title: Prior administration of a non-steroidal anti-androgen failed to prevent the flare-up caused by a luteinizing hormone-releasing hormone agonist in a patient with metastatic prostate cancer.
abstract: BACKGROUND
  'Flare phenomenon' after initial luteinizing hormone-releasing hormone agonist administration is a widely approved concept in the treatment of prostate cancer. In most guidelines, concomitant therapy with anti-androgens is recommended to prevent this flare phenomenon. However, there are few reports describing serum prostate-specific antigen transitions after hormonal therapy. Here, we present a case of a man who experienced the biochemical and clinical flare phenomenon despite prior anti-androgen use and who has detailed data.
  
  
  METHODS
  A 70-year-old Asian man with metastatic prostate cancer (multiple bone) was referred to our hospital. He was treated with prior anti-androgens and luteinizing hormone-releasing hormone agonist. Regardless of prior use of anti-androgens, his low back pain caused by bone metastases was deteriorated and serum prostate-specific antigen level was raised from 974.8 ng/mL to 2,555.5 ng/mL within 3 weeks. Then, his serum prostate specific antigen level started to decrease along with the pain. The nadir reached 1.0 ng/mL and remained for 6 months. Because the serum level of prostate-specific antigen then began to increase again, anti-androgen was discontinued for anti-androgen withdrawal syndrome. Then the serum level decreased again to less than 0.1 ng/mL. Until now, his serum prostate-specific antigen level has been maintained at less than 0.1 ng/mL for more than 30 months without any clinical progressions.
  
  
  CONCLUSIONS
  We present the case of a patient in whom a clinical flare caused by an leuteinizing hormone-releasing hormone agonist was not prevented by prior anti-androgen administration. In addition, the nadir level of prostate-specific antigen when he received leuteinizing hormone-releasing hormone monotherapy was ten times lower than when he received concomitant therapy, and period of anti-androgen withdrawal syndrome was longer than usual. In this case, anti-androgen was probably not effective from the initial administration. Awareness of the possibility of ineffectiveness of anti-androgens is important in the treatment of symptomatic metastatic prostate cancer. Leuteinizing hormone-releasing hormone antagonist and surgical castration is a more reliable clinical approach for the prostate cancer patients with symptomatic metastatic disease.
authors.affiliation: Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. sho.uehara@jfcr.or.jp.
authors.forename: Sho
authors.initials: S
authors.lastname: Uehara
authors.affiliation: Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. takeshi.yuasa@jfcr.or.jp.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Yuasa
authors.affiliation: Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. y-fujii.uro@tmd.ac.jp.
authors.forename: Yasuhisa
authors.initials: Y
authors.lastname: Fujii
authors.affiliation: Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. yanoaki@saitama-med.ac.jp.
authors.forename: Akihiro
authors.initials: A
authors.lastname: Yano
authors.affiliation: Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. shinya.yamamoto@jfcr.or.jp.
authors.forename: Shinya
authors.initials: S
authors.lastname: Yamamoto
authors.affiliation: Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. hitoshi.masuda@jfcr.or.jp.
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Masuda
authors.affiliation: Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. ifukui@jfcr.or.jp.
authors.forename: Iwao
authors.initials: I
authors.lastname: Fukui
authors.affiliation: Department of Urology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. jyonese@jfcr.or.jp.
authors.forename: Junji
authors.initials: J
authors.lastname: Yonese
mesh_terms: D000368:Aged; D000726:Androgen Antagonists / Q000008:administration & dosage*; D000813:Anilides / Q000627:therapeutic use; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage*; D018450:Disease Progression; D007987:Gonadotropin-Releasing Hormone / Q000819:agonists*; D006801:Humans; D008297:Male; D009362:Neoplasm Metastasis; D009570:Nitriles / Q000627:therapeutic use; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000097:blood / Q000150:complications / Q000188:drug therapy*; D014105:Tosyl Compounds / Q000627:therapeutic use
chemical_list: D000726:Androgen Antagonists; D000813:Anilides; D000894:Anti-Inflammatory Agents, Non-Steroidal; D009570:Nitriles; D014105:Tosyl Compounds; D007987:Gonadotropin-Releasing Hormone; C053541:bicalutamide; D017430:Prostate-Specific Antigen