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Elderly Man With Elevated PSA Level

Elderly Man With Elevated PSA Level

A 79-year-old man has an elevated prostate-specific antigen (PSA) level
(11.3 ng/mL). About 1 month earlier, when he was hospitalized for a serious
urinary tract infection (UTI), his PSA level was 13.3 ng/mL. The more recent
level was obtained after he received antibiotic therapy for the UTI.

HISTORY

The patient has had symptoms of urinary tract obstruction for several
years; these have recently worsened, and he now experiences nocturia 4 or 5
times a night. For many years, he has had chronic obstructive pulmonary disease
(COPD), associated with a smoking history of 55 pack-years; symptoms
include a daily productive cough and dyspnea on exertion. He uses a variety
of nebulizers and theophylline.

The patient remains active and plays golf weekly. He lives at home with
his wife, who had a minor stroke several years ago. Although she has recovered
and has no major disability, she no longer drives, and her husband has
become the main caretaker in the household.

PHYSICAL EXAMINATION

The patient appears his stated age. There is mild expiratory wheezing in
the upper lung fields. Heart beat is regular, with an increased P2 sound. Percussion
of the bones reveals no tenderness.

LABORATORY AND IMAGING RESULTS

Results of a chemistry panel are normal. Alkaline phosphatase level is slightly
elevated at 250 U/L (normal, less than 225 U/L), but hepatic transaminase levels
are normal. Hemoglobin level is 16.2 g/dL; hematocrit is 52%; and white blood cell
and platelet counts are normal. Chest film findings of a low diaphragm and hyperinflation
are consistent with COPD. An ECG shows a borderline P pulmonale and
large R waves in the precordium but is otherwise normal.

Which of the following options is most appropriate for this patient?

  1. Perform a biopsy, and if the results are positive for prostate cancer,
    obtain a metastatic workup. If results of the workup are negative, proceed
    with a radical prostatectomy.
  2. Perform a biopsy, and if the results are positive for prostate cancer,
    obtain a metastatic workup. If results of the workup are positive, refer the
    patient to an oncologist for chemotherapy prior to any surgery.
  3. Proceed with a transurethral prostatic resection (TUPR) to relieve symptoms,
    and obtain bone studies to detect metastatic disease. Defer further
    therapy pending symptoms of metastatic disease.
  4. Proceed with TUPR to relieve symptoms, and obtain bone studies to detect
    metastatic disease. Initiate hormonal therapy for any metastatic disease
    immediately following the operation.

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