Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy.

Abstract

case report E544Cite as: Can Urol Assoc J 2013;7(7-8):e544-6. http://dx.doi.org/10.5489/cuaj.175 Published online August 19, 2013. AbstractThe incidence of prostate cancer in transsexual patients is very low with only few reported cases. Many years before presenting with prostate cancer, these patients receive hormone ablation as a part of their gender therapy. Their disease is already defined as castrate resistant, and the treatment and follow-up of such patients remains a challenge. We report a case of a male-to-female transgender woman who was diagnosed with metastatic prostate cancer, 31 years post-feminization. Case reportIn 1970, a 45-year-old woman underwent male-to-female sex reassignment surgery, including bilateral orchidectomy. Since then she had started feminizing estrogen therapy, which included conjugated estrogen tablets 1.25 mg daily with no other hormone manipulation therapy. She had no documented family history of prostate cancer.At the age of 75, she presented with obstructive voiding urinary symptoms and was found to have a serum prostatespecific antigen (PSA) level of 13.5 ng/mL; no previous PSA level had been measured (Fig. 1). Her testosterone value was in the castrate range. She underwent a transurethral resection of the prostate and the histology revealed a Gleason 7 prostatic adenocarcinoma. Staging scans did not reveal any evidence of gross metastatic disease. In July 2000, the patient completed a course of external beam radiotherapy (20 fractions of 55.00 Gy) with curative intent. Treatment was well-tolerated. For 18 months following radiotherapy, her PSA values stabilized to about 20 ng/mL. Two years later, her PSA has risen to 37 ng/mL, at which time antiandrogen therapy was initiated (flutamide 250 mg, three times a day) and her estrogen replacement therapy was converted to diethylstilboestrol (1 mg once a day). Four months later, her repeat PSA value decreased to 20 ng/mL. At the end of the same year, diethylstilboestrol had been replaced with ethinyl estradiol (150 mcg once a day), which did not seem to have an effect on future PSA values. At that time a restaging bone scan was done which revealed a suspicion of single metastasis in the proximal femur. She remained asymptomatic. Fourteen months later, her PSA level increased to 40 ng/mL and a repeat bone scan demonstrated significant progression of osseous metastatic disease. At that time palliative chemotherapy was initiated. The patient was treated with mitoxatrone every 21 days and with prednisone 5 mg orally twice daily. She was given 6 cycles of chemotherapy with no toxic side effects. Her PSA initially rose from 53 ng/mL at the start of chemotherapy to 75 at the third cycle and reached plateau at 78 ng/mL after the sixth cycle. Repeated bone and computed tomography scan during chemotherapy showed stable appearances. On August 27, 2005, she was admitted to hospital with general deterioration in health. The next day, the patient died of thromboembolic event. DiscussionThe development of prostate adenocarcinoma in feminized tr...

Cancer in Transgender People: Evidence and Methodological Considerations

“…It is possible that prostate cancers in transwomen are more aggressive because these malignancies develop despite low levels of testosterone and high levels of estrogen (38). All reported cases of prostate cancer among transwomen who underwent gender affirmation had orchiectomy, and all were receiving hormonal therapy.…”

A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria

“…At the present time there are only four cases reported in the world literature. [48][49][50][51] In view of the high incidence of this malignancy within the male population, e.g. up to 50% by eight decades, it is difficult to attribute these cases to hormonal therapy.…”

Metastatic Prostate Cancer 35 Years After Sex Reassignment Surgery

“…2 She also received radiotherapy with curative intent. After her PSA rose to 37 ng/mL from 20 ng/mL, she was started on antiandrogen therapy with flutamide and diethylstilboestrol that was subsequently changed to ethinyl estradiol.…”

“…1 Prostate gland size and function are thought to be largely linked to levels of testosterone circulating in the male body; thus it is not surprising that a decrease in testosterone leads to a decrease in size of the prostate gland. 2 Conventional treatment of progressive prostate cancer is to remove the source of the testosterone, historically through surgical orchiectomy and more recently through chemical castration. Prostate cancers resistant to antiandrogen therapy are termed "castrate resistant" or "hormone resistant."…”

“…To our knowledge, 6 previous cases have been reported in the English literature (Table). 2,[4][5][6][7][8] In these published cases, the patients presented to their primary care providers (PCPs) with complaints of hematuria, difficulty urinating, or bone pain. In some cases, the PCP was unaware that the patient had transitioned from male to female, especially if the patient had undergone gender reassignment surgery, thus delaying possible treatment.…”