Reproductive · Year 2 · from Reproductive
Case 3: Prostate Cancer
Clinical Image
Source: Wikipedia - Prostate cancer - CC BY-SA 4.0
Case Presentation
A 62-year-old African American male presents for routine health maintenance. He has no urinary symptoms. Family history is significant for prostate cancer in his father, diagnosed at age 65. Digital rectal examination reveals a firm nodule in the right posterior lobe of the prostate. PSA is 8.2 ng/mL (elevated). Given the abnormal DRE and elevated PSA, the patient is referred for multiparametric MRI of the prostate, which shows a PI-RADS 5 lesion in the right peripheral zone. MRI-fusion targeted biopsy reveals Gleason 4+3=7 (Grade Group 3) adenocarcinoma involving 4 of 12 cores, with 60% tumor involvement in the most affected core. Staging workup with CT abdomen/pelvis and bone scan shows no evidence of metastatic disease. After multidisciplinary discussion and shared decision-making, the patient elects to undergo robot-assisted radical prostatectomy. Surgical pathology confirms pT2c disease (bilateral involvement) with negative surgical margins. Post-operative PSA is undetectable. The patient is counseled about expected side effects including temporary urinary incontinence and erectile dysfunction, with discussion of rehabilitation strategies.
Key Learning Points
- Prostate cancer most commonly arises in the peripheral zone (palpable on DRE), in contrast to BPH which develops in the transition zone
- African American ancestry is associated with 2-3 times higher prostate cancer incidence and mortality; family history also increases risk
- Gleason grading assesses cancer aggressiveness; the primary pattern is more significant (4+3 is worse than 3+4)
- Treatment options for localized disease include active surveillance (for low-risk), radical prostatectomy, and radiation therapy, with choice based on disease characteristics and patient factors