1. NYU Medical Grand Rounds Clinical Vignette Josie Ni, PGY-3 9/13/11 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 63 year old man presents with urinary frequency and nocturia for 3 months. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Patient had his first screening prostate specific antigen (PSA) in 2007 at age 59. The level was 0.6 (normal). He was asymptomatic until early 2010, when he began to develop urinary frequency and nocturia. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: GERD Left inguinal hernia Past Surgical History: Vasectomy Melanoma excision Hemorrhoidectomy Social History: Lives with famiy, works as a tutor for Kaplan No alcohol, tobacco, or drugs Family History: No family history of prostate cancer Allergies: No known drug allergies Medications: Prilosec 20mg by mouth daily Nasonex 1 spray intranasally twice daily Vitamin B complex 1 tablespoon by mouth daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Physical Examination General: awake alert and oriented, well- nourished man in no acute distress. Vital Signs: list T:98.7 BP:125/75 HR:70 RR:12 and O2 sat:100%RA Digital rectal exam with small firm nodule, prostate size approximately 45 grams. Remainder of physical exam was normal. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Laboratory Findings CBC: 6.5/15.2/253 (all values within normal limits) Basic Metabolic panel: creatinine 0.9 Remainder of basic was within normal limits Hepatic panel: all values within normal limits PSA 3.6 (normal is less than 4) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Other Studies ECG: normal sinus rhythm Chest X-Ray: no infiltrate U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Prostate cancer Or Benign Prostatic Hyperplasia Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Transurethral ultrasound guided biopsy was performed (12 core), and a single focus of gleason 6 was detected. Because of low volume and concerns regarding erectile dysfunction the patient chose active surveillance. MRI performed 3 months later showed a 5mm highly suspicious lesion Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. MRI U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. A repeat 20 core biopsy showed 2/10 positive for Gleason 8 (high grade) cancer on the right and 1/10 positive for Gleason 6 on the left. Patient was no longer a candidate for active surveillance. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Pelvic lymph node dissection and bilateral nerve sparing radical prostatectomy was performed in 7/2010. Surgical margins were negative. First PSA after resection was undetectable. However, 3 and 6 months later repeat PSAs were 0.24 and 0.84. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Adenocarcinoma, gleason 8 without extracapsular extension. Also with presumed occult metastases. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS