nyu medical grand rounds clinical vignette josie ni, pgy-3 9/13/11 u nited s tates d epartment of v...

NYU Medical Grand Rounds Clinical Vignette

Josie Ni, PGY-3

9/13/11

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 63 year old man presents with urinary frequency and nocturia for 3 months.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•ECG: normal sinus rhythm

•Chest X-Ray: no infiltrate

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Prostate cancer

Or

• Benign Prostatic Hyperplasia

Working or Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

MRI

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Adenocarcinoma, gleason 8 without extracapsular extension.

• Also with presumed occult metastases.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS