Diagnosis of Stage 3 Prostate Cancer

Daniel J. George, MD:This case presentation involves a 65-year-old gentleman who presented to his urologist with some urinary incontinence. His digital rectal exam was normal, but he was found to have a PSA of 10.8 ng/mL. This prompted a transrectal ultrasound and a biopsy, revealing Gleason score 7 cancer, 3+4, and multiple cores. He underwent a workup with a bone scan and a CT scan, showing no evidence of metastatic disease, and was presented with treatment options for intermediate-risk prostate cancer. He elected to undergo radical prostatectomy, and pathology confirmed the Gleason score 7 cancer but with evidence of extra capsule extension in negative nodes, which is pathological T3aN0 disease. After surgery, his PSA was undetectable.

This is a very common presentation. The patient is about the average age for prostate cancer and, on his initial PSA screening, was found to have 10.8 ng/mL. Although the urinary incontinence doesn’t necessarily go along with common symptoms associated with prostate cancer, we can see it as a urinary obstructive symptom from overflow incontinence. This patient may have had an enlarged prostate and evidence of some urinary obstruction resulting in that incontinence.

His choice of treatment for intermediate-risk prostate cancer really comes down to either surgery or radiation forms. For somebody like this, if we treat him with radiation therapy, we might offer him an additional short course of hormonal therapy. For many men, surgery represents a very reasonable option and gives us the advantage of treating the urinary symptoms as well as his prostate cancer.

Continuing on with this case, the patient went about 2 years with an undetectable PSA, at which point in time, his PSA started to rise rapidly over a short period of time to about 35 ng/mL. He was referred to a medical oncologist for the further treatment of recurrent prostate cancer. He was worked up with a bone scan and a CT scan, which at the time were negative, and he was started on androgen deprivation therapy. He had a good initial response to androgen deprivation therapy, with his PSA declining to about 0.5 ng/mL, but over the course of less than a year, his PSA, again, began to rapidly rise.

During that period of time, he underwent a workup with a CT scan and a bone scan, at which point—when his PSA was around 15 ng/mL—he was found to have multiple new bony metastases in his spine, pelvis, femur, and rib cage on the bone scan. However, his CT scan confirming the bone metastases didn’t show any visceral disease or lymph node disease.

The patient was initially followed with just hormonal therapy. His PSA continued to rapidly rise, and 3 months later, it was up to about 145 ng/mL, at which point in time he began noticing some increased fatigue as well as some migratory bone pain. The patient opted for treatment with abiraterone and prednisone and was offered the additional treatment of radium-223, which he elected to do.

Over the course of his first 3 treatments of radium-223, his PSA declined significantly down to a level less than 10 ng/mL, while his ALP remained stable. He completed all 6 treatments of radium-223, at which point he underwent restaging with a CT scan and a bone scan, essentially showing stable disease with no new lesions identified in his bones. The patient tolerated therapy well overall, but he did have a little bit of grade 2 fatigue that was transient, as well as some grade 2 anemia.

In this case, the patient developed an undetectable PSA following radical prostatectomy for about 2 years, at which point his PSA began to rapidly rise. He did get worked up to show no clear evidence of metastatic disease on a bone scan and a CT scan, but remember, his prostate is removed. His primary is gone. He has, by definition, metastatic disease, whether it’s widely metastatic or it’s regional—we can’t really see by scanning at that point in time. But even with his PSA up to 35 ng/mL and his starting on androgen deprivation therapy, in my mind, this is a patient with metastatic disease—microscopic metastatic disease, if you will.

Transcript edited for clarity.

December 2012

• A 65-year old gentleman presented to a urologist with urinary incontinence
• Digital rectal examination was unremarkable
• Serum prostate-specific antigen (PSA) level of 10.8 ng/mL
• Transrectal ultrasound and biopsy revealed adenocarcinoma of the prostate gland with Gleason score 7(3 + 4)
• Bone scan and CT showed no evidence of metastasis
• The patient opted for radical prostatectomy; pathology confirmed Gleason 7 prostate cancer with evidence of extracapsular extension and negative nodes; pT3aN0
• Immediately following surgery, his PSA level was undetectable (<0.1 ng/mL)

December 2014

• Two years later the patient developed disease progression
  • PSA level increased rapidly to 15 ng/mL
  • He was asymptomatic
• He was referred to an oncologist by his urologist
• Bone scan and CT were negative
• He was started on androgen deprivation therapy and had an initial response of PSA decline to 0.5 ng/mL

December 2015

• Over the next year, his PSA level increased to 35 ng/mL
• Repeat imaging studies were done:
  • Bone scan showed multiple boney metastases in the spine, pelvis, ribs, and femur
  • CT scan showed no visceral or nodal disease
• Within 3 months his PSA level rose to 145 ng/dL and he began complaining of fatigue and pain
• He was started on abiraterone and prednisone
• Additionally, he opted for therapy with radium-223
• After 3 infusions of radium-223 his PSA declined to <10 ng/dL; ALP remained stable
• After 6 cycles of treatment, CT and bone scan confirmed stable disease with no new metastases
• The combination was generally well tolerated; the patient experienced grade 2 anemia and fatigue