ONCAlert | Upfront Therapy for mRCC
Prostate Cancer Case Studies

Case Studies: Treatment Recommendations Upon Metastasis in CRPC

Daniel J. George, MD, rationalizes the appropriateness for initiating radium-223 in a patient whose disease progresses following androgen deprivation therapy and AR targeted therapy and reviews clinical considerations for monitoring a patient such as the one in this case.

Treatment Recommendations Upon Metastasis in CRPC

mCRPC Treated With Radium-223 Therapy

January 2015

H&P:

  • A 71-year old gentleman presented with urinary incontinence  
  • Past medical history: HBP controlled with lisinopril 
  • On digital rectal examination prostate was enlarged
  • Patient was asymptomatic

Imaging:

  • Transrectal ultrasound and biopsy revealed adenocarcinoma of the prostate gland with a Gleason score 9 [4+5] with 9 of 12 cores positive
    • PSA, 10.2 ng/mL
  • CT scan was negative for metastases
  • He was started on a 3-month depot injection of leuprolide 22.5 mg and treated with 7800 cGy IMRT

April 2016

  • Patient returned for 3-month injection; his PSA level increased to 47 ng/mL
    • CT/Bone scans were negative for metastases
  • He was started on enzalutamide
    • PSA, 12 ng/mL  

October 2016

  • 6 months later the patient complained of severe fatigue and lower back pain
    • Imaging with CT and bone scan showed multiple metastases of the spine and pelvis
    • PSA levels increased to 76 ng/mL
    • ALP, 268 U/I
  • Radium-223 therapy was initiated in addition to continuing enzalutamide
  • After 3 infusions of radium-223
    • PSA declined to 31 ng/mL
    • ALP decreased to 80 U/l
    • CT scan showed no new bone metastases
    • Fatigue decreased, and patient’s physical activity increased
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