Paraphrase

22 May Paraphrase

1-Today I am going to talk to you about prostate cancer. The purpose of my presentation is to discuss the role of diagnostic imaging in prostate cancer patient. I will start my presentation by introducing the condition of the pathology, then I will mention the general symptoms, investigation staging and treatment of the condition. Then I will focus on the patient case study pathway. Finally, I will summarise my presentation and I will give you time for questions after the presentation.

2- Prostate cancer is a fatal disease that affects millions of men worldwide every year. Its clinical behavior ranges from low grade tumours that never develop to aggressive tumours those growths into metastases disease (Johnson et al, 2014). The cause of the disease has not been found, but several related risk factors have been known, such as genetics, age and diet. Prostate cancer is the highest prevalent non-skin malignant tumors diagnosis in male patients in the UK, accounting 24% of entirely new cancers. The main prospect of developing prostate cancer is related to advancing age, that has been seen diagnoses occurring in men over the age of 65 and is rare in those 40 years of age (Stephens et al, 2008)

3- prostate gland is a walnut’ sized structure which located between the penis and the bladder and surrounds the urethra, just lies posteriorly to rectum. It has functional relation with urinary and reproductive systems and its main role is to produce the liquid part of semen. Prostate gland divided into three distinctive anatomic zonal components: the central zone, transitional zone and the peripheral zone which compromises 70% by volume (Tempany & Franco, 2012).

4- The preponderance of prostate cancers is adenocarcinomas that initially derived from the outer or peripheral zone of the prostate gland. In early stage, prostate cancer hardly shows symptoms and is mostly diagnosed by fortunate PSA test, but overtime patient may present to clinic with lower urinary tract symptoms such as: trouble starting urine, pain during urination, increased urgent of urination, poor stream, erection trouble so on (Wijesinha & Fridenberg, 2007)

5- The initial tests for diagnosing prostate cancer are a Prostate Specific Antigen (PSA) blood test and a Digital Examination (DRE). Prostate Specific Antigen (PSA) is a molecule of carbohydrate and protein which produces by of prostate with high absorptions in the seminal fluid. Its main purpose is to retain semen fluid state and able to help to move around. PSA is measured in blood. amount of PSA Small level in blood is normal; however a high level of Prostate specific Antigen (PSA) in blood is a likely indicator of prostate cancer but this should be done combined with Digital Rectal Exam (DRE) as PSA level can raise by other factors, for instance u infection. Digital Rectal Examination (DRE) is an examination of pelvic organs wher a doctor puts a finger into patient’s back passage to detect abnormality in the prostate gland (Lynch & Burgess, 2011). maging has massive role in detection, localizing, grading and staging of prostate cancer Plain images are well known for the investigation of sclerotic bone lesions, mainly in metastatic prostate cancer. Computed tomography is also used to discover the spread of cancer within pelvis and SPECICT has significant advantage in revealing the anatomical and functional aspect of the bone. Particularly, magnetic resonance has important tool to distinguish the cancer in the zonal component of the prostate (Mcardle O’mahony, 2008).

6- once the cancer has detected TRUS guided biopsy will carry out to help grade or stage the cancer. Trans Rectal ultrasound biopsy is an ultrasound guided biopsy. It contains a sample of prostate tissue to be examined under a microscope. The biopsy is done through the rectum; patient will have local anesthetic to avoid any discomfort. The prostate cancer in the biopsy sample will give Gleason grade by the doctor according the cells form under a microscope (swallow et al, 2012). “There will be more than on grade cancer in the biopsy sample therefore a total Gleason score is worked out by adding together two Gleason grades. The first is the most common grade in all the samples. The second is the highest grade of what’s left. when these two grades are added together, the total is called the Gleason score. Gleason score the most common grade the highest other grade in the samples” (Bone camp et al, 2011). The higher the Gleason score, the more the aggressive the cancer is A Gleason score suggests that the cancer is slow-growing, 7 indicate that the cancer grow at a moderate rate, and 8, 9 or 10 imply that the cancer may grow rapidly (Prostate Cancer UK, 2014). “Prostate cancer staging is recorded by the method of TNM (Tumour-Nodes- spread in and around the prostate, The N Node) stage shows if the cancer has spread to the lymph nodes, and the M (Metastases) stage shows whether the cancer has spread to other parts of the body such as bones” (Wittekind et al, 2014). According to the TNM classification system prostate cancer grouped in to four stages: Stage I: Cancer is described within the prostate only and this cannot be discovered during the Digital Rectal Exam (DRE), can be found during other medical procedures. Stage (A & B): A small tumour that can be felt during the DRE procedure and the cells are abnormal. The tumour has developed in to both parts of the prostate gland Stage Ill: The cancer has spread outside of prostate outer layer. Stage IV: The cancer has spread to other parts of the body such as bone, lymph focus on case nodes (Cancer Net, 2014).

8- According to Ramon & Denis (2007), the choice of prostate cancer treatments should include different factors into account. For instance, age, the stage and grade of the cancer, side effects and life expectant are vital indications for treatments of prostate cancer. Common primary options of treatment for patients with prostate cancer are: Watchful waiting: It is a treatment strategy to delay the treatment until it is required. Watchful waiting treatment used with patient who do not show up any symptoms or with patient’s who do not accept treatment related side effects. Prostatectomy: A medical term for surgical removal of the prostate gland. It is a standard treatment for patient’s life expectant for more than 10 years. Radiation therapy: used for lymph node involvement cancer with patient’s life expectancy more than 10 years. Hormone therapy: used for advanced or metastases prostate cancer, symptomatic patient’s. Chemotherapy: used when the hormone therapy doesn’t work or used combined with radiotherapy treatment Most health professionals use the 5-year prostate cancer survival rate method to discuss patient’s prognosis. The five-year prostate cancer survival rate is based mainly on people who had treated the disease previously. According to recently research data: survival rate for local stage and regional stage cancer are almost 100%, whereas for distant stage cancer is 28% (American Cancer Society, 2014).

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9- Case study and clinical presentation A previous fit and well 62-year-old African-British man is presented to his GP complaining of back pain and urinating problem. Initially, the nurse carried out urine test on patient, the dipstick urine test revealed negative result. Then GP asked for PSA test. PSA test displays a high level of PSA in the patient’s blood which was 20ng/ml ITurner et al, 2013. Patient was in NSADs treatment for his back pain.

previously fit and well 62-year-old African- British man presented to his General Practitioner (GP) with back pain and urinating problems. Initially, the nurse carried out urine test on patient, the dipstick urine test revealed negative result. Then GP asked for PSA test. Prostate Specific Antigen (PSA) test displays a high level of PSA in the patient’s blood which was 20ng/ml (Turner et al, 2013 Patient was in Nonsteroidal ant-inflammatory drugs (NSADs treatment for his back pain.

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10- Digital Rectal Examination The GP carried out DRE exam (Philippou et al, 2014 Patient’s prostate was larger and harder than normal. Patient diagnosis with T3 Prostate tumour. Patient referred to a urology specialist for biopsy test.

To help for the next stage, the General Practitioner carried out Digital Rectal Examination (DRE). On rectal examination the result revealed that patient has had stage T, prostate tumour (Philippou et al, 2014). The patient was referred to the urology department for further biopsy test to find out the grade of the cancer.

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11- Trans rectal ultrasound biopsy Patient had TRUS guided prostate biopsy swallow et al, 2012). Patient diagnoses with Gleason score 9 (5+4) The higher the Gleason score is, the more aggressive the cancer (Prostate cancer UK,2014)

Trans rectal ultrasound biopsy ( TRus) is only carried out cancer is suspected as a result of a raised Prostate specific Antigen (PSA) test The prostate biopsy result discovered that patient was diagnosis with Gleason score 9 (5+4), which is a higher risk of tumour growing to help reach the bottom line of the cancer condition. patient booked for MRI scan to assess the progress of the lesion.

12- The radiology request card was generated. Prior to the MRI scan, as an MRI protocol, patient filled out MRI safety questionnaire. Patient has not had any complications with contrast, no history of metal implant and consent was obtained.

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Radiographic imaging

MRI of 1.5T field strength was used and T and Ta weighted (W) sequences was requested T weighted image was obtained to detect for post biopsy haemorrhage. Ta weighted image was used to localise the tumour (Akin & Hricak, 2007).

MRI of 1.5T field strength was used and T1 and T2 weighted (w) sequences was requested. MRI of the prostate requires the use of an anorectal coil and phased array body coil. T1 weighted image for the entire pelvic is used for the detection of post biopsy haemorrhage. T2 weighted image is obtained for localising and staging the tumour (Akin & Hricak, 2007).

14- MRI has limitation on identifying lymph nodes; this is due to the microscopic character of nodal metastases. However, the use of “lympho-tropic ultra-small superparamagnetic particles of iron-oxide (USPIO)” as contrast media will help to detect the nodal metastases, mainly from the uptake of the iron-oxide contrast on the lymphatic nodes (Pinto et al, 2012).

Patient had ultrasmall superparamagnetic iron-oxide IV contrast media (Ferumoxtran- 10) prior to his scan, intravenously by slow drip infusion. Scan time: 24 hours’ delay, MR lymphangiography (MRL). After IV injection, the contrast particles force out from vascular to interstitial space then moved to lymph nodes via lymphatic vessels. Scan method: 5mm slice; T2 weighted gradient echo sequence, echo time of (ET 18ms. On the MRI image (Fig 1), the normal lymph nodes appeared dark due to the uptake of iron oxide particles within the contrast, while the cancerous nodes remain hyper intense in T2 weighted image (arrow), this is due to the lack of physiological uptake of the cancerous cells (Barentsz et al, 2007). The T2 -W image is shown that the cancer has spread to the regional lymph nodes (N1)

15- Bone scintigraphy is a nuclear imaging procedure to find deformities in bone, using small amount of radioactive material, commonly 99mTc-methylene diphosphonate P%mTc-MDP) as bone-imaging agent. Bone scintigraphy is the desirable modality for investigation bony metastatic of prostate cancer. The aim of 99mTc-methylene diphosphonate radionuclide agent is to identify skeletal pathological conditions such as tumour, metastases, infections and sites of skeletal trauma. ssmTechnetium mTc)- labelled diphosphonates rapidly absorbs in bone after injection, sites of abnormal bone shows increased uptake of these radio tracer agent due to rapid cell production in the area (Rajarubendra & Lawrentschuk, 2010). To improve interpretation of the abnormal noted uptake in bone scintigraphy, additional use of single-photon emission computed tomography (SPECT-CT images important because bone scintigraphy images are non-specific, which describes the general details of the skeleton where single-photon emission computed tomography (SPECT-C) combines the anatomical and functional technique which allows localising the lesion. The resultant images of SPECT-CT (Fig.2) are showing that the cancer has spread from patient’s prostate to surrounding bone (Soundararajan et al, 2013)

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Patient diagnosis After patient had broad examination test such as PSA test, DRE, TRUS guided biopsy, MRI scan, and SPEC-CT, patient diagnoses with stage Ill metastatic prostate cancer that is T3 N1 M1b

T3 Tumour extends outside prostate N13= Metastases in regional lymph nodes M1b= Bon’s metastases

After patient had broad examination test such as PSA test, DRE, TRUS guided biopsy, MRI scan, and SPEC-CT, patient diagnoses with stage lll metastatic prostate cancer that is T3N1M1b

T3 Tumour extends outside prostate N13 Metastases in regional lymph nodes M15 Bon’s metastases (Wittekind et al, 2014)

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Patient Treatment choice

Multidisciplinary team After 10-month chemo involved:

A specialists nurse, Urologist Oncologist Radiographer Patient Decision time No need prostatectomy First line of treatment is ADT Achieved by LHRH agonists. (Wilson et al, 2015).

effective working collaboration among health professionals is necessary to meet patients complex needs The inter professional team felt no need for prostatectomy as the cancer cells are already spread to the lymph and bones They decided Androgen deprivation therapy (ADT) alone for patient treatment Patient was involved in his treatment options and he accepted. ADP is the prime option of treatment for metastatic prostate cancer; these can be achieved using luteinising hormone- releasing hormone (LHRH) agonist (outhwarte 2013).

HRH works by inhabiting gonadotropin secretion from the pituitary gland as a result the production of sex steroid by testis will stop Prostate cancer is sex steroid dependant tumour stopping the testosterone from reaching the prostate cancer cells means the tumour will stop growing or t could shrink as well LHRH s highly dynamic therapy with solid tumour patient’s response rate above 90% at presentation LHRP a lifelong treatment for patient with metastatic disease and it doesn’t cure the condition but it has the ability to keep the disease under control been treated with LHRH agonist drug for 10 months initially, patient’s PSA level decreased he reacted well After 8 months treatment, patient suffered extreme sacral pain and his PSA level start to rise The MDT decided to combine chemotherapy with hormone therapy using docetaxel. After 8 cycle docetaxel treatment patient suffered life threatening disease Patient developed liver metastases increased hrs back pain and had anaemia. after 3 years’ treatment he has died as his body was resist to the medication (Wilson et al,2015)

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Side effect of treatment Feeling tired and weak Sexual dysfunction (Gilson et al, 2014) Hot flush and sweating Anemia Reduced bone mineral density (BMD) Bone fracture

Patient had complications related to his treatment such as anaemia, fatigue, felt tired, hot flushes and sweating. He was advised to eat iron rich diet and instructed to do some exercises during the treatment Patient had also regular screening of diabetes and cholesterol, and also measurements of bone mineral density (BMD) serum vitamin D and calcium levels were monitored to come over the complications (Gilson et al, 2014).

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Role of Imaging in patient management

· SPECT/CT

Assesses the anatomic al and functional condition of area the bone (Soundarajan et al, 2013)

· TRUS

Examine hypoechoic area

Ideal for TRUS guided biopsy (Harvey et al, 2012)

· Magnetic Resonance Imaging (MRI)

1 – Helpful for localising cancer within the prostate

2- Improves detection of transition zone cancer

3- Evaluates aggressiveness of the tumour (Jung et al, 2015)

· SPECT

Detect the pathologic condition of the skeleton

But images are non -specific

Trans rectal ultrasound is used to assess the hypoechoic area of the prostate, which is generally related to cancer but not precise enough for diagnoses purpose that is due to the inconstant appearance of the lesion on TRUS, However Harvey et al (2012) point out that ultrasound is a standard modality to guide biopsy for the microscopic diagnosis of prostate cancer (Harvey et al., 2012) SPECT is the desirable modality for investigation the pathological condition of the skeleton. However, Single Photon Emission Computed Tomography images are nonspecific that describes the general condition of the skeleton including infections, sites of skeletal trauma makes difficult to differentiate the cancer on the image. Castellucci al (2015) suggest for the combination of SPECT-CT fused images to overcome the problem of SPECT image interpretation. SPECT/CT images are more reliable because they combine the anatomical and functional images of the skeleton unlike the SPECT image only produces the general functioning of the skeleton. The majority prostate cancer found in the peripheral zone that positioned in the posterior side the prostate; however 25% to 40% of the prostate cancer also found in the transitional zone which located in the anterior. Logically for its anterior position, transitional zone prostate is difficult to detect by digital rectal examination and also poorly diagnoses by transrectal ultrasonography due to its heterogeneous appearance. MR sequences such as ‘dynamic contrast material enhanced MR imaging, diffusion weighted imaging (DF) and MR spectroscopic imaging have the potential to provide additional information for detection and characterization of zonal prostate (Jung et al, 2015).

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CONCLUSION

Early stage detection of the cancer based on clinical results: PSA test Gleason score Weakness regarding extension and location of the Cancer Imaging, inadequate in finding of small cancer Important role in Staging Follow-up Treatment MRI has the ability to differentiate the zonal anatomy of prostate.

Although the early stage of prostate cancer detection rely on the clinical examination results such as PSA test and the Gleason score, the ability to define the stage, location and size of cancer remains low. imaging modalities also have difficulty in detection of small volume cancer but plays important role in staging cancer to and aggressiveness of the cancer. MRI has the edge over identify the progress convectional and CT modalities in detection of zonal prostate cancer, due to its higher spatial and contrast resolution