1a). The British Prostate Testing for Cancer and Treatment Study recommends a 10 core biopsy. (Level of evidence: 2a) In prostate > 50 ml up to 18 cores can be considered. Additional biopsy cores can be taken towards suspicious findings on DRE or TRUS. Indications for seminal vesicle biopsy are not well defined and their use remain controversial. Biopsies of the transition zone provide a low detection rate and sampling is not recommended on initial biopsy. (Level of evidence: 2a) EAUN 2011

26 Template Biopsy? NICE 2010 Suitable after unequivical or negative TRUS-biopsy in patients suspected of having prostate cancer Little evidence to support use for a mapping technique or for active surveillance Advises use only with special arrangements for clinical governance, consent and audit or research, but acknowledges further research required.

27 Aftercare Stay in department for up to 30 minutes post biopsy Advise again of risks of bleeding/infection Ensure has written information and who to contact if any problems Appointment for results

28 TNM Staging

29 Local MDT Discussion

30 Role of CNS Discuss/perform prostate biopsy Be a link between biopsy time and results Diagnosis clinic Discuss diagnosis/reiterate what consultant has said in understandable language Provide written information/decision aids Provide useful safe websites, details of local and national support Be available to answer questions

31 Any Questions?