Nonmetastatic CRPC: Initial Diagnostic Workup

Julie Graff, MD:Here we have a 66-year-old retired African American man who presents to his doctor with difficulty urinating (reduced urinary flow) and hematuria. His past medical history includes hypertension. For that, he takes enalapril, 10 mg a day.

The patient’s father had lung cancer at the age of 73. The patient undergoes a blood test and is found to have a PSA of 9.8 ng/ml. He has a biopsy of his prostate that shows Gleason 4 + 3 adenocarcinoma.

The patient opts to go through with a robotic-assisted radical prostatectomy with pelvic lymph node dissection. His report shows that he has pT3b disease with focal extracapsular extension but negative margin. He does have lymph node involvement, but he does not have metastatic disease. His postsurgical PSA is 0.64 ng/dl. The patient undergoes adjuvant radiation therapy alongside leuprolide acetate, and his PSA drops to undetectable levels.

In January of 2014 we have a patient who’s an African-American male, retired, who presents with difficulty urinating, decreased urinary stream, as well as hematuria. His past medical history includes hypertension for which he takes enalapril 10 mg a day.

So, this is the case of a man who’s African American and has at least an intermediate risk of prostate cancer based on his Gleason score of 7. Pathologically, he has an increased risk for cancer recurrence based on his positive lymph node involvement. And indeed, after the surgery, he has a residual PSA. So clearly, the surgery didn’t remove all of the disease. He undergoes adjuvant radiation therapy alongside leuprolide acetate in an attempt to cure his cancer in case some of the cancer is left over in the pelvis. However, you can’t tell if it has been cured unless you withdraw the leuprolide acetate and see if the PSA remains undetectable or not.

In the United States, most prostate cancer is found localized. This is in part because of screening with the PSA. However, that has been controversial lately, and we’ve seen patients presenting a little later in their disease course. If someone presents to the clinic with hematuria or difficulty urinating, the PSA is no longer a screening test. In this situation, it’s actually a diagnostic test. The patient’s presentation of prostate cancer is pretty classic for someone who comes to the clinic because of symptoms and doesn’t have prostate cancer detected by PSA.

I agree with the initial testing done in this case. The first part was checking a PSA, which was clearly elevated. The second part was doing a biopsy. Both of those are very appropriate.

The initial treatment, in this case, seems reasonable to me. There’s some debate over starting with surgery versus starting with radiation. But it’s not entirely clear which way is best. So, I’m in support of what was done here.

Once ADT is started, I see the patient every 3 months. In my clinical practice, I give leuprolide shots, 22.5 mg, every 3 months, and I check in with the patient each time. If a patient’s really anxious about the side effects though, I might see him a month after starting just to check in. But typically, this is done every 3 months.

Transcript edited for clarity.

January 2014

• A 66-year old retired African American male presents with reduced urinary flow and hematuria.
• PMH: High blood pressure. Currently taking enalapril 10 mg.
• FHx: Father lung cancer — age 74.
• Patient walks 3 miles a day.
• PSA 9.8 ng/ml
• Prostate biopsy shows Gleason 7 (4+3) prostate cancer
• Undergoes robotic-assisted laparoscopic prostatectomy (RALP) and pelvic lymph node dissection (PLND)
• Results show:
  • pT3b (focal extracapsular extension and seminal vesicle invasion) — margins negative
  • N1
  • M0
• Post-operative PSA=0.64 ng/ml
• Patient undergoes adjuvant radiation therapy and is started on leuprolide acetate.
• PSA drops to undetectable levels

January 2016

• PSA starts to rise to 0.3 ng/ml
  • Repeated 3 months later — 0.7 ng/ml
  • Bone scan and prostate-specific membrane antigen (PSMA) scan both negative
  • Diagnosis nonmetastatic castration-resistant prostate cancer (CRPC)
  • Patient declines additional therapy at this time

November 2017

• PSA continues to rise over the next 18 months going up to 9.8 ng/ml
• Bone scan shows lesion in the left superior pubic ramus
• Patient is asymptomatic