Caucasian Male DOB:1961
Has Severe Plaque Psoriasis since 2003
Has received Embrel, Stelera and Tremfya biologics but, no longer on an immune suppressant as of 03/18/2022 due to concern of advanced metastatic prostate cancer.

Diagnosed By PSA Score 942.40 06/24-2022-07/06/2022
Advance Metastatic Prostate Cancer with Ductal subtype with focal cribform architecture in carcinoma (it is rare, unfortunately aggressive) 4 cores out of 15 with another questionable core with necrosis and questionable atypical cells
Stage 4 Gleason 8 3 Lytic Lesions (unusual or rare)
CT Scan, Pylarify Pet Scan, Bone Scan, 3T 3D guided MRI with write over
07/15/2022 Transperineal Biopsy
Started Firmagon 7/6/2022 Zytiga with Prednisone 7/20/2022 and Docetaxel Chemotherapy on 08/11/2022
Ductal Prostate Cancer is aggressive, it cannot be monitored by psa score alone.
As it can still spread by low non existing psa numbers.
PSA 942.40 7/6/2022 To 2.87 08/03/2022
To 1.07 08/11/2022 To 0.41 09/01/2022
To 0.34 09/13/2022 Testosterone <7
To 0.24 10/18/2022 Testosterone <7
The good news is no lesions on ribs, lung, liver, heart or brain, from scans dated between 6/28/2022 to 07/15/2022 We pray that is still true.
Have to wait for new scans until our Medical Oncologist is willing to do one.
My husband’s BRCA test came back with a mutation for BLM.
Everyone has two copies of the BLM gene, which we randomly inherit from each of our parents. Mutations in one copy of the BLM gene can increase the chance for you to develop certain types of cancer in your lifetime. And here we are with a certain rare type of prostate cancer…
So, my husband is BRCA Negative but with BLM one copy gene mutation
We are not versed on familial and therapeutic implications with PARPi inhibitors.

We requested a Decipher test, we were told this number is only useful when the cancer is contained to the prostate.
We also requested genome sequencing done on the biopsy samples.
The Tumor genomics were an-
Oncomine targeted panel with Tier 2 variants in p53 and CDH1 and Tier 3 in DNMT3A, HRAS, WT1.
So, our next move is to maybe send out the original 4/15 core samples to Foundation
One or do a guardiant test.
We still need to look into Immunotherapy possibly for the future
My husband has an active interest is his health, and he is very much in tune and in communication with his physicians. We discuss findings and coshare the results.
He discusses and decides what he wants to do and what he is comfortable doing…Livimg…
Ductal Adenocarcinoma is an unusual or rare sub type of prostate cancer often missed altogether or sadly under diagnosed…and clinically under staged.
Presently, AMPC Standard of Care is the only treatment available.
Ductal subtype Advanced Metastatic Prostate Cancer may cause Lesions that spread up from pelvic area to ribs, liver, lung, heart and brain, plus other areas.
We are afraid of a clinician treated it the same as Advanced Metastatic Prostate Cancer.
Biopsy 07/15/2022 Prostate cancer (C61) DIAGNOSIS :
A. Prostate core, left anterior apex, biopsy: Prostatic adenocarcinoma, Grade Group 4 (Gleason score 4+4=8) with ductal features, involving 5% (1 mm) of 1/1 core.
B. Prostate core, left anterior base, biopsy: Prostatic adenocarcinoma, Grade Group 4 (Gleason score 4+4=8) with ductal features, involving 95% (13 mm) of 1/1 core.
E. Prostate core, midline apex, biopsy: Prostatic adenocarcinoma, Grade Group 4 (Gleason score 4+4=8) with ductal features, involving 70% (9 mm) of 1/1 core.
O. Prostate, MR target prostate core x5, biopsy: Prostatic adenocarcinoma, Grade Group 4 (Gleason score 4+4=8) with ductal features, involving 30%, 10% (2 mm, 1 mm) of 2/5 core fragments.
K. Prostate core, left lateral apex x2, biopsy: Benign fibromuscular tissue with hemorrhage and rare atypical cells; cannot exclude reactive myofibroblasts.
Below seems to be benign...

C. Prostate core, right anterior apex, biopsy: Benign prostatic tissue with acute inflammation.
D. Prostate core, right anterior base, biopsy: Benign prostatic tissue.
F. Prostate core,midline base, biopsy: Benign fibromuscular tissue and skeletal muscle.
G. Prostate core, left posterior apex, biopsy: Benign fibromuscular tissue.
H. Prostate core, left posterior base x2, biopsy: Benign prostatic tissue with hemorrhage.
I. Prostate core, right posterior apex, biopsy: Benign prostatic tissue.
J. Prostate core, right posterior base, biopsy: Benign prostatic tissue.
L. Prostate core, right lateral apex, biopsy: Benign prostatic tissue.
M. Prostate core, right lateral base, biopsy: Benign prostatic tissue.
N. Prostate core, left lateral base, biopsy: Benign fibromuscular tissue and skeletal muscle.

6/28/22: CT scan - Prostate/seminal vesicles/urinary bladder:
The prostate is irregularly enlarged with mixed internal attenuation measuring approximately 8.7 x 7.3 x 6.6 cm (series 4, image 148; series 605, image 73), and is noted to invade the posterior aspect of the bladder and abut the rectum posteriorly.
The urinary bladder is distended.
Lymph nodes: Left external iliac nodal conglomerate with heterogeneous internal attenuation measuring approximately 5.5 x 4.8 cm (series 4, image 128).
This nodal conglomerate splays the external iliac artery and external iliac vein.
Additional enlarged left external iliac lymph node measuring 1.6 x 1.5 cm (series 4, image 153).
Left common iliac lymph node measuring 1.2 x 1.3 cm (series 4, image 102).
Prominent right external iliac lymph node measures 1.3 x 1.3 cm (series 4, image 153).
Additional prominent lymph nodes are visualized.
Bones/Soft tissues: Multiple destructive osseous metastases, some of which have soft tissue components, for example:
*Right iliac destructive lesion with large soft tissue component which appears to invade the right iliacus muscle and right gluteal musculature, measuring approximately 11.8 x 9.6 x 11.1 cm (series 4, image 112; series 604, image 59)
* Right sacral destructive lesion with soft tissue component measuring approximately 4.3 x 2.2 x 4.4 cm (series 4, image 135; series 604, image 92), extending into the right piriformis muscle
IMPRESSION:
1. Heterogeneously enlarged and nodular prostate which invades the urinary bladder and contact the rectum, consistent with primary prostate malignancy.
2. Left external iliac nodal conglomerate noted to be PSMA avid on subsequently performed PET-CT consistent with metastases. Additional pelvic lymphadenopathy visualized, possibly also metastases.
3. Multiple destructive osseous lesions with soft tissue components as described above found to be avid on subsequently performed PSMA PET, consistent with metastases.
4. Moderate left hydroureteronephrosis to the level of the pelvis where there is extrinsic compression from the heterogeneously enlarged prostate.

7/1/22 PSA 942.40 7/2/22: PSMA PET - IMPRESSION:
1. Marked, heterogeneous enlargement of the prostate gland with multifocal PSMA avidity and photopenic, likely necrotic areas, compatible with prostatic malignancy. This mass invades the left posterolateral urinary bladder with associated upstream left moderate hydroureteronephrosis and abuts the rectum, for which involvement is not excluded.
2. Large PSMA avid left external iliac metastatic nodal conglomerate.
3. Intensely PSMA avid osteolytic lesions with soft tissue involvement, including largest destructive lesion in the right iliac bone, a left proximal femoral shaft lesion with cortical thinning and intramedullary soft tissue replacement, and a lytic lesion in the right sacrum with invasion into the right S3 and probably S4 neuroforamina. Correlate clinically and consider further evaluation with MR pelvis as clinically warranted. Advise weight-bearing precautions.
4. Multiple PSMA avid mediastinal and axillary lymph nodes, possibly metastatic.
5. Overdistended urinary bladder. Correlate for urinary retention.

EXAM: PET-CT SKULL BASE TO MID-THIGH CLINICAL HISTORY:
PCA (PSA >800, clinically T3b-T4, large invasive mass right pelvis on CT).
Initial staging.
TECHNIQUE:
PET/CT skull base to thigh-initial treatment strategy
CORRELATION:
Outside CT abdomen and pelvis dated 06/28/2022
FINDINGS:
Mean liver SUV: 3.9 Mean blood pool SUV: 0.9 Mean right parotid gland SUV: 16.0
HEAD/FACE: Physiologic PSMA uptake is seen in the lacrimal and salivary glands.
Mastoid air cells and paranasal sinuses are clear.
NECK: Physiologic PSMA uptake is seen in neck muscles.
CERVICAL NODES: No abnormal PSMA uptake.
MEDIASTINUM/HEART/GREAT VESSELS: Physiologic PSMA uptake in the mediastinal blood pool.
*Mild coronary artery calcifications.
LUNGS: No abnormal PSMA uptake.
PLEURA/PERICARDIUM: No abnormal PSMA uptake.
**THORACIC NODES: Multiple PSMA avid mediastinal lymph nodes,
for example: - right hilar, SUV 4.4 (image 142) - subcarinal, 1.7 x 0.6 cm, SUV 3.6 (image 142) -
left lower paratracheal, 1.1 x 0.6 cm, SUV 3.9 (image 132)
Multiple bilateral axillary lymph nodes,
for example: - right axillary, 1.6 x 0.9 cm, SUV 6.9 (Image 126) - left axillary, 1.1 x 0.7 cm, SUV 2.1 (image 136)
HEPATOBILIARY:Physiologic, intense and homogeneous PSMA uptake is seen in the liver.
SPLEEN: Physiologic PSMA uptake. PANCREAS: No abnormal PSMA uptake.
ADRENAL GLANDS: No abnormal PSMA uptake.
KIDNEYS/URETERS/BLADDER: Excreted physiologic PSMA activity is present.
Bilateral photopenic renal cysts, largest measuring 13.4 cm on the left upper pole (image 204).
Moderate left hydroureteronephrosis.
Overdistended urinary bladder to the level of the umbilicus,
increased from prior

CT dated 06/28/2022.
ABDOMINOPELVIC NODES:
Peripherally PSMA avid left external iliac nodal conglomerate with photopenic,
likely necrotic center, 5.9 x 4.7 cm, SUV 48.8 (Image 261).
BOWEL/PERITONEUM/MESENTERY: Physiologic PSMA uptake in the small bowel and colon. No abnormal PSMA uptake.
PROSTATE GLAND/SEMINAL VESICLES: Marked irregular enlargement of the prostate gland with probable extension into the left posterior wall of the urinary bladder and abutting the anterior rectal wall, measuring approximately 9.1 x 8.6 x 6.8 cm.
Heterogeneous PSMA avidity with multiple foci interposed between areas of photopenia corresponding to hypodense, likely necrotic areas,
as follows: - involving the left hemiprostate gland from the base to the apex,
SUV 53.6 at the apex and SUV 47.2 at the base - right apical soft tissue nodularity bulging the capsule with probable extracapsular extension into the periprostatic fat, SUV 20.8 (image 284) -
left to midline posterior apical soft tissue nodularity bulging the capsule and abutting the rectum,
SUV 24.4 (image 286)

BONES/SOFT TISSUES: Multiple PSMA avid osseous lesions, for example: -
destructive lesion involving the right iliac bone with large soft tissue component extending medially into the iliacus muscle and laterally into the gluteal musculature,
measuring approximately 11.6 x 10.8 cm, SUV 68.8 (image 261) -
destructive lesion in the right sacrum with soft tissue component extending into the right S3 and probably S4 neuroforamina, measuring approximately 3.8 x 2.2 cm, SUV 53.0 (image 268) -
left proximal femoral diaphysis with cortical thinning and intramedullary soft tissue replacement,
SUV 37.7 (image 329) OTHER FINDINGS:
Atherosclerotic calcifications.

7/6/22: Bone scan -
FINDINGS: Osseous findings: Foci of radiotracer uptake in the left proximal femoral shaft, right iliac bone, right sacrum (best seen on postvoid images) corresponding to PSMA avid bone metastases on seen on recent CT.
No additional avid bone lesions.
Foci of radiotracer activity present in the bilateral shoulders, sternum and knees consistent with degenerative changes.
Kidneys: Excreted radiotracer activity is visualized in renal collecting system with mild left hydroureteronephrosis, not significant changed prior CT.
Distended bladder which persists on postvoid imaging suggestive chronic outflow obstruction.

IMPRESSION: MDP avid pelvic and right femoral osseous metastasis,
corresponding to PSMA avid disease on recent PET. 7/10/22:

MRI prostate -
IMPRESSION:
1. Extensive prostate neoplasm with invasion into the bladder, rectum, and seminal vesicles.
2. Left external iliac metastatic lymph node.
3. Right iliac and right sacral osseous metastases.

EXAM:
NM BONE SCAN SINGLE PHASE WHOLE BODY CLINICAL HISTORY:
Prostate cancer. Evaluate for osseous metastases.
TECHNIQUE:
Anterior and posterior whole body images were obtained approximately 2 hours following IV administration of 24.4 mCi of Tc99m-MDP.
Spot views:
AP chest with arms up, lateral skull, postvoid pelvic
COMPARISON: No prior bone scans in our system.
CORRELATION:
PET-CT PSMA July 1, 2022
FINDINGS:
Osseous findings: Foci of radiotracer uptake in the left proximal femoral shaft, right iliac bone, right sacrum (best seen on postvoid images) corresponding to PSMA avid bone metastases on seen on recent CT.
No additional avid bone lesions.
Foci of radiotracer activity present in the bilateral shoulders, sternum and knees consistent with degenerative changes.
Kidneys: Excreted radiotracer activity is visualized in renal collecting system with mild left hydroureteronephrosis, not significant changed prior CT.
Distended bladder which persists on postvoid imaging suggestive chronic outflow obstruction.
Soft tissue/other findings: Unremarkable…

Medications
Firmagon Injection @28 days
Zytiga & Prednisone @Daily
Chemotherapy Docetaxel @21 Days for 6 Sessions
start 8/18/2022