AKT · Renal & urology/Urological cancer & LUTS

Prostate cancer

Adenocarcinoma of the prostate (peripheral zone) — androgen-driven, commonly bone-metastasising

Overview

The commonest cancer in men, usually a peripheral-zone adenocarcinoma. Often indolent and detected via PSA/DRE, but can metastasise to bone (sclerotic lesions, back pain). Risk-stratified by PSA, Gleason/grade group and stage. Management ranges from active surveillance (low-risk) to radical treatment, with androgen deprivation for advanced/metastatic disease.

Recognise

Often asymptomatic (PSA/DRE-detected); LUTS, haematuria; advanced — bone pain, pathological fracture, spinal cord compression, weight loss
DRE: hard, irregular, nodular prostate (asymmetry, loss of median sulcus)
Bone metastases are SCLEROTIC (osteoblastic) and raise ALP; spinal metastases risk cord compression

Red flags

Metastatic spinal cord compression (back pain + neurology) → emergency MRI + dexamethasone + oncology
Bone pain/pathological fracture/hypercalcaemia → metastatic disease; severe symptoms with very high PSA

Differentials & how to tell them apart

Benign prostatic hyperplasiasmooth, non-tender prostate; PSA mildly raised; LUTS without nodule

Prostatitistender prostate, infection/pain, raised PSA acutely

Other bone-met primariesbreast/lung/kidney/thyroid — but prostate mets are characteristically sclerotic

Investigations

PSA (with counselling) + DRE; multiparametric MRI of the prostate BEFORE biopsy (NICE); transperineal/TRUS biopsy (Gleason/grade group); staging — bone scan, CT for high-risk disease; the diagnosis/grade/stage drive management.

Management

Risk-stratified: active surveillance (low-risk) → radical surgery/radiotherapy → ADT for advanced disease

1PSA + DRE, then multiparametric MRI before biopsy; biopsy for grade group and stage. Low-risk localised disease → active surveillance.Gate: Metastatic spinal cord compression (back pain + neurology) → emergency MRI, dexamethasone and oncology; a GnRH agonist needs anti-androgen cover to prevent tumour flare.
2Localised intermediate/high-risk → radical prostatectomy or radiotherapy (counsel incontinence/ED); advanced/metastatic → androgen deprivation therapy + bone-targeted treatment; manage complications.

Active surveillance — for low-risk localised disease — monitor PSA/MRI/biopsy, avoid over-treatment

Radical prostatectomy or radical radiotherapy (± brachytherapy) — for localised intermediate/high-risk disease; side-effects — incontinence, erectile dysfunction, bowel/bladder

Androgen deprivation therapy (GnRH agonist/antagonist, anti-androgen) — for advanced/metastatic disease; GnRH agonists need anti-androgen cover to avoid initial 'tumour flare'

Bone-targeted therapy + manage cord compression — bisphosphonate/denosumab; dexamethasone + radiotherapy/surgery for cord compression

Key points

Hard, irregular, nodular prostate ± raised PSA, with SCLEROTIC bone mets and a raised ALP = prostate cancer → mpMRI before biopsy, then risk-stratified treatment (active surveillance for low-risk). Watch for metastatic cord compression (dexamethasone + MRI). GnRH agonists need anti-androgen cover (flare).

Monitor & prognosis

PSA trend, treatment side-effects, metastatic complications (bone, cord).

Often indolent (low-risk excellent); metastatic disease is treatable but not curable.

Source: NICE NG131 (prostate cancer); cross-ref MSK/acute_care (cord compression)