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Prostate Cancer in a Man With Multiple Previous Cancers

Prostate Cancer in a Man With Multiple Previous Cancers

ABSTRACT: Multidisciplinary Consultations on Challenging Cases The University of Colorado Health Sciences Center holds weekly second opinion conferences focusing on cancer cases that represent most major cancer sites. Patients seen for second opinions are evaluated by an oncologist. Their history, pathology, and radiographs are reviewed during the multidisciplinary conference, and then specific recommendations are made. These cases are usually challenging, and these conferences provide an outstanding educational opportunity for staff, fellows, and residents in training. The second opinion conferences include actual cases from genitourinary, lung, melanoma, breast, neurosurgery, and medical oncology. On an occasional basis, ONCOLOGY will publish the more interesting cases discussions and the resultant recommendations. We would appreciate your feedback; please contact us at second.opinion@uchsc.edu. E. David Crawford, MD, and Al Barqawi, MD, Guest Editors University of Colorado Health Sciences Center and University of Colorado Cancer Center Denver, Colorado

The patient is a 67-year-old male with mild obstructive symptoms and an American Urology Association symptom score of 8.[1] He was noted to have a prostate-specific antigen (PSA) level of 3.2 ng/mL. Because this represented a significant increase in his PSA velocity (rate of change over time), he proceeded to have a biopsy, which was positive for prostate cancer. He has no other complaints and visits us for an opinion on the treatment of his prostate cancer.

History, Physical Exam, and Laboratory Findings

Dr. L. Michael Glodé: The patient's past medical history is remarkable for a previous neoplasm. Ten years ago, he was diagnosed with a pituitary adenoma that was treated with radiation therapy. Eight years ago, he underwent a right nephrectomy for renal cell carcinoma. Three years ago, he developed a Hürthle cell adenoma and papillary carcinoma of the thyroid, treated with a near-total thyroidectomy. He is also being treated for hypertension and hyperlipidemia. Of note, he has a positive family history of cancer, with reported renal cell carcinoma in his father, brain cancer in his sister, and testis cancer in two of his nephews.

A physical exam reveals the patient's blood pressure is 131/79 mm Hg, heart rate is 66/min, respiratory rate is 16/min, temperature is 97.5°F. He is in no acute distress. Lungs are clear to auscultation. Abdomen is soft, nontender, without organomegaly. There is no lymphadenopathy. His skin exam is normal. Rectal exam reveals a soft, approximately 20-g prostate, without nodularity.

Laboratory findings include the following: PSA = 3.2 ng/mL, testosterone = 195 ng/dL (institutional normal range: 122-534 ng/dL), sodium = 141 mmol/L, potassium = 3.7 mmol/L, creatinine = 1.9 mg/dL, bilirubin (total) = 0.7 mg/dL, thyroid-stimulating hormone = 0.08 µIU/dL, free T4 = 0.99 ng/dL, white blood cell count = 6.1 × 109/L, hemoglobin = 14.3 g/dL, and platelet count = 187 × 109/L.

Pathology

Dr. Glodé: Drs. Lucia and La Rosa, would you please review the patient's prostate biopsy findings?

Dr. Scott Lucia: Pathologic slides from an outside hospital, with corresponding identification for this patient, were reviewed. The histologic grade of prostate cancer, or Gleason score, is determined by assigning a pathologic grade to the two most prevalent patterns noted in the cancer tissue, with the larger numbers representing more undifferentiated tumors. These two scores are added together for a maximum possible score of 10. In this case, two biopsy regions demonstrated the presence of cancer. The right midsection reveals adenocarcinoma of the prostate, Gleason 3+3=6, involving 5% to 10% of two cores. The right base demonstrates prostatic adenocarcinoma, Gleason 3+4=7, involving 20% of each of two cores (Figure 1).

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