Unusual anti-angiogenic effect of combined hormonal blockade.

Abstract

A 72-year-old white man with a history of Gleason score 6 (3 3) clinical stage T2bNxM0 prostate cancer was initially treated in May 1997 with external beam radiation therapy. The patient had a prostate specific antigen (PSA) nadir of 0.6 ng./ml. in April 1998 and from that point PSA rapidly increased with a doubling time of 3.6 months. Computerized tomography of the abdomen and pelvis in addition to bone scan revealed no evidence of gross distant spread. Before initiation of therapy PSA had increased to 4.9 ng./ml. (normal less than 4.0). The patient was started on 7.5 mg. leuprolide intramuscularly once per month, and 50 mg. bicalutamide and 5 mg. finasteride orally once per day for recurrent occult prostate cancer. Examination of the skin before initiation of chemotherapy showed diffuse areas of superficial dilated small blood vessels of the chest, neck and cheeks of the face (arborizing telangiectasia), which the patient stated had been present for most of his adult life. These vessels, representing capillaries or small arteries (arterioles), were associated with an intense pink color of the surrounding skin. After 4 months of chemotherapy the patient complained of what he called a rash over the chest. Close examination of the skin demonstrated no evidence of rash, but rather a mosaic pattern of normal (lighter) skin color within residual arborizing telangiectasia (see figure). The lighter coloration occurred because of the apparent random regression of communicating and branching small blood vessels. The skin of the chest represented a window displaying an anti-angiogenic response to chemotherapy. Concomitant with these skin changes was a decrease in serum testosterone to less than 20 ng./dl. (normal 212 to 755) and a decrease in PSA from 5.6 to 0.05 ng./ml.