Prostate Cancer 2 - The Case of Mr. Powers' Prostate Cancer Recurrence
Mr. Powers is a young appearing, healthy 73-year old male who underwent a radical prostatectomy nine years ago for prostate cancer. He now has evidence of prostate cancer recurrence. You are expected to direct the evaluation, education, and management of this patient.
LEARNING OBJECTIVES for The Case of Mr. Powers' Limp MoJo
Describe the natural history and the common patterns of progression of prostate cancer
List the signs & symptoms of metastatic prostate cancer
List the options for management of metastatic prostate cancer and describe the mechanisms by which these treatments work
Mr. Powers Finally Returns to Clinic
Mr Powers has spent the last several years travelling the world and enjoying himself ("Yea, baby"). Prior to that, he underwent a radical prostatectomy nine years ago for a moderately-differentiated prostate cancer. While his PSA was undetectable in the year following surgery, it began to rise slowly after that, consistent with a recurrence of the cancer. He suffered moderate erectile dysfunction after the procedure, but recovered nicely to his full swinging potential with a Swedish vacuum-suction device. Unfortunately, the many raves, go-go parties, and time-travels filled up his schedule and he was subsequently lost to follow-up. Now, Mr. Powers reports no urinary problems and no bone pain. On physical exam, his MoJo is intact and his prostatic fossa is empty (as one would expect after a radical prostatectomy). His PSA level is checked and comes back 68 ng/ml. Mr. Powers noticeably cringes upon learning that the traditional gold-standard therapy for advanced prostate cancer was bilateral orchiectomy. "Not my wedding tackle, Baby," he rants. The rationale for this therapy is that testosterone (and other androgens) actively stimulate the growth of prostate cancer. His urologist mentions that orchiectomy for prostate cancer are rarely performed in the United States now that equally effective medical therapies exist. After therapeutic review of his treatment options, Mr. Powers is started on injections of goserelin (Zoladex). This drug and the similar drug leuprolide (Lupron) work by the following mechanism: (Please check the single best answer.)
a. Inhibitor of testosterone synthesis b. Gonadotropin releasing-hormone agonist c. Toxic to Sertoli cells in the testis d. Testosterone receptor antagonist e. Inhibitor of the conversion of testosterone to DHT (dihydrotestosterone)
Mr. Powers Refers a Family Member
Mr. Powers' PSA falls dramatically when checked a few weeks after his first injection of goserelin (Zoladex). And again he makes plans for time travel ("Way to go, baby"). Mr. Powers comes in every three months for this injection, and his PSA is followed closely. Several months later, Mr. Powers' father shows up at the clinic, saying that his son forced him to get medical attention since he is having trouble urinating. In addition, Mr. Powers Sr. mentions that his back and hip have been so painful over the last few months that he has been forced to limit his "usual" nocturnal activities. On physical examination, his abdomen is distended, his MoJo is intact, and his prostate is rock-hard and 5cm in breath. His spine and hip are tender to palpation, and his neurologic exam is intact. Ultrasound of his pelvis shows a distended bladder, and placement of a Foley catheter yields 800cc of urine, resulting in much relief to the elder Mr. Powers. Later, his PSA is measured at 258ng/ml. Plain films of his hip and spine reveal small osteoblastic lesions. Which is the most appropriate next step? (Please select the single best answer.)
a. Radical prostatectomy b. Gonadotropin releasing-hormone agonist c. External beam radiotherapy to the prostate d. Hormone therapy e. Repeat PSA in 3 months
Take-Home Messages - from Prostate Cancer 2 - The Case of Mr. Powers' Prostate Cancer Recurrence
Prostate cancer is a slow-growing tumor which often disseminates in a step-wise fashion, moving from the prostate to the pelvic lymph nodes, and then to the spine and pelvic bones.
Signs and symptoms of advanced and metastatic prostate cancer include urinary retention and bone pain.
The primary treatment option for metastatic prostate cancer is hormone therapy.
The gold-standard for hormone therapy for prostate cancer has traditionally been bilateral orchiectomy. In the United States, this has now been largely replaced by medical castration with goserelin (Zoladex) and leuprolide (Lupron).
Both goserelin and leuprolide are gonadotropin releasing-hormone agonists which shut down the sex-hormone axis and eliminate the production of testosterone from the testes.