Introduction
This case report is submitted for expert opinion on intermittent androgen blockade and local treatment in advanced Ca Prostate with pelvic lymph adenopathy.
Patient information
Mr.H. L was 44 years when he consulted urologist for increased frequency of micturition and incomplete voiding sensation in 2008.
Diagnosis
Ultrasonogram showed enlarged prostate with irregular contours and his PSA was 85ng/ml. He underwent Trans- rectal ultrasound guided Prostate biopsy which showed Adenocarcinoma Gleason 5+4. His CT scan showed prostatomegaly with infiltration of seminal vesicles and bladder base. He had significant pelvic (bilateral external iliac) lymphadenopathy. Tc99 Bone scan was negative for metastases.
Treatment
He received Androgen deprivation treatment (ADT) with LHRH agonists and anti-androgens. Pelvic External beam Radiotherapy 40Gy in 20 fractions along with a boost dose of 20Gy in 10 fractions to the prostate was delivered using 3D Conformal plan. He continued ADT till February 2011. His PSA dropped to < 0.09 and remained at that level till Feb 2011. PSA was 0.2 from May 2011 till July 2012.
Outcomes & follow up
Subsequent PSA recordings were 1.1 ng /ml in Jan 2013 and 2.7 ng /ml in July 2013. CT and bone scan were repeated and there was no evidence of metastatic disease. He was again on ADT from July 2013 till Nov 2013. PSA dropped to 0.03 in November 2013 when he discontinued ADT. PSA values were 0.4 in FEB 2014, 0.5-MAY 2014, 1.6-Jan 2015 & 1.1 in May 2015. He was off ADT till Jan 2016.
His PSA was 4.7 ng /ml in Jan 2016. CT & Bone scan- negative for metastases. He was reluctant to receive injections and opted for anti-androgens, which he discontinued on account of gynecomastia in November 2016 when his PSA was 2.5ng/ml. His PSA increased to 9.7ng/ml in May 2017 (CT & Bone scan repeated - negative for metastases) and he received ADT with LHRH agonist, which he continued till October 2017 when his PSA came down to 0.2 ng/ml.
In July 2018, his PSA was 6.3ng/ml and he started taking anti-androgens, with which it came down to 2 in December 2018. Subsequent readings, on irregular medications were 3.8 in March 2019 and 7.5 ng/ml in April 2019. FDG PET CT was done which shows abnormal area of uptake in the Right paramedian posterior contour of the prostate. No evidence of metastatic disease.
His PSA is 2.1 ng/ml in July 2019 on regular anti- androgens.
