Case Overview: 69-Year-Old Man With Advanced CRPC

Jorge A. Garcia, MD, FACP: For our case today, we’re going to review the history and management of a 69-year-old man with metastatic castration-resistant prostate cancer. This patient initially presented at age 69, and his presentation was somewhat unique because he presented with intermittent back pain and anorexia, or loss of appetite. At the time, his past medical history was remarkable only for hyperlipidemia that was controlled with the statins. The patient did not have any family history or social history that was contributory to his HPI [history of present illness]. His physical exam was unremarkable. However, his digital rectal exam [DRE] did demonstrate an asymmetric gland. Otherwise, it was unremarkable.

His initial clinical work-up included a biopsy with a transrectal ultrasound and demonstrated the presence of adenocarcinoma. His stage initially was a T2N0M0, and his group grade was 4. He also underwent germline testing and tested negative for the typical panel for DNA-repair deficiencies and also for MSI [microsatellite instability] high. His imaging tests demonstrated no evidence of distant metastases or lymphadenopathy, at least with the chest CT [computed tomography] and the abdomen CT as well. His bone scan was negative, and his initial PSA [prostate-specific antigen] at the time was 24.9 ng/mL.

At the time, the patient was offered local definitive therapy, so again he was a patient with intermediate to high-risk prostate cancer, high-risk just by virtue of his PSA. He was offered local definitive radiation therapy with radiotherapy and androgen deprivation therapy [ADT]. His PSA after 6 months was 11.2 ng/mL. At 12 months, unfortunately, during his ADT treatment with a testosterone-suppressed level, his PSA rose to 18.6 ng/mL. The patient at the time developed some back discomfort and some difficulty walking. His bone scan at the time unfortunately demonstrated the presence of multiple vertebral metastases, specifically at the level of L3 and L4.

At the time, he was diagnosed with castration-resistant disease with metastatic disease to the bone. This was specifically just by virtue of his low testosterone level. His serological progression while on androgen deprivation therapy, and obviously his symptomatic progression with back pain that was confirmed by CT scan and a bone scan, demonstrated the presence of lumbar disease. The patient saw his medical oncology group, and the decision was for him to initiate systemic therapy with radium 223 dichloride. He completed 6 infusions, and the treatment was completed without any major significant toxicities.

Transcript edited for clarity.

Case:A 69-Year-Old Man with Advanced Castrate Resistant Prostate Cancer

Initial presentation

• A 69-year-old man presented with intermittent back discomfort and loss of appetite
• PMH: hyperlipidemia controlled on a statin, no known family history of cancer
• PE: DRE revealed asymmetric, boggy prostate; otherwise unremarkable

Clinical Workup

• Biopsy with TRUS showed adenocarcinoma of prostate
  • Stage T2N0M0
  • Grade group 4
• Germline genetic testing: MLH1, MSH2, MSH6, PMS2, BRCA1/2, ATM, PALB2 and CHEK2
• Chest/abdominal/pelvic CT scan showed no evidence distant metastases or lymph node involvement
• Bone scan was negative
• PSA 24.9 ng/mL

Treatment and Follow-Up

• EBRT + ADT was started
• Follow up at 6 months, PSA 11.2 ng/mL
• At 12 months PSA 18.6 ng/mL
  • Patient reported increasing back discomfort and difficulty walking
  • Bone scan at that time showed multiple vertebral lesions at L3/L4
• Treatment with radium-223 dichloride was initiate
  • 6 infusions were completed, treatment was well tolerated