Question 1

I am a general surgeon in a district general hospital. A patient presented with bilateral paraparesis (lower-limb power 2/5), a hard prostate on digital rectal examination and a PSA above 100; advanced prostate cancer with spinal metastasis was considered the cause. We have no hormonal therapy, so we performed a bilateral orchidectomy, and he was walking within five days. On follow-up he developed excessive heat, central abdominal obesity, breast enlargement and a high TSH. How should this hormonal disturbance be managed?

Dr. Shafiq Ahmed · Accepted Answer

These symptoms are due to androgen depletion: with testosterone abolished, patients can develop post-menopausal-type symptoms. Management is multifold. We educate patients first not to panic, and start gabapentin and sometimes an anti-anxiety medication. Patients on androgen deprivation are started on calcium and vitamin D supplements and advised a high-protein, low-fat diet, regular exercise and sunlight exposure, because their bones become fragile and they are prone to obesity, coronary artery disease and hypertension. In metastatic, stage 4 disease this is a multimodality approach. Most patients settle within a few months, although hot flushes can be very distressing. You did the right thing for your patient: surgical castration is the most commonly practised option where injectable androgen analogues or antagonists are not available and patients cannot follow up regularly with the health system.

Question 2

In a patient with total PSA greater than 10, a digital rectal exam that does not show nodularity, and no access to biopsy, what would be your recommendation for management options?

Dr. Shafiq Ahmed · Accepted Answer

False positive PSA results are very common, so I would follow this patient regularly, and the first step is to check for infection: give a course of antibiotics and repeat the PSA after 6 weeks; if the raised PSA was due to infection, it should show a downward trend. If it does not trend down, you should have a very high suspicion of prostate cancer. Second, check the free-to-total PSA ratio: a ratio below 25% further supports the diagnosis. Third, a PSA between 4 and 10 carries around a 30% chance of cancer, and between 10 and 20 more than 30%, so a PSA that stays above 10 is itself a reason to refer him, even with a normal digital rectal examination, to a centre with MRI and prostate biopsy; where follow-up is unavoidable, a PSA velocity of more than 0.75 per year is a further warning sign. Once other causes are ruled out, a patient with a PSA in this range should be suspected of prostate cancer and referred for advanced investigation rather than dismissed.

Question 3

What is the management of prostatic calcification in a 60-year-old man with no obstructive symptoms, PSA within normal limits at 2.8, and a prostate that is not enlarged?

Dr. Shafiq Ahmed · Accepted Answer

Prostatic calcification is common with age and is often found incidentally; it can be associated with chronic prostatitis. In patients with chronic inflammation of the prostate, the secretions within the glandular part become impacted and calcium is slowly deposited; that is the mechanism of the calcification. If the patient is asymptomatic and the PSA is normal, there is no need to worry. If he is symptomatic, try medical management first; only if that fails should a surgical procedure be considered. Prostatic calcification itself does no harm to the patient; it is a telltale sign of chronic infection in the gland.

Question 4

How effective is HIFU (high-intensity focused ultrasound) in early-stage prostate cancer?

Dr. Shafiq Ahmed · Accepted Answer

In India and other developing countries this facility is not widespread and it has not been accepted by the urology community, although it is practised in the West by urologists, and possibly by medical oncologists and interventional radiologists. Prostate cancer is slow growing, but BPH grows alongside it as men age, and the two together obstruct the urethra and the ureteric orifices. In my practice, patients with locally advanced or even metastatic disease often do not die of the cancer itself but of the obstructive effects of the prostate mass; a cancer invading the bladder neck and trigone, for example, threatens the patient through ureteric obstruction. That is why, as a urologist, I counsel surgical candidates with early or locally advanced cancer towards robotic radical prostatectomy, and for younger patients with oligometastatic disease, one to three bone spots, I counsel surgery to the prostate as well. In surgery I have three objectives: clear cancer margins, early continence and preserved erections.

Question 5

How does orchidectomy compare with radical prostatectomy?

Dr. Shafiq Ahmed · Accepted Answer

There is no comparison, because they serve different purposes. Orchidectomy is chosen for metastatic, stage 4 disease: for example the patient just discussed, with multiple spinal metastases who could not walk, or any patient with widespread metastasis to lymph nodes or bones. Radical prostatectomy is chosen for patients with an expected lifespan of more than 10 years who are fit for surgery, with organ-confined or locally advanced disease; in oligometastatic disease, meaning up to three spots in the bones showing uptake on PSMA PET, we subject these patients to radical surgery as well. Orchidectomy is a form of androgen deprivation. Today it is hardly done in India, because androgen deprivation therapy is available as injections and now also as tablets, and it is reserved for stage 4 disease.

Question 6

What ultrasound findings differentiate chronic prostatitis from prostate cancer?

Dr. Shafiq Ahmed · Accepted Answer

Ultrasound can show anything in prostate cancer: about one third of lesions are isoechoic, and others hypoechoic or hyperechoic. Both prostatitis and cancer can show increased blood flow, but on Doppler chronic prostatitis shows uniformly increased vascularity across the whole prostate, whereas in prostate cancer it is confined to one specific point, such as a nodule. However, ultrasound is not used on its own to decide between the two. The decision rests on clinical judgement, the PSA value and age: chronic prostatitis is a disease of young, sexually active men in their 40s and early 50s, while prostate cancer is a disease of old age. If a 60 to 65 year old man presents with a PSA of 10 and urinary symptoms, I would diagnose BPH, keep a suspicion of prostate cancer and evaluate him accordingly.

Question 7

Can tumour lysis syndrome occur at the start of radiotherapy?

Dr. Shafiq Ahmed · Accepted Answer

Yes. Tumour lysis syndrome can happen in any tumour, and the majority of cases are in solid tumours; it is most often seen with chemotherapy in fast-growing, bulky cancers such as high-grade lymphomas and acute leukaemias, and it has been reported after radiotherapy. It is not specific to prostate cancer.

Question 8

Is orchidectomy chosen because it costs less than androgen deprivation drugs, rather than only because those drugs are unavailable?

Dr. Shafiq Ahmed · Accepted Answer

Orchidectomy is certainly a cost-effective, one-time procedure that achieves androgen deprivation with certainty, and in my experience it is rather superior to injectable treatment. At the same time, health insurance is becoming widespread in developing countries, helping patients afford the medications. For a man, losing the testes has a real psychological impact, so if a patient can afford it or the treatment is available, androgen deprivation therapy by injection or tablets is preferable. Orchidectomy remains a well-accepted procedure for patients with stage 4 disease.

Live Discussion with Dr. Shafiq Ahmed