Staging Prostate Cancer: MRI and PSMA PET CT Scans

On Doppler ultrasound, chronic prostatitis typically shows uniformly increased vascularity across the whole prostate, whereas prostate cancer shows increased vascularity at one specific point, such as a nodule. However, we don't rely on ultrasound alone to distinguish the two — it comes down to clinical judgement, PSA value, and age, since chronic prostatitis is a disease of younger, sexually active men in their 40s to early 50s, while prostate cancer is a disease of old age; I would be hesitant to diagnose chronic prostatitis in a 60-65 year old with a PSA of 10 and urinary symptoms — that points toward BPH with a suspicion of prostate cancer to rule out. On tumour lysis syndrome: yes, it can happen with any treatment — radiotherapy or chemotherapy — in any tumour, most often solid tumours; it is not specific to prostate cancer.

Yes, that's correct. Orchidectomy is a cost-effective, one-time procedure, and increasingly patients in developing countries are also getting health insurance that covers the ongoing medications, so when it comes to overall treatment, orchidectomy can even be considered superior in efficacy compared to injectable treatment, and there's no harm in doing it. However, losing a testicle is a point of real psychological impact for a man, so if a patient can afford it or the treatment is available, I would suggest androgen deprivation therapy via injections or medication as preferable — orchidectomy remains a well-suited procedure specifically for patients with stage 4 disease.

What you're describing is the androgen depletion syndrome — you have abolished testosterone, so the patient develops post-menopausal-type symptoms. In our practice, for patients who have undergone androgen deprivation, we educate them not to panic, start gabapentin and sometimes an anti-anxiety medication, and for central obesity and related issues advise calcium and vitamin D supplements, a high-protein, low-fat diet, regular exercise, and sunlight exposure, since bones become fragile and there is increased risk of coronary artery disease and hypertension. We sometimes also use denosumab if the patient is very incapacitated by hot flashes and sweating. You did the right thing for your patient — surgical castration is the most practical option where injectable androgen analogues or antagonists aren't reliably available.

False positivity of PSA is very common, so I would follow this patient regularly, first checking for infection. I would repeat the PSA after 6 weeks — if the high PSA was due to infection, a course of antibiotics should show a downward trend by then; if it doesn't trend down, you should have a high suspicion of prostate cancer. You can also check the free-to-total PSA ratio — if it's less than 25%, that supports the diagnosis. If the DRE is normal and there's no biopsy facility, you can follow the patient for a year and check PSA velocity — if it goes beyond 0.75 per year, refer to a centre with TRUS-guided biopsy or MRI facilities. With a PSA of 10-20, there is roughly a 10-30% chance of harbouring prostate cancer, so this should be investigated further rather than dismissed.

This is a sign of chronic prostatitis — patients with chronic infection in the prostate get calcium deposited in the glandular secretions over time, which is the mechanism behind the calcification. If the patient is asymptomatic and PSA is normal, I would not worry. If symptomatic, try medical management first, and only if that fails should you consider a surgical procedure. Prostatic calcification itself does not cause any harm — it is simply a telltale sign of chronic infection in the prostate.

Multiparametric MRI evaluates several parameters, including the size and activity of the lesion, and can detect extracapsular disease, meaning cancer that has grown beyond the prostate capsule, with up to 90 percent accuracy.

A bone scan is indicated when PSA rises above 20 nanograms per millilitre, when the tumour is classified as T3 or T4, or when biopsy shows a Gleason score of 8 to 10.

PSMA PET CT can identify both bony and soft tissue or solid organ spread of prostate cancer in a single scan, making it the most commonly used tool for detecting distant metastasis.

Accurate staging is what allows doctors to plan the next step with confidence, whether that is surgery, radiotherapy or a systemic approach.