What is the recommended management plan for a patient with a history of localized prostate adenocarcinoma (PROSTATE cancer), treated with radiotherapy, and in remission, with recent cystoscopy results showing no bladder cancer, but with a history of focal nodular hyperplasia and normal phenotype fatty liver disease?

Management Plan for a Patient with Treated Prostate Cancer and History of Focal Nodular Hyperplasia

For a patient with localized prostate adenocarcinoma in remission after radiotherapy, with normal laboratory values, negative FIT test, and history of focal nodular hyperplasia and fatty liver disease, the recommended management is active surveillance with regular PSA monitoring and annual digital rectal examination. 1

Follow-up Protocol for Prostate Cancer in Remission

PSA Monitoring

• PSA should be measured every 3-6 months for the first 2 years after radiotherapy, then annually thereafter 1
• Following curative radiotherapy, PSA should reach 1 ng/ml within 16 months 1
• Rising PSA or adverse PSA doubling time should trigger further investigation 1

Physical Examination

• Digital rectal examination should be performed at each follow-up visit to assess for local recurrence 1
• Special attention should be paid to the prostate and bladder neck area given the history of radiation effects noted on cystoscopy 1

Imaging Considerations

• Routine imaging is not required in the absence of PSA elevation or concerning symptoms 1
• If PSA rises, consider multiparametric MRI before repeat biopsy 1
• For patients with rising PSA after treatment, molecular imaging (PSMA-PET) may be considered if conventional imaging is negative 1

Management of Focal Nodular Hyperplasia and Fatty Liver

Focal Nodular Hyperplasia

• FNH is a benign condition that typically requires no specific treatment or intervention 2
• No evidence suggests FNH is premalignant, and asymptomatic FNH can be left untreated without risk 2
• Routine follow-up with ultrasound every 1-2 years is reasonable to monitor stability 3, 4

Fatty Liver Disease

• Monitor liver function tests annually 3
• Encourage lifestyle modifications including:
  • Weight management if overweight
  • Regular physical exercise
  • Limited alcohol consumption
  • Balanced diet low in processed foods and sugars 3

Bladder Monitoring Post-Radiation

• Given the history of radiation to the prostate area and cystoscopy findings showing "mild indentation of prostate into bladder neck," annual assessment of urinary symptoms is recommended 1
• Repeat cystoscopy is not routinely required unless there are new urinary symptoms or hematuria 1

Special Considerations

Radiation-Related Effects

• Radiation effects on the bladder neck are common after prostate radiotherapy and typically don't require intervention unless symptomatic 1
• Monitor for late radiation toxicity to bladder and rectum, which should be less than 5% at 2 years 1

Exercise Recommendations

• Regular exercise should be encouraged as it reduces fatigue and improves quality of life in men who have undergone treatment for prostate cancer 1

When to Consider Further Intervention

• If PSA begins to rise, calculate PSA doubling time; a doubling time <10 months suggests more aggressive disease 1
• Early salvage radiotherapy (if not already maximally radiated) should be considered for biochemical recurrence, ideally when PSA is <0.5 ng/ml 1
• Early hormonal therapy is not routinely advised for PSA relapse but is an option for those with short PSA doubling time (<3 months) 1

This management plan prioritizes monitoring for prostate cancer recurrence while acknowledging the benign nature of the patient's focal nodular hyperplasia and fatty liver disease, which require minimal intervention in the absence of symptoms or progression.