Castration-resistant prostate cancer: Optimal management of a patient with good performance status
Discussant: Camillo Porta, MD

A 67-year-old geography teacher with a 10-year history of hypertension, well controlled on medication, was diagnosed 4 years ago with prostate cancer (Gleason score 7 [3 + 4]) and asymptomatic bone metastases. Luteinizing hormone-releasing hormone agonist every 3 months was started and PSA normalized. In the last 2 months, his PSA level increased to 22 ng/mL, but he was asymptomatic. Bone scan confirmed progression of bone metastases. There was no PSA response after addition of antiandrogen flutamide, nor was there a withdrawal response when flutamide was discontinued. His PSA level rose to 53 ng/mL in 2 months. Patient now complains of fatigue and mild bone pain. No abnormalities are found during physical examination. ECOG PS: 1.

• Laboratory: Alkaline phosphatase 1.25 x upper normal limits; creatinine, calcium, liver function tests, platelets, WBC normal; Hgb 12.5 g/dL
• Bone scintigraphy: Few new hot spots in pelvis and spine consistent with progression of osteoblastic metastases.
• Chest X-ray: Normal
• Abdominal CT scan: Enlarged lymph nodes along aorta and vena cava up to 3 cm
• Patient started on zoledronic acid