Acute anterior myocardial infarction in 1999 treated using angioplasty + stenting of the medial interventricular artery (IVA) for failed reperfusion with thrombolytic. Subsequently certain atypical anginal episodes occurred that led to brief hospitalizations. A submaximal ergometric test was uncertain for symptoms and ECG; the residual global left ventricular function was normal (apical hypokinesis).

The patient currently reports a stable clinical situation taking the following treatment: Sinvacor 20 mg 1 tab/day; Triatec 5 mg 1 tab/day; Cardioaspirin 100 mg 1 tab/day; Esidrex 25 mg 1 tab/day.

2 years ago, a diagnosis was given of Parkinson´s disease with a rapidly deteriorating clinical situation. Currently under treatment with Mirapexin 0.7 mg at a dosage of 1.5 tab 3 times a day. The following tests were run:

- A brain MRI on 26 May 2005 with the following report: "moderate enlargement in the bilateral subarachnoid spaces in the parietal region. No significant changes detectable in signal coming from the encephalic parenchyma. Regular representation of base nuclei. Small stabilized post-vascular lacuna at the pontomesencephalic passage on the right side."

- Brain SPECT with DATSCAN with the following report: "The scintigraphy test, conducted through administration of a presynaptic receptor tracer, shows a net reduction in captation corresponding to both the Putamen in a picture compatible with striatal dopaminergic denervation.

Following the appearance of irritative urination problems (nocturia 2-3 times, urgent urination) the patient underwent blood chemistry tests, prostate ultrasound, and specialized urological examination :

Urine clear, sediment negative. No bladder residue found in ultrasound. PSA 5.25. Upon rectal exploration, the prostate appears to be of normal volume, with edge of right lobe hard, fixed. Therefore echo-guided prostate biopsy was recommended, performed, with sampling of 3 lateral and 3 parenchymal fragments per side for a total of 12 samples. This prostate biopsy detected prostatic adenocarcinoma in both lobes (Gleason score 3+4). The specialist explained to the patient the need for radical treatment and possible treatment approaches, with radical prostatectomy surgery or radiotherapy. The patient reports that the prostatectomy surgery was recommended to him. He is not currently undergoing any treatment for the urological disease.

QUESTIONS

1) Please illustrate the advantages and disadvantages between radical prostatectomy and radiotherapy.

2) What therapy do you suggest?

3) What is the prognosis?

Medical Report:

RE:

To whom it may concern,

I have reviewed the patient´s medical history as sent to me by Medical Opinion and enclosed is my opinion regarding the management of his urological problems.

The patient is a 66 year old male patient which was lately diagnosed with prostate cancer. His past medical history is remarkable for Ischemic heart disease and rapidly progressive Parkinson´s disease.

Due to irritative voiding symptoms he underwent Urological evaluation and was found to have a normal size prostate with a firm right lobe. PSA blood test revealed elevated levels of 5.25ng/ml. Prostatic biopsy diagnosed Adenocarcinoma of prostate Gleason score 7(3+4) in both lobes.

A 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 number of positive and negative cores at the biopsy. Additional information is needed in order to use the MSKCC nomograms.

Assuming that the clinical stage was T₂a (palpable, half of 1 lobe or less) then by the "Partin Tables" the predicted pathological stage would be as follows:

Organ confined disease 44% (39-50)

Capsular penetration 46% (40-52)

Seminal vesicles involvement 5% (3-8)

Lymph node metastasis 4% (2-7)

Considering the low chances that the disease is organ confined surgery will no 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.

When considering his medical background I do believe that radiation is the right choice. His Ischemic Heart Disease and the progressive Parkinson makes him a high risk patient for surgery. His neurological status will worsen the degree of incontinence expected after surgery and will effect his quality of life. Radiation treatment might exacerbate the irritative symptoms but these can be controlled by anti-cholinergic treatment. This treatment, with or without alpha-blockers should be offered already for improvement of his present voiding problems.

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