A 71 year old white male presented to his primary care physician for a routine checkup.

He had his blood drawn for a workup, and the only complaint he had was of an increase in the frequency of urination. The patient is on several medications, Lisinopril, hydrochlorothiazide, simvastatin, baby aspirin, and a liver cleanse formula. When asked about his past medical history it included hypertension, hyperlipidemia, which is stable, tendonitis gastroesophageal reflux and borderline diabetes. He has had a tonsillectomy and carotid artery surgery. His family history included diabetes, stroke, hypertension, and myocardial infarction. As for the patient's social history, he is married with eight adult children. He does not smoke, He drinks six alcoholic beverages per week and two coffee/sodas per day. He is retired from the flooring installation business and has a lot of exposure to inhaled chemicals. The lab results came back with an increased PSA of 9.25 ( 0-4.0ng/mL Avg 5.0 2xAvg 9.6 ). The patient has had increased PSA in the past, about three years ago, with negative biopsies. His Primary Care Physician referred him to a urologist for follow up. Ten days later the patient had his first appointment with the urologist. A prostate massage was biopsy.

Six weeks after his initial visit with the urologist he presents for a prostate ultrasound and biopsy. The patient had no definitive hypo-echoic areas. The capsule is intact, and the seminal vesicles are normal size, though there were some scattered central and peripheral calcifications. The procedure involved 1

taking 18 biopsies from 7 sites. The Pathology report revealed a prostatic adenocarcinoma with a Gleason score 3+3=6) involving 3% of one core in the right base and focal high-grade prostatic intraepithelial neoplasia was identified in the right mid, left base and left apex. Perineural invasion was also identified in the right base. This refers to the cancer spreading into the space surrounding a nerve. Radiotherapy was discussed with the patient as well as waiting and watching. The patient expressed interest in proceeding with radiotherapy. He was referred to an oncologist. Cancer is a disease in which abnormal cells in the body grow out of control. The prostate is a small, walnut sized structure that makes up part of a man's reproductive system. It is located located just below the bladder and in front of the rectum, it surrounds the urethra. The job of the prostate is to produce fluid that makes up a part of semen. Prostate cancer are cancer cells from the prostate. It is classified as an adenocarinoma, glandular cancer. Early-stage prostate cancer grows slowly, because of this it can take 10 to 30 years before a prostate tumor is large enough to cause symptoms or for doctors to find it. Some of the symptoms that are associated with prostate cancer are Delayed or slowed start of urinary stream, leakage of urine, slow urinary stream, straining when urinating or not being able to empty all urine, blood in the urine or semen, and bone pain or tenderness, this is only when the cancer has spread. Though most of the time these symptoms are caused by other prostate problems that are not cancer. The PSA blood test is done to screen for prostate cancer. Because of this testing, most prostate cancers are found before they can cause any symptoms. 2

This also will be used to monitor your cancer after treatment, this level should begin to rise before there are any symptoms. A Prostate biopsy is the only test that can confirm the diagnosis of prostate cancer. This is where tissue from the prostate is viewed underneath a microscope. Biopsy results are reported using something called a Gleason grade and a Gleason score. The Gleason grade is how aggressive the prostate cancer might be. Grades tumors on a scale of 1-5 based on how different from the normal tissue cells are. Often more than one grade is present in the same sample. The grade is used to make a Gleason score, on a scale of 2-10. This is done by adding the two most prominent grades together. The more increased the score the more likely the cancer is to have spread beyond the prostate gland. 2-4 low grade; 5-7; 8-10 high grade cancer ( poorly differentiated cells). High-grade prostatic intraepithelial neoplasia, HGPIN, is characterized by complex structurally benign glands lined by cells which are similar morphologically to prostate cancer and is generally considered to be a precursor of prostate cancer. Prostate Cancer is the third most common cause of death, from cancer, in men and is the most common in men over the age of 75. It is rarely found in men younger than 40 years old. People who are at higher risk include: AfricanAmerican men, who are also likely to develop cancer at every age, men who are older than 60 and have a father or brother with prostate cancer. Others that are at risk include: Men who are exposed to agent orange, abuse alcohol, eat a diet

high in fat, especially animal fat, who are tire plant workers, painters or farmers or who have been exposed to cadmium. The prognosis varies greatly, and it is affected by whether the cancer has spread outside of the prostate and how abnormal the cancer cells are when diagnosed. Those who have prostate cancer that has not spread, as well as some whose cancer has not spread much outside of the prostate, can be cured. Hormone treatment can extend life for many years for those patients who cannot be cured. Two days later the patient had his first appointment with the Oncologist to discuss treatment options. The treatment option discussed were External beam radiation therapy alone vs external beam radiation therapy plus permanent interstitial seed implant vs radical prostatectomy. Radiation therapy uses high energy radiation to kill the cancer cells by damaging their DNA. Because this can also damage normal healthy cells as well, treatment has to be carefully planned so that side effects are minimized. The radiation that is used for treatment may come from a machine that is outside of the body, or it may come from a radioactive material placed in the body near the tumor cells, or injected into the bloodstream. External-beam radiation therapy is mostly delivered in the form of photon beams, either x-rays or gamma rays. A machine aims the radiation at the cancer and moves around the body which sends radiation from all directions. The exact location of the prostate is mapped and then treatments will be received over time. Generally 5 days a week for 6 to 9 weeks, each of these treatments is about 15 minutes in length and should be painless. Patients usually receive external-beam radiation therapy in

daily treatment sessions over the course of several weeks. The number of sessions depends on many factors, including the total dose of radiation that will be given to the patient. Brachytherapy is a choice for men who have low risk prostate cancer. This is a type of internal radiation therapy where the doctor places radioactive material inside the prostate. There are two kinds, Low dose and High dose. This can be used with external beam radiation therapy. In Low dose rate(LDR) Brachytherapy, a low-dose sources of radiation, or seed implants, are placed throughout the prostate. Each seed is smaller than a grain of rice. The number of seeds depends on the size of the prostate. Each day the radiation will get weaker and it will run out in 2 to 10 months. Once it is gone, the seeds will remain in the prostate. The seeds are implanted as an outpatient procedure. In High dose rate(HDR) Brachytherapy, tiny catheters are placed throughout the prostate. One or more sources of high does radiation will be placed in the catheters for each treatment, then the material will be removed after a few minutes. These catheters will be in the prostate for the entire course of treatment, but will be removed once all treatments have been received. This requires the patient to stay in the hospital or clinic for the entire course of the treatment. Surgery is a choice for men who have early-stage prostate cancer and are in good health. This surgery is called a prostatectomy. There are a few different options for surgery. First is an open prostatectomy, The prostate is removed through a single long cut made in the abdomen, and the lymph nodes can be checked to see if the cancer has spread. This can also be used for nerve-sparing surgery. Second, laparoscopic surgery, in which the doctor uses a laparoscope. This surgery involves several small cuts in the naval and abdomen where the surgery tools are inserted. Nerve-sparing surgery is also an option with this type. Third, is a perineal prostatectomy, this type of surgery is not used very often. It is when the prostate is removed through an incision between the scrotum and anus. The surgeon is

not able to check the lymph nodes and nerve-sparing surgery is harder to do. The patient has decided on external beam radiation therapy plus LDR Brachytherapy. Five days later the patient presented for gold seed fiducial implantation. The seeds were placed initially at left base and apex and then the right and mid-gland. One week after implantation patient presented for stimulation. External beam radiation therapy treatment started two weeks after stimulation for 5 days a week for 43 treatments, about 9 weeks. The patient had blood drawn three weeks after starting treatment. CBC WBC 4.5 (4.1-10.9 K/uL) Lymph 1.0 23.2%L (0.6 4.1 K/uL) 10.0-58.5%L Mid 0.5 10.5%M (0.0- 1.8 K/uL) 0.1- 24.0%M Gran 3.0 66.3%G ( 2.0- 7.8 K/uL) 37.0-92.0%G RBC 4.23 M/uL (4.20 -6.30 M/uL) Hgb 11.5 g/dL (12.0-18.0 g/dL) Hct 36.8 % (37.0-51.0 %) MCV 87.0 fL (80.0-97.0 fL) MCH 27.2 pg (26.0-32.0 pg) MCHC 31.3 g/dL (31.0- 36.0 g/dL) RDW 13.8 % (11.5 -14.5 %) PLT 268 K/uL ( 140-440 K/uL) MPV 9.1 fL (0.0 -99.8 fL) His WBC and RBC are on the lower end of normal and his Hgb and Hct are both just under normal. These results are consistent with someone who is going through radiation therapy. Throughout the treatments the patient was more tired than normal, He had blood drawn again two weeks later and a complete metabolic panel and a lipid panel run. All results were in normal range except for the patients Glucose, which was 204 mg/dL ( 80100mg/dL). Three weeks later the doctor ordered another glucose. Glucose 113 ( 80-100 mg/dL) HBA1c 5.9 ( 4.0-6.9%) est avg glucose 123 mg/dL 6

A week after treatment the patient had another PSA run. The results came back as 2.7 ng/mL ( 0.0-4.0 ng/mL). The patient's PSA was back within normal range. Two months after treatment the patient had another Complete metabolic panel run and all test were in normal range except for the Glucose 112 mg/dL ( 80-100mg/dL). In conclusion,I do not believe the patient's increased glucose is related to the cancer, since it was increased before the patient found out about the cancer, and it was still increased after the treatments ended. The patient's treatment was successful, but he will be watched closely to make sure that it does not come back or spread. This will involve regular checkup's and will include serial PSA tests, every three months.