Judd W. Moul, MD, FACS: Options to Control Recurrent Metastatic Disease

CASE 2: Metastatic Castration Resistant Prostate Cancer (mCRPC)

Frank B. is a married, 69-year-old real estate attorney from Lancaster, Pennsylvania. He also works as a part-time basketball coach and church volunteer.

His prior medical history is notable for hyperlipidemia, controlled with statins and diet

In February 2007, he underwent radical prostatectomy after presenting with a PSA of 19.7 ng/mL; patient was asymptomatic at the time of surgery

Pathologic evaluation of the radical specimen revealed prostate adenocarcinoma Gleason grade 7 (4 + 3), stage T3aN0M0

Following a biochemical recurrence in July 2012, the patient was initiated on ADT with depot leuprolide and bicalutamide

Within 6 months, his PSA reached a nadir of 0.4 ng/mL

ADT was associated with periodic hot flashes and erectile dysfunction, which were managed with vardenafil

In January of 2014, he was admitted to the hospital for moderate to severe back pain and spinal cord compression; his PSA at the time was 15 ng/mL, and his testosterone level was 37 ng/dL.

MRI revealed the presence of multiple abnormalities in the L1-L2 region; subsequent biopsy of these lesions was consistent with prostate adenocarcinoma

Palliative external beam radiotherapy was administered and ketoconazole was added to the patient’s ADT

Within 3 months, his PSA had declined to 9 ng/mL and patient is using NSAIDs for pain management

In December 2014, the patient’s PSA had again risen to 25 ng/mL; his testosterone level was 22 ng/dL.

Patient was asymptomatic, and MRI showed the spine lesions to be stable

He declines further treatment at the time due to his daughter’s upcoming wedding in December

Pain is managed sufficiently with NSAIDs

In February 2015, he presents to his oncologist with increasing PSA and worsening performance status (PS2); his back pain is no longer sufficiently controlled by NSAIDs.