CME INFORMATION

FACULTY AFFILIATIONS AND DISCLOSURES

Case Studies

Case 1 from the practice of Atif M Hussein, MD: A 71-year-old man treated in 1999 with external-beam radiation therapy (EBRT) for Gleason 7 adenocarcinoma of the prostate. Post-EBRT PSA nadir was 0.2, but it rose to 6.7 by 2001, at which point leuprolide was initiated, resulting in a PSA decline to 3.1. In 2003 his PSA level began rising and, despite the addition of bicalutamide, increased to 80 with bone scan evidence of multiple metastases. He received a second round of EBRT, six cycles of docetaxel with prednisone and zoledronic acid with continuation of leuprolide (presented to Dr Anthony V D’Amico, Dr Laurence Klotz and Dr Daniel P Petrylak).

Case 2 from the practice of Srinath Sundararaman, MD: A 54-year-old man diagnosed with synchronous rectal (T3N1M0) and prostate (T2aNxM0, Gleason 7) carcinomas in 2002. He was treated with neoadjuvant capecitabine, leuprolide and pelvic radiation therapy and underwent an APR with subsequent reanastomosis. After surgery, he received a seed implant boost to the prostate bed, adjuvant capecitabine and was maintained on leuprolide for two years. He returned for follow-up in 2005 with a PSA level of 9 associated with a nine- to 10-month doubling time (presented to Dr D’Amico, Dr Klotz and Dr Petrylak).

Case 3 from the practice of Benjamin M Tripp, MD: An 82-year-old man who presented five years earlier with a PSA level of 158, a 265-g prostate and 18 benign biopsies. Finasteride was initiated. A bone scan performed soon thereafter was diffusely positive, but 16 additional biopsies and TURP tissue were negative for adenocarcinoma. Rib biopsy showed metastatic, poorly differentiated prostate cancer. He received combined androgen blockade (bicalutamide and leuprolide) with zoledronic acid. His PSA nadired at 0.1, but six months later it rose to 15.4. After a short biochemical response to bicalutamide withdrawal, his PSA level resumed its climb, indicating androgen-independent prostate cancer (presented to Dr D’Amico, Dr Klotz and Dr Petrylak).

Case 4 from the practice of Martin K Dineen, MD: A 66-year-old man with a PSA level of 7 was diagnosed with Gleason 6 prostate cancer and treated with EBRT in 1996. He enrolled in a clinical trial, received high-dose adjuvant bicalutamide for two years and did well until the sixth year postdiagnosis, when his PSA level rose from undetectable to 2.2 within a 12-month period. After a positive TRUS biopsy of the prostate bed, whole-gland salvage cryoablation was performed. 18 months later, his PSA level began to rise and he received an LHRH agonist, to which he has experienced a durable response with a continuous undetectable PSA level (presented to Dr D’Amico, Dr Klotz and Dr Petrylak).

Case 5 from the practice of Michael A Simon, MD: A 61-year-old man who underwent a nerve-sparing radical prostatectomy revealing pT2 Gleason 6 prostate cancer with negative nodes and margins. He presented three months postoperatively with a PSA of 0.7, rising to 0.9 four weeks later. Systemic disease workup was negative, with the exception of an incidental 3-cm kidney mass suspicious for renal cell carcinoma. Salvage EBRT was initiated to address any residual local disease, resulting in a PSA decline to 0.6 (presented to Dr D’Amico, Dr Klotz and Dr Petrylak).

Case 6 from the practice of Alan M Nieder, MD: An 81-year-old man, status-post radical prostatectomy 20 years prior, presented with a PSA of 12 and a nine-month doubling time. Physical examination, CT scan and bone scan results showed no clinical evidence of metastatic disease. The patient was started on LHRH agonist monotherapy and had an undetectable PSA within three months of the first injection (presented to Dr Judd W Moul and Dr William K Oh).

Case 7 from the practice of James A Reeves, MD: A 48-year-old man presented with a PSA level of 9 and a normal digital rectal exam. Prostate biopsy showed nine of 12 positive cores with bilateral evidence of Gleason 6 and 7 adenocarcinoma with no evidence of perineural invasion. Bone and CT scans were negative for metastatic disease, and he elected to undergo radical prostatectomy (presented to Dr Moul and Dr Oh).

Case 8 from the practice of Joseph F Pizzolato, MD: A 74-year-old man with a history of radical prostatectomy and continuous postoperative antiandrogen therapy since 1994 recently presented with a rising PSA (nine-month doubling time) and diffuse skeletal metastases. He received radiation therapy for impending spinal cord compression and then began a trial of ketoconazole. His PSA level of 75 quickly rose to 120 in the presence of increasing hip pain. He enrolled on the CALGB-9401 clinical trial and initiated docetaxel with a randomization to bevacizumab versus placebo. His PSA level dropped to 17, and interim scans show evidence of disease improvement (presented to Dr Moul and Dr Oh).

Case 9 from the practice of Raul Ravelo, MD: A 51-year-old asymptomatic man presented with a PSA level of 57.6. Biopsy revealed high-volume, Gleason 7 prostatic adenocarcinoma with perineural invasion. Bone and CT scans showed no evidence of metastatic disease. He underwent radical prostatectomy, which revealed approximately 90 percent infiltration with tumor, positive surgical margins and extraprostatic adipose tissue invasion (presented to Dr Moul and Dr Oh).

Case 10 from the practice of Dr Hussein: A 61-year-old man with a history of symptomatic, surgically managed Crohn’s disease presented with a rise in PSA level from 2.3 to 6.1 over a one-year span. Prostate biopsy revealed Gleason scores of 8 and 9 in five of 12 cores. While seeking multiple treatment opinions, he received four doses of monthly leuprolide. He ultimately underwent a radical prostatectomy, which revealed seminal vesicle involvement, 12 negative lymph nodes and negative surgical margins. His two-month postoperative PSA level was undetectable (presented to Dr Moul and Dr Oh).