Prostate Mass (Case 31)

Prostate Mass (Case 31)


Amy L. Curran MD and Clifford H. Pemberton MD


Editors’ Note: The editors felt that the section on oncology should include the issues of (1) recurrent malignant disease, (2) caring for metastatic disease, and (3) care when treatment is no longer efficacious or advised. We chose the chapter on prostate cancer as the chapter in which to integrate these principles.


Case: The patient is a 65-year-old man who presents for an annual examination. He has no complaints, and his only medical condition is well-controlled hypertension. Previously the physician and patient had decided to obtain annual prostate specific antigen (PSA) testing based on the patient’s positive family history of prostate cancer. This year the PSA is found to be slightly elevated at 5 ng/mL, compared to a level of 2.1 ng/mL a year ago. On physical exam, his digital rectal exam (DRE) is remarkable for right-sided prostatic induration. The patient undergoes an ultrasound-guided biopsy taken at the suspicious area and sampling throughout the gland. Pathology confirmed adenocarcinoma of the prostate with a Gleason score of 6.


 


Speaking Intelligently



There are several approaches to treating early-stage prostate cancer, and the optimal treatment must be tailored to the patient. Because a large percentage of patients die with prostate cancer, rather than dying from prostate cancer, it is important to first determine the patient’s life expectancy. Next, one can utilize information about the tumor to assess its recurrence risk. Low-risk prostate cancer is defined by small tumors (T1 or T2a), Gleason scores ≤ 6, and PSA < 10 ng/mL.


What Is a Gleason Score?


A Gleason score is assigned to prostate cancer based upon its histopathologic appearance. Gleason grades range from 1 to 5, with 5 having the worst prognosis. A Gleason score of 1 is a well-differentiated cancer that has small, uniform glands, whereas a Gleason grade of 5 represents a poorly differentiated tumor that lacks glands and has sheets of cells. The pathologist assigns a grade to the two most common tumor patterns; the two grades are added together to give a Gleason score (≤6 is well differentiated, 7 is moderately differentiated, and 8–10 is poorly differentiated).


Therapeutic Options for Prostate Cancer



















Radical prostatectomy

• For tumors confined to the prostate in patients with a life expectancy >10 years and well enough to undergo major surgery.


• Significant risk of incontinence and erectile dysfunction.


External-beam radiation therapy

• Similar progression-free survival to surgery for low-risk patients.


• Addition of pelvic lymph node irradiation and/or androgen-deprivation therapy for higher risk groups.


• Advantages include avoiding surgical complications, and less incontinence and erectile dysfunction.


• Disadvantages include long treatment course, bowel and bladder symptoms during treatment, and late radiation proctitis.


Brachytherapy

• Involves planting radioactive sources into the prostate tissue.


• Treatment is completed in 1 day and is effective for low-risk tumors.


• Patients with very large or small prostate glands, bladder outlet obstruction, or prior transurethral resection of the prostate (TURP) are not good candidates for brachytherapy.


• General anesthesia is required for placement.


Hormonal therapy

• Androgen-deprivation therapy through either administration of a luteinizing hormone-releasing hormone (LHRH) agonist or orchiectomy.


• Used routinely with definitive radiation therapy for higher risk disease as well as for metastatic disease.


• Adverse effects include osteoporosis with greater incidence of fracture, obesity, insulin resistance, and dyslipidemia.


Active surveillance

• Monitoring course of the disease with the expectation to intervene if the cancer progresses.


• Reasonable option for men with low-risk cancers and a short life expectancy.


The patient in this case opted for treatment with external beam radiation and had a complete response with normalization of his PSA. For 9 years he was considered disease free with regard to his prostatic cancer. Unfortunately, 9 years after treatment the patient presented to the ED with severe back pain. The pain began about 4 weeks earlier and had worsened in the past few days, making it difficult for him to sleep. He is taking over-the-counter medications, including acetaminophen and ibuprofen, with little benefit.


Differential Diagnosis










Back Pain in a Patient with a History of Cancer


Bone pain/spinal cord compression from metastatic disease

Compression fracture

Musculoskeletal low back pain


PATIENT CARE


Clinical Thinking


• Patients with cancer commonly present with pain, especially at original diagnosis or at disease progression. Sometimes the pain can be acute caused by a medical emergency such as spinal cord compression or a bowel obstruction. More frequently, cancer patients have chronic pain and need ongoing care including monitoring of pain medications, referral to pain specialists for procedures, consultation and treatment with radiation oncology, and psychosocial support.


• Although there is a broad differential diagnosis (including disk herniation and spinal stenosis) in patients presenting with back pain, those with a history of cancer should be imaged to rule out metastatic disease to the spine and the possibility of cord compression.


• A dose of corticosteroids should be given before definitive diagnosis, if spinal cord compression is possible.


• Intravenous narcotics are appropriate front-line therapy when a patient presents in severe pain refractory to oral medications. In addition to narcotics, adjuvant medications such as corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants can both assist with pain control and allow patients to use lower doses of narcotics.


• Patients with severe chronic pain often require a combination of long-acting narcotics for baseline pain control and short-acting narcotics for breakthrough pain. A common starting point is to prescribe about two thirds of a patient’s total daily narcotic dose as long-acting medications and provide about 10% of this dose in short-acting narcotics as needed. One can utilize a “narcotic calculator” to change between IV pain medications and commonly prescribed oral medications.


• A bowel regimen should be started to decrease constipation, which is a common adverse reaction to narcotics.


History


• Develop your own way of taking a pain history. Refer below to the Interpersonal and Communication Skills section, which gives an example of a pain algorithm.


• Whether a patient presents with chest pain from a myocardial infarction, abdominal pain from an acute abdomen, or back pain from metastatic disease, your approach should be similar, modifiable, efficient, and accurate.


• Specifically, for this patient, it is important to elicit the patient’s prior history of prostate cancer, the high level of pain that keeps him awake at night, and the fact that his pain is refractory to over-the-counter medications and/or positioning.


• These details should raise your index of suspicion that his back pain might have a serious etiology.


Physical Examination


• Vital signs and general appearance are important.


• Fever can be a sign of systemic disease (either tumor or infection).


• Perform a thorough musculoskeletal exam of the back with attention to tenderness of soft tissue overlying the spinous processes.


• Note limitation in mobility, as well as decreased chest expansion on pulmonary exam.


• A straight-leg-raising test should be performed and is positive when the leg cannot be elevated beyond 60 degrees and the test causes sciatic pain.


• A complete neurologic exam should be performed, including strength at the ankle and large toe dorsiflexion (L5), plantar flexion strength (S1), and reflexes at both the knee and ankle.


• A rectal exam should be performed to ensure normal rectal tone.


Tests for Consideration













• Metabolic panel including basic electrolytes, renal function, and calcium.

$12


• PSA.

$26


• Complete blood count (CBC).

$11


 



IMAGING CONSIDERATIONS







→ MRI of the spine. Though, in general, low back pain does not mandate early imaging, when you are concerned about metastatic disease, it is important to obtain an MRI scan of the entire spine; it is the test of choice. It is quite common for patients to have multiple foci of disease.

$534

Related posts:

Hematuria (Case 16) Elevated Blood Counts (Case 26) Weight Loss (Case 41) Abnormal Movements (Case 55) Amenorrhea (Case 42) Constipation (Case 23)

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Oct 3, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Prostate Mass (Case 31)

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