Case Impressions: 66-Year-Old Man With mCSPC


Ralph V. Boccia, MD: This is a case of a 66-year-old man who presented with mild intermittent back pain. His past medical history background was that he has diabetes medically controlled and takes over-the-counter analgesics for this back pain that he’s describing. His family history is remarkable for no family history of known cancers. On physical exam, the physician does a digital rectal exam. Unfortunately there is an enlarged prostate, but it is otherwise unremarkable, no nodules or anything like that.

They send off blood work and his PSA [prostate-specific antigen] is significantly elevated at 70 ng/mL. He sends him to the urologist, and the urologist does a core biopsy. Sadly, unfortunately, he has adenocarcinoma of the prostate. His Gleason score is 4+4, so 8. They send him for a bone scan, and that shows 4 spinal lesions at T8, T9, L1, and L2, as well as 1 in the right femur. He has a CT scan of the chest, abdomen, and pelvis, and he had no sign of visceral or distant metastases other than the bone metastases.

He’s considered to have stage IV, potentially metastatic castration-sensitive disease. This is an initial diagnosis of prostate cancer. His ECOG performance status is good—it’s a 1. He’s minimally symptomatic from his cancer. Treatment is offered and he’s started on androgen deprivation therapy and apalutamide, 240 mg a day. Two months later his PSA is rechecked and is already down to 10 ng/mL. Repeat imaging is done, and he has no new skeletal lesions.

This is a relatively typical patient presenting with de novo metastatic disease. We know that bone metastases are the most common place that the prostate cancers metastasize to, other than some of the locoregional nodes. This is a fairly common problem that we have to deal with on a regular basis. His prognosis is not that great because he is considered to have what we would consider to be high-volume disease. High-volume disease is defined as either visceral metastasis, which he does not have, or 4 or more bony lesions, 1 of which must be outside the axial skeleton. He’s already got 4 spinal lesions and 1 in the femur, so he qualifies for having bony metastatic disease of high volume.

The prognosis for patients for with high-volume bony metastases is not good. For low-volume patients treated with androgen deprivation therapy alone, which is the old standard of care, their progression-free survival is somewhere on the order of just under 2 years. Sadly, for those with high-volume disease, their prognosis is much worse, and their progression-free survival is on the order of less than 9 months. Overall survival is not great either and tends to be under 3 years from old single-agent androgen deprivation therapy alone.

Transcript edited for clarity.

Case: A 66-Year-Old Male with Metastatic Castrate-Sensitive Prostate Cancer

Initial presentation

  • A 66-year-old man presented with mild intermitted back pain
  • PMH: DM; medically controlled; OTC analgesics for pain
  • FH: No known family history of cancer
  • PE: DRE revealed an enlarged prostate; otherwise unremarkable

Clinical Workup

  • PSA 70 ng/mL
  • Core needle biopsy with TRUS showed adenocarcinoma of prostate
    • Gleason score (4+4)
  • Bone scan revealed 4 spinal lesions (T8/T9, L1/L2) and 1 in the right femur
  • Chest/abdominal/pelvic CT scan was negative for distant metastases
  • Diagnosis: stage IV mCSPC
  • ECOG PS 1

Treatment and Follow-Up

  • He was started on ADT + apalutimide 240 mg qDay
  • At 2-month follow up: PSA 10 ng/mL
  • No new lesions on repeat imaging
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