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Carcinoma of the prostate

Short summary

72-year-old male was diagnosed with Adenocarcinoma of prostate gleason score 7 (4+3). Treatment options with intent to cure are surgery, radical prostatectomy, or external beam radiation combined with hormonal therapy.

Patient's questions

1) Which treatment, among the following, do you believe would be most appropriate:
a. Surgery ?
b. Traditional radiotherapy ?
c. Brachitherapy (according to the referral urologist, a brachitherapy would not be appropriate in this case since the biopsy results show the Gleason grade (4+3) is too high) ?
2) Can you recommend a center where brachitherapy can eventually be performed?
3) What is the prognosis?

Medical Background

Sex: M, Age: 72 years

No relevant pathology in the patient’s medical history.
The patient is currently being treated with Citalopram for depression and anxiety from which he suffers periodically.
Blood tests taken after suspending Avodart medication for 6 months, showed a PSA of 8.2 ng/ml ( < 4) and a free PSA of 8.9 ng/ml with ratio of free in total PSA of 9.6 (> 18.0 %).
A transrectal ultrasound of the prostate was performed showing the following prostate size: 37 x 45 x 26 mm, echogenically dishomogeneous due to the presence of hyperechogenic spots, such as the results of a phlogistic process; middle lobe slightly obstructing the opening of the bladder neck; adenomatous thickening found in the central region of the gland, 19 x 18 mm, physiological for the age.
A prostate biopsy was performed with the following histological diagnosis:
1 – Prostate, right lobe     2 – Prostate, left lobe
1 – Prostate bioptic samples at the site of adenocarcinoma, Gleason grade 4 ;   
       combined grade 7 (4+3).  
2 – Minuscule bioptic samples from the prostate insufficient for a histopathology
      circumstantial diagnosis”.
The patient was examined by a urologist who requested a complete abdominal CT scan and a bone scintigraphy. The results are reported below. While waiting for these results, the patient was treated with Androcur Depot (1 vial immediately and 1 vial after 15 days) and Zoladex (1 vial).
As requested by the urologist, a CT scan of the inferior and superior abdomen, with contrast agent, was performed. 
Liver is within the normal range for size, morphology and parenchymal profile.
Signs of hepatic statosis.
No images of focal pathology.
Biliary tree within the normal range.
Spleen with normal size and densitometric characteristics.
Absence of obvious expansive alterations in the pancreatic region.
No relevant images in the adrenal beds.
Kidneys basically within the normal range for size, morphology and parenchymal thickness. Small cystic images at the right inferior lobe level. Elimination of iodized organ-specific contrast agent basically normal and symmetrical.
Thin atheromatous thicknesses and small calcifications in the abdominal aorta wall within the subrenal region with no caliber alterations.
Lymph glandular micronodules in lumboaortic region. Some lymph nodes with dimensions between 7 and 10 mm are found also at the hepatic hilum and celiac tripod level as well as in the intra-aortocaval region. Controls on their development are recommended.
Modest repletion of the bladder with no major endoluminal alterations.
Prostate with size within the high normal limits, and appearing dishomogeneous. Modest irregularities found in the parenchymal profile but with no certain signs of infiltration in the periprostatic structures. Some lymph nodes of reactive appearance are noted bilaterally in the inguinal region”.
A bone scintigraphy taken did not show hyperfixation areas of the osteotrope tracer attributable to repetitive alterations.
Following are the results of the assessments completed in order to evaluate the patient’s clinical condition:
1) Blood exams:
- Glycaemia                           102 mg/dl       (70 – 105)
- Azotaemia                            31 mg/dl       (10 – 50)
- Creatinine                           1.00 mg/dl      (0.6 – 1.20)
- Protein                                             7.2 g/dl           ( 6 – 8)
- Electrophoresis:                 within normal limits;
2) ECG: sinusal rhythm, atrioventricular conduction within the normal range,
    no pathological alterations found.
In reference to what is described above, the patient had another urology exam where a prostatectomy surgery with traditional methods (not a laparoscopy) was recommended to him.
The patient consulted another urologist who instead recommended a cycle of radiotherapy (about 40 applications) along with the following medication treatment:
-       Casodex 50 mg 1 capsule a day for 1 year
-       Zoladex for about 2 years.
Currently the patient is following this pharmacological treatment.
Medical opinion
The patient diagnosed with prostate cancer at this stage is entitled for treatment with a curative intent. Treatment options with intent to cure are surgery, radical prostatectomy, or external beam radiation combined with hormonal therapy. Brachytherapy is recommended for patients with prostatic adenocarcinoma Gleason 6 or less and therefore this treatment modality is not an option in this case.
Prediction tools were developed in order to facilitate a proper decision regarding the treatment of choice for a patient with prostate cancer. The "Partin tables" first published at 2001 and lately updated (Urology.2007 Jun; 69(6):1095-101) are based on PSA levels, clinical stage & biopsy Gleason score. The tables predict for the chances of the disease to be organ confined (OC), for the chances for prostatic capsular penetration (CP) by the disease and for the chances of lymph node metastasis (LN) or seminal vesicles (SV) involvement. Another predictive tool is the Kattan nomogram developed at the MSKCC. These nomograms predict not only for the above mentioned disease features but can also predict for disease progression after the fore mentioned treatment modalities.
The information regarding the patient's disease, lack details regarding the clinical stage and the number of positive and negative cores at the biopsy.
Assuming that the clinical stage was T1c (no palpable tumor when sent for biopsy due to elevated PSA) then by the "Partin Tables" the predicted pathological stage would be as follows:
Organ confined disease       43% (35-51)
Capsular penetration            47% (40-54)
Seminal vesicles involvement 8% (4-12)
Lymph node metastasis              2% (1-4)
Additional information is needed in order to use the MSKCC nomograms.
Considering the low chances that the disease is organ confined surgery will not be curative and the treatment of choice is radiation treatment. Long term results of radiotherapy for prostate cancer published by Bolla et al. (Eur Urol 1999; 35:23-26) demonstrated that androgen suppression prior to and during radiation improves disease free survival and adjuvant hormonal therapy with and after radiation improves survival in high risk patient. The patient is regarded a high risk patient for locally advanced disease and therefore should be treated with hormones and radiation.
The clinical data presented to me lack information regarding the voiding problems the patient has. It is mentioned that the patient was on Avodart treatment which was suspended 6 months before the prostate biopsy was done. According to the prostatic size on ultrasound it is mildly enlarged with a middle lobe obstructing the bladder outlet. Knowledge regarding his voiding problems should be addressed as well, before the final decision regarding the treatment of the patient is made.