BPH Treatment and Cancer Risks in Older Patients

Q: BPH Treatment and Cancer Risks in Older Patients

Hello： 1. The PSA level has been elevated for over two months due to surgery. While surgery and inflammation can cause an increase, it should generally decrease. If inflammation is present, it should be well-managed. Additionally, what is the current stage of

Treatment for Benign Prostatic Hyperplasia (BPH)

Hello Doctor: My father is 70 years old.
At the end of last year, he was referred to a major hospital due to elevated PSA levels and urinary difficulties detected at a clinic.
The doctor recommended laser surgery to treat benign prostatic hyperplasia (BPH) and performed cancer screening on the tissue samples to avoid the need for a biopsy.
He has BPH with lower urinary tract symptoms and a serum PSA level of 10.514.
During the surgery, the physician assessed a high likelihood of benign conditions; however, post-examination of the tissue revealed 5% of atypical cellular nodular hyperplasia.
The submitted specimen consisted of fragments of prostate tissue, with the largest measuring 0.9 x 0.4 x 0.2 cm and a total weight of 12.0 grams in fresh condition.
The fragments appeared brownish and elastic.
All sections were taken and labeled A to D.

Microscopic description: The sections showed fragments of prostate tissue with glandular components and their fibromuscular stroma exhibiting nodular hyperplasia.
Several closely arranged atypical glandular lesions were also present (17 chips).
Special staining: Immunohistochemical staining was performed using antibodies against 34 betaE12 (high molecular weight cytokeratin), p63, and p504s.
The atypical glands did not show immunoreactivity to 34betaE12 and p63 antibodies but did show immunoreactivity to p504s antibody.

Comment: Consideration of adenocarcinoma, Gleason score 3 + 3 = 6 (grade group).
Follow-up arrangements for bone scan and CT scan indicated no issues during the report review.
My father heard that PSA levels should decrease after surgery, so he requested another blood test, but the result showed PSA still at 10.4.
The doctor indicated that there might be cancer cells in the peripheral area of the prostate that were not removed and recommended a complete surgical resection as soon as possible.
However, my father just had laser prostate surgery two months ago, and his blood test showed a white blood cell count of 30-49, indicating ongoing inflammation, for which he is taking anti-inflammatory medication.
I would like to ask if the PSA test results at this time are accurate and whether they could be affected by inflammation and the fact that he has not yet fully recovered from surgery.
Does the above examination report confirm the presence of cancer? Additionally, my father has five cardiac stents; is it appropriate for him to undergo a second surgery in the short term, or would other treatment methods be more suitable?

Xiao Ling, 40~49 year old female. Ask Date: 2023/04/18

Dr. Du Shixi reply Urology

Hello:
1.
The PSA level has been elevated for over two months due to surgery.
While surgery and inflammation can cause an increase, it should generally decrease.
If inflammation is present, it should be well-managed.
Additionally, what is the current stage of the tumor? This is crucial for determining treatment options.
Has the physician provided any clarification on this?
2.
A Gleason score of 6 is generally considered favorable, but treatment should be initiated.
3.
It is advisable to discuss the suitability of a radical prostatectomy with the primary physician.
This decision should be based on a comprehensive assessment of the patient's overall health, age, and the grade and stage of the prostate cancer, along with the patient's preferences.
Given the presence of a cardiac stent, evaluations from cardiology and anesthesiology are necessary.
Furthermore, a radical prostatectomy may lead to issues with sexual function and urinary control (temporary or permanent incontinence), so the patient should also consider these potential impacts.
4.
Other treatment options should also be considered: If the risks of a radical prostatectomy are deemed too high for the patient, or if the patient is averse to the side effects of surgery, alternative treatments such as radiation therapy and hormone therapy may be considered, depending on the stage of the cancer.
It is recommended to have further discussions with the physician to better understand the father's condition and treatment options.

Reply Date: 2023/04/18

More Info

When considering the management of Benign Prostatic Hyperplasia (BPH) and the associated risks of prostate cancer in older patients, several factors must be taken into account, especially in the context of your father's recent medical history and current health status.

Firstly, it is important to understand that BPH is a common condition in older men, characterized by an enlargement of the prostate gland, which can lead to urinary symptoms such as difficulty urinating, increased frequency of urination, and nocturia. The management of BPH often involves lifestyle changes, medication, and in some cases, surgical interventions like laser therapy, which your father underwent.

In your father's case, the elevated PSA (Prostate-Specific Antigen) level of 10.514 ng/mL is concerning, as normal PSA levels are typically below 4 ng/mL. Elevated PSA can indicate the presence of prostate cancer, but it can also be influenced by other factors such as inflammation, infection, or recent procedures like surgery. The fact that your father had a laser procedure just two months ago could certainly affect the accuracy of the PSA test results. Post-surgical inflammation can lead to transient increases in PSA levels, which may not necessarily indicate cancer progression. Therefore, it is crucial to interpret the PSA results in the context of his recent surgery and current inflammatory state.

The biopsy results showing 5% atypical glandular proliferation and a Gleason score of 3+3=6 suggest a low-grade prostate cancer. While this indicates the presence of cancerous cells, the low Gleason score suggests that the cancer is likely to be less aggressive. However, the presence of atypical glands raises the concern for potential progression, which is why your father's healthcare provider is recommending further intervention.

Regarding the recommendation for a radical prostatectomy (complete removal of the prostate), this is often considered when there is a significant risk of cancer progression or when cancer is detected in the prostate tissue. However, given your father's age (70 years) and the presence of multiple cardiac stents, the risks associated with undergoing another surgical procedure must be carefully weighed against the potential benefits. Surgical risks in older patients, especially those with cardiovascular issues, can be higher, and the recovery may be more complicated.

In terms of alternative treatment options, if surgery is deemed too risky, there are other management strategies available. These may include active surveillance, where the cancer is monitored closely without immediate treatment, or hormone therapy, which can help manage cancer growth by reducing testosterone levels. Additionally, radiation therapy is another option that can be considered, especially if surgery poses significant risks.

Ultimately, the decision regarding the next steps should involve a thorough discussion with your father's healthcare team, including a urologist and possibly an oncologist. They can provide insights into the risks and benefits of each treatment option, considering your father's overall health, the characteristics of the cancer, and his personal preferences. It is also essential to monitor his PSA levels over time to assess any changes that may indicate the need for further intervention.

In conclusion, while the presence of atypical cells and elevated PSA levels raises concerns for prostate cancer, the recent surgical intervention and current inflammatory state must be considered when interpreting these results. A multidisciplinary approach involving careful monitoring and consideration of all treatment options will be crucial in managing your father's condition effectively.

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