Week 6 Discussion Question A Risk management is a matter of identifying the situations that could cause your project to fail. Common risks include loss of staff, decreased funding, decision point approvals not completed in a timely manner, and content not being available. Brainstorm three or four other risks that you have seen in your professional experience. If you are having trouble identifying projects, brainstorm with your classmates or contact your instructor.Once you have 3-4 risks, identify at least two ways to prevent each and two ways to resolve them, if they happen in spite of your preventions. Post your ideas. Question B How does the Work Breakdown Structure (WBS) help to minimize risks? How often should a risk analysis be conducted? Why are risks often overlooked? 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 a.

1. Week 6 Discussion
Question A
Risk management is a matter of identifying the situations that
could cause your project to fail. Common risks include loss of
staff, decreased funding, decision point approvals not completed
in a timely manner, and content not being available. Brainstorm
three or four other risks that you have seen in your professional
experience. If you are having trouble identifying projects,
brainstorm with your classmates or contact your instructor.Once
you have 3-4 risks, identify at least two ways to prevent each
and two ways to resolve them, if they happen in spite of your
preventions. Post your ideas.
Question B
How does the Work Breakdown Structure (WBS) help to
minimize risks? How often should a risk analysis be conducted?
Why are risks often overlooked?
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

2. 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

3. 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

4. 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).
In image
9- Case study and clinical presentation A previous fit and well

5. 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.
image
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.
image
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

6. 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.
13- image
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

7. 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)
16- image
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

8. T3N1M1b
T3 Tumour extends outside prostate N13 Metastases in regional
lymph nodes M15 Bon's metastases (Wittekind et al, 2014)
17- image
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)

9. 18- image
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).
19- image
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

10. 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).
20- image
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

11. in detection of zonal prostate cancer, due to its higher spatial
and contrast resolution