What are the next steps for a patient presenting with dysphasia and unintended weight loss, with a computed tomography (CT) scan of the chest/abdomen/pelvis showing multiple sclerotic foci consistent with osseous metastatic disease, multiple pulmonary nodules, mediastinal (medial) hilar lymphadenopathy, and an enlarged prostate gland with macrocalcifications?

From the Guidelines

The patient's clinical presentation and imaging findings strongly suggest metastatic prostate cancer, and the next steps should include a comprehensive evaluation to confirm the diagnosis and assess the extent of disease. Given the patient's symptoms of dysphagia and unintended weight loss, along with the computed tomography (CT) scan findings of multiple sclerotic foci consistent with osseous metastatic disease, multiple pulmonary nodules, mediastinal (medial) hilar lymphadenopathy, and an enlarged prostate gland with macrocalcifications, a thorough diagnostic workup is essential. This should include:

• A prostate-specific antigen (PSA) blood test to confirm the diagnosis and determine the severity of the disease 1
• A prostate biopsy to confirm the diagnosis and determine the Gleason score
• Bone scan and MRI of the spine to assess the extent of bone metastases, as bone scan and MRI are superior to CT scan in diagnosing and following up on bone metastases 1
• An upper endoscopy to rule out esophageal involvement or a separate primary malignancy, given the patient's dysphagia
• Complete blood count, comprehensive metabolic panel, and testosterone levels to assess the patient's overall health and guide treatment decisions
• Referral to medical oncology and urology for multidisciplinary management, as treatment decisions should be discussed within a multidisciplinary tumor board 1 If metastatic prostate cancer is confirmed, treatment would likely include androgen deprivation therapy (such as leuprolide 7.5 mg monthly or goserelin 3.6 mg monthly) possibly combined with an androgen receptor antagonist like enzalutamide (160 mg daily) or abiraterone (1000 mg daily with prednisone 5 mg twice daily), as these treatments have been shown to improve outcomes in patients with metastatic prostate cancer 1. Palliative radiation therapy may be needed for symptomatic bone lesions, and the patient's response to treatment should be closely monitored, with imaging studies such as CT scans and bone scans used to assess the response to therapy 1. This approach is warranted because the constellation of findings—sclerotic bone lesions, pulmonary nodules, hilar lymphadenopathy, and enlarged prostate—strongly suggests metastatic prostate cancer with both skeletal and pulmonary involvement, explaining the patient's constitutional symptoms and weight loss. The patient's treatment plan should prioritize minimizing morbidity, mortality, and improving quality of life, and should be guided by the most recent and highest quality evidence, including the studies by 1 and 1.

From the FDA Drug Label

The efficacy of XTANDI in patients with CRPC (N = 4692), mCSPC (N = 1150), or nmCSPC with high‑risk BCR (N = 1068) was demonstrated in six randomized, multicenter clinical trials. Patients received concomitant GnRH therapy or had prior bilateral orchiectomy, unless otherwise indicated AFFIRM (NCT00974311): XTANDI versus Placebo in Metastatic CRPC Following Chemotherapy PREVAIL (NCT01212991): XTANDI versus Placebo in Chemotherapy-naïve Metastatic CRPC

The next steps for a patient presenting with dysphasia and unintended weight loss, with a computed tomography (CT) scan of the chest/abdomen/pelvis showing multiple sclerotic foci consistent with osseous metastatic disease, multiple pulmonary nodules, mediastinal (medial) hilar lymphadenopathy, and an enlarged prostate gland with macrocalcifications, may include:

• Further evaluation to confirm the diagnosis of metastatic prostate cancer
• Consideration of GnRH therapy or bilateral orchiectomy
• Evaluation for chemotherapy or other systemic treatments
• Consideration of enzalutamide (XTANDI) as a treatment option, based on the results of clinical trials such as AFFIRM and PREVAIL 2 Key considerations include:
• The patient's overall health and performance status
• The extent of metastatic disease
• The presence of any symptoms or complications related to the cancer
• The potential benefits and risks of different treatment options

From the Research

Next Steps for Patient with Dysphasia and Unintended Weight Loss

The patient's presentation with dysphasia and unintended weight loss, along with the CT scan findings of multiple sclerotic foci consistent with osseous metastatic disease, multiple pulmonary nodules, mediastinal (medial) hilar lymphadenopathy, and an enlarged prostate gland with macrocalcifications, suggests a possible diagnosis of metastatic prostate cancer 3, 4, 5.

Diagnostic Considerations

• The patient's symptoms and imaging findings are consistent with advanced prostate cancer, which often presents with metastatic disease to the bones, lungs, and lymph nodes 5.
• The presence of an enlarged prostate gland with macrocalcifications on the CT scan is also suggestive of prostate cancer 6.
• Prostate-specific antigen (PSA) is a useful biomarker for detecting prostate cancer, and elevated PSA levels are often seen in patients with metastatic disease 3, 6.

Treatment Options

• The standard initial systemic therapy for advanced prostate cancer is androgen-deprivation therapy (ADT), which can help to reduce PSA levels and slow disease progression 3.
• However, patients with metastatic prostate cancer often progress to castration-resistant prostate cancer (CRPC), which has a high mortality rate 3.
• Nursing professionals play a vital role in symptom recognition and reporting, identification of disease progression, patient education, and implementation of individualized treatment strategies 5.

Further Evaluation and Management

• A full staging workup, including a prostate biopsy, may be necessary to confirm the diagnosis and assess the extent of disease 4.
• The patient's symptoms, such as dysphasia and unintended weight loss, should be managed aggressively to improve quality of life 5.
• Regular monitoring of PSA levels and imaging studies can help to assess response to treatment and detect disease progression early 3, 5.