My Oncologist says she has tried all her bags of tricks and nothing has worked keeping PSA under control . Diagnosed with advanced PC in 2918 with PSA over 200 referred to Urologist put on Zolodax injections. Worked for short while then became castrate resistant , began Zitiga, PSA kept rising , began Xandi and could not tolerate so stopped pills. Apartently not a candidate for radium 223 because of lymph node mets (questionable). Also she felt because of age I should not be a candidate for chemo.....so its go home be comfortable for whats left of life
More info on treatment below I am in Canada
ID/DIAGNOSIS: William Reginal Jones is a 86 year old gentleman with metastatic castrate resistant prostate cancer (bone, ?abdominal/pelvic lymph node metastases). On enzalutamide.
ONCOLOGY HISTORY:
Metastatic castrate-resistant prostate cancer to bone and LNs
INVITAE - variant of unknown significance - c.1031G>A (p.Arg344Gin) heterozygous
- Diagnosed in summer 2018, PSA was 221.
- TRUS guided biopsy showed Gleason score 9/10.
- Restaging investigation showed a lesion in the right iliac bone concerning for metastatic disease. No mention of any lymphadenopathy.
- Radiation to prostate completed
- (prior imaging did not show any mets on bone scan and some possible abd/pelvic LNs, bilateral hydro on CT scan)
- PSA Jan 2019 - 2.9; Mar 2019 - 1.76, June 13, 2019 - 0.20; Sept 12, 2019 - 0.15; Sept 12, 2019 - 0.15
- March 2020 - Started on abiraterone and prednisone - baseline PSA 4.6
- PSA Apr 1, 2020 - 7.6; June 2, 2020 - 6.3
- Sept 2020 - Switched abd/pred to abi/dexamethasone (0.5 mg daily) - PSA 8.0
- PSA Nov 23, 2020-10.7; Jan 7, 2021-13.9; Feb 26, 2021 - 14.3; May 15, 2021- 19.7
-June 24, 2021 - Progression of bone metastases.
- PSA July 26, 2021 - 29.1
- September 2, 2021 - Rising PSA, started on enzalutamide 80 mg po daily (50% dose)
- PSA October 18, 2021 - 52.5 - increase enza to 120 mg po daily (75% dose)
- Nov 1, 2021 - Pt increased to 160 mg po daily
- PSA Nov 15, 2021 - 70.2
- PSA Dec 30, 2021 - 102
PMHx: Followed by Dr. Morash for hydronephrosis. For now no plans for nephrostomy tube unless worsening renal function (CrCl 31 ml/min)
INTERVAL HISTORY:
Mr. Jones was assessed by Dr. Malone for painful R scapula, 8 Gy in 1 #. Late January 2022.
He had terrible pain flare after the radiation, now it settled to a dull ache
Dec 30, 2021 - blood work - HGB 107, WBC 10.2, Neut 8.2, Plts 341, Cr 208 (baseline), lytes normal, ALP 146, lytes normal and LFTs normal, PSA 102
Dec 20, 2021 - Bone Scan Whole Spect
Comparison with the last exam of June 24, 2021.
-Progression in size of the main active lytic bone metastasis in the superior right scapula. Progression in size also of another lytic metastasis in the left posterior iliac crest.
-Unchanged small active lesion in T3 but presence of a new lytic active lesion in
the left superior scapula.
-Unchanged degenerative changes in the lower lumbar spine and signs of osteoarthritis in both knees. Also unchanged are faint focal uptakes in the 10th and 11th right ribs insistent with remote fractures.
Impression: Presence of active bone metastasis as detailed above with signs of progression since the last exam.
Dec 17, 2021 - CT scan of the thorax abdomen and pelvis (without IV contrast)
Comparison is made to the previous CT scan performed on July 21, 2021
IMPRESSION: MULTIPLE ENLARGED LYMPH NODES WITHIN THE RIGHT INFRACLAVICULAR AND THE RIGHT AXILLARY REGION AS DESCRIBED. THE LARGEST LYMPH NODE MEASUREs 2.7 CENTIMETERS IN DIAMETER AND IS SUSPICIOUS FOR METASTATIC NODES.
-ILL-DEFINED, AGGRESSIVE, LYTIC LESION WITHIN THE RIGHT SCAPULA EXTENDING INTO THE RIGHT GLENOID AS DESCRIBED. FINDINGS ARE HIGHLY SUSPICIOUS FOR METASTASIS
-Multiple retroperitoneal lymph nodes below the renal veins have remained stable in appearance.
-There is severe, right-sided hydronephrosis with hydroureter. The overall it shows no interval change. There is bilateral atrophic appearance of the kidneys
-No inflammatory changes or abscess.
ASSESSMENT:
-86 year old gentleman with metastatic castrate resistant prostate cancer, rising PSA and worsening lymphadenopathy and new bone mets on enzalutamide. Pt also not tolerating full dose enzalutamide. He has had some improvement in painful bony symptoms with radiation treatment to the scapula
-Unfortunately, we do not have any further systemic treatment options. I do not think he is a candidate for RAD 223 due to lymphadenopathy (extent seems out of keeping for COVID vaccine alone and there is multiple RP LNS). Not a candidate chemotherapy based on his poor performance status and concerns regarding toxicity. His wife inquired whether or not he could go back on abiraterone however given that he had both radiological and PSA progression on abiraterone this would no longer be funded and unlikely to be of any clinical benefit.
-The goals of care are symptom management and maintaining current quality of life.
-They have now been connected with the nurse practitioner. CCAC assessment is pending.
-I have not booked a follow-up appointment. In the future if he has any flares of bony pain this can certainly be assessed by Dr. Malone for consideration of further palliative radiation therapy. He will continue to be seen by Dr. Satterfield's office regarding his LHRH agonist.
Is this all or where to from here??????????
Bone Mets or Arthritis?
Advanced Prostate Cancer to bone and liver
Information on nmCRPC disease state? 
Dr says Enzalutimide... what about Cabazitaxel?
At the crossroads (again)
