Clinical case
64-year-old man with an elevated PSA
Objectives
- Interpret an elevated PSA and recognize that it is not equivalent to a diagnosis of cancer.
- Understand the usefulness of multiparametric MRI and the PI-RADS system to guide the biopsy.
- Interpret the result of a prostate biopsy: Gleason score and ISUP grade group.
- Identify localized, favorable intermediate-risk prostate cancer.
- Recognize the main treatment options: active surveillance in selected patients, radical prostatectomy and radiotherapy.
- Understand PSA follow-up after treatment.
Answer each question before seeing the information from the next stage.
Stage 1 · First visit
An elevated PSA at a check-up
A 64-year-old patient comes to the Urology department because of an elevated PSA found during a medical check-up.
Medical history:
Physical examination: digital rectal exam with a prostate of approximately 35 grams, regular surface, preserved consistency and no palpable nodules.
Laboratory:
Medical history:
- Controlled hypertension.
- No family history of prostate cancer.
- No previous surgeries.
- Good general condition.
- Estimated life expectancy over 10 years.
Physical examination: digital rectal exam with a prostate of approximately 35 grams, regular surface, preserved consistency and no palpable nodules.
Laboratory:
- Total PSA: 6.8 ng/mL.
- Previous PSA, 18 months earlier: 4.2 ng/mL.
- Urinalysis: normal.
Question 1
What is the most appropriate initial approach?
Stage 2 · Prostate MRI
Multiparametric MRI
The PSA is repeated four weeks later, with a result of 6.6 ng/mL.
A multiparametric prostate MRI is performed.
Findings:
A multiparametric prostate MRI is performed.
Findings:
- Prostate volume: 38 cm³.
- 12 mm lesion in the right posterolateral peripheral zone.
- Classification: PI-RADS 4.
- No evidence of extracapsular extension.
- Seminal vesicles unremarkable.
- No suspicious pelvic lymphadenopathy.
Question 2
What does finding a PI-RADS 4 lesion mean?
Question 3
What is the most appropriate next step?
Stage 3 · Biopsy result
Biopsy pathology
A targeted and systematic transperineal prostate biopsy is performed.
Pathology report:
The patient has a PSA of 6.6 ng/mL and a digital rectal exam with no nodules.
Pathology report:
| Parameter | Result |
|---|---|
| Diagnosis | Acinar adenocarcinoma of the prostate |
| Gleason | 3 + 4 = 7 |
| ISUP grade group | 2 |
| Gleason pattern 4 | 10% |
| Positive cores | 3 of 14 |
| Maximum involvement | 35% of one core |
| Intraductal carcinoma | Not identified |
| Cribriform pattern | Not identified |
Question 4
How is a Gleason 3 + 4 = 7 interpreted?
Question 5
How would you classify this patient's risk?
Stage 4 · Treatment decision
What do we offer the patient?
The patient returns to the office to learn about his treatment options.
He is in good general condition, exercises regularly and has no major comorbidities.
He is told that he has localized prostate cancer and that there are different treatment strategies.
He is in good general condition, exercises regularly and has no major comorbidities.
He is told that he has localized prostate cancer and that there are different treatment strategies.
Question 6
What is the most appropriate approach?
Question 7
Which of the following statements about radical prostatectomy is correct?
Stage 5 · Chosen treatment
After the decision
After receiving information about the benefits and risks of the different options, the patient decides to undergo a laparoscopic radical prostatectomy, based on personal preference.
The possible complications are explained, including urinary incontinence, erectile dysfunction, bleeding, infection and injury to neighboring structures.
The operation is performed without complications. The patient does well and is discharged from the hospital.
Final pathology:
The possible complications are explained, including urinary incontinence, erectile dysfunction, bleeding, infection and injury to neighboring structures.
The operation is performed without complications. The patient does well and is discharged from the hospital.
Final pathology:
- Acinar adenocarcinoma.
- Gleason 3 + 4 = 7.
- ISUP grade group 2.
- Tumor confined to the prostate.
- No seminal vesicle invasion.
- Negative surgical margins.
- Pathologic stage: pT2.
Question 8
What does it mean that the tumor is pT2?
Question 9
What follow-up is essential after a radical prostatectomy?
Stage 6 · Follow-up
Three months later
The patient returns for a check-up three months after surgery.
Results:
Results:
- PSA: <0.01 ng/mL.
- Urinary continence: uses an occasional pad.
- No postoperative complications.
- Continues with functional rehabilitation.
Question 10
What is the most appropriate interpretation?
A classmate asks you:
Final integration question
What is the main lesson of this clinical case?
Case completed
Final result
0/11
What does this case teach us?
- An elevated PSA is not a diagnosis: the elevation is confirmed and the individual risk is assessed before any treatment is indicated.
- Multiparametric MRI identifies suspicious lesions and guides the biopsy; PI-RADS 4 indicates a high probability of clinically significant cancer, but it is not a histologic diagnosis.
- The diagnosis requires histology: a biopsy targeted to the lesion, usually combined with systematic sampling, with a preference for the transperineal route when available.
- Gleason 3 + 4 = 7 corresponds to ISUP grade group 2. With a PSA below 10 ng/mL, a low percentage of pattern 4 and localized disease, the case has the features of favorable intermediate risk.
- In localized, favorable intermediate-risk cancer there are several options: active surveillance in very selected cases, radical prostatectomy and radiotherapy. The choice depends on life expectancy, the tumor, comorbidities and the patient's preferences.
- pT2 means a tumor confined to the prostate; the margins and the grade group provide prognostic information.
- PSA follow-up is part of the treatment: an undetectable PSA is a favorable response, but follow-up continues in the long term.
Key concepts for the exam
- Elevated PSA ≠ diagnosis of prostate cancer.
- PI-RADS ≠ histologic diagnosis.
- The diagnosis of prostate cancer requires a biopsy.
- Gleason 3 + 4 = 7 corresponds to ISUP grade group 2.
- Prostate cancer ≠ immediate surgery for every patient.
- pT2: tumor confined to the prostate.
- After radical prostatectomy, PSA is monitored.
Final pearl
Diagnosis and treatment must be based on an individualized assessment of risk, histologic findings and the patient's preferences.
References
- EAU Guidelines on Prostate Cancer
- National Cancer Institute: Prostate Cancer Treatment (PDQ, health professional version)
Teaching note: This case is fictional and designed for medical students. Treatment decisions are simplified for educational purposes; in practice they require individualized assessment and discussion of the available alternatives.