Medical Diagnosis: CARCINOMA OF THE PROSTATE

A 72 yr old male diagnosed with carcinoma of the prostate. No relevant pathology in his medical history. Currently treated with Citalopram for depression and anxiety.

Blood tests taken on after suspending Avodart medication for 6 months, showed PSA of 8.2 ng/ml and free PSA of 8.9 ng/ml with ratio of free in total PSA of 9.6 (>18.0 %).

Ultrasound of the prostate showed prostate size: 37 x 45 x 26 mm, with a hyperechogenic spots, middle lobe slightly obstructing the opening of the bladder neck; adenomatous thickening in the central region of the gland, A prostate biopsy showed 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 samples from prostate insufficient for a histopathology diagnosis

The patient was examined by a urologist who requested complete abdominal CT scan and bone scintigraphy. The patient was treated with Androcur Depot and Zoladex.

Results of CT scan of inferior and superior abdomen:

Liver - normal range for size and morphology. Signs of hepatic statosis. No images of focal pathology. Biliary tree within the normal range. Spleen - normal size and densitometry.

No alterations in pancreas. No relevant images in adrenal beds.

Kidneys - normal range for size, and morphology. Small cystic images at the right inferior lobe level. Elimination of iodized organ-specific contrast agent normal and symmetrical.

Thin thicknesses and calcifications in abdominal aorta wall within the subrenal region.

Lymph glandular micronodules in lumboaortic region. Some lymph nodes are found at the hepatic hilum and celiac tripod level and the intra-aortocaval region. Controls on their development are recommended.

Modest repletion of the bladder with no major alterations.

Prostate size within the high normal limits, dishomogeneous. Modest irregularities in the parenchymal profile but with no signs of infiltration in the periprostatic structures. Some lymph nodes of reactive appearance are noted in the inguinal region.

A bone scintigraphy did not show hyperfixation areas of the osteotrope tracer attributable to repetitive alterations.

Results of completed assessments to evaluate the patient’s medical 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

) ECG: sinusal rhythm, atrioventricular conduction within normal range, no pathological alterations found.

The patient had another urology exam where a prostatectomy surgery with traditional methods (not a laparoscopy) was recommended .

The patient asked for a second medical opinion form another urologist who recommended a cycle of radiotherapy (about 40 applications) along with the following medication treatmen t of Casodex and Zoladex.

Currently the patient is following this pharmacological treatment.

Medical questions referred to Medical Opinion online consultation service:

1) Which treatment,would be most appropriate:

a. Surgery

b. Traditional radiotherapy

c. Brachitherapy

2) Can you recommend a medical center where brachitherapy can eventually be performed?

3) What is the prognosis?

 

Medical Opinion given by the online doctor:

 

I have reviewed the patient´s past medical history, sent to me online by Medical Opinion services. Enclosed is my opinion regarding the management of his Prostate disease.

The Patient is an otherwise healthy 72 year old man diagnosed with prostate cancer. Due to elevated levels of PSA he underwent transrectal ultrasound guided prostaic biopsy that revealed Adenocarcinoma of prostate gleason score 7 (4+3) in the right side of his prostate. Systemic imaging, CT scan of abdomen & pelvis and bone scintigraphy were negative for metastatic disease. Renal functions are within the normal limits.

A patient diagnosed with prostate cancer at this stage is entitled for treatment with a curative intent. Treatment options 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 is not an option in this case.

Prediction tools developed to facilitate a proper decision regarding the treatment of choice for a patient with prostate cancer can be used. The information regarding the patient´s disease lacks 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 predicted pathological stage is 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.

Considering the low chances that the disease is organ confined surgery will not be curative and the treatment of choice is radiation treatment combined with androgen suppression prior to and during radiation to improve disease free 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 lack information regarding the voiding problems the patient has. The patient was on Avodart treatment which was suspended 6 months before the prostate biopsy was done. Knowledge regarding his voiding problems should be addressed as well, before the final decision regarding the treatment of the patient is made.

I will be happy to answer any question regarding the future treatment of this patient.

Sincerely,

Dr. …