Patient Name: John R.
Matthews
DOB: 04/09/1958 (Age: 67)
MRN: 28394712
Gender: Male
Date of Visit: 06/24/2025
Clinic: GU Oncology - Phase I Trials
Referring Physician: Dr. Sandra Chen, MD
Attending: Dr. Kevin L. Rothman, MD
Visit Type: Pre-screening and eligibility evaluation
Chief Complaint:
Follow-up and clinical trial eligibility evaluation for advanced prostate cancer.
History of Present Illness:
Mr. Matthews is a 67-year-old male with metastatic castration-resistant prostate adenocarcinoma (mCRPC),
initially diagnosed in September 2022 following elevated PSA (27.4 ng/mL), abnormal DRE, and prostate
biopsy confirming Gleason 4+4=8 adenocarcinoma without neuroendocrine or small cell differentiation.
He was treated with ADT (leuprolide) and subsequently added abiraterone/prednisone (Oct 2022-Jun 2023).
PSA progressed from 3.2 to 9.4 ng/mL by June 2023. Enzalutamide was initiated July 2023; however,
progression was confirmed radiographically in March 2024 with new osseous lesions. He declined taxane
chemotherapy and also refused PARP inhibitor therapy (olaparib), despite a positive BRCA1 mutation. No
additional lines of therapy have been administered since.
Last systemic treatment was discontinued 05/20/2025. The patient remains on leuprolide and continues to
have castrate levels of testosterone.
Past Medical History:
- Prostate adenocarcinoma (stage IV, BRCA1+, mCRPC)
- Hypertension (controlled)
- Hyperlipidemia
- GERD
- Mild chronic kidney disease (baseline Cr 1.1)
Past Surgical History:
- Appendectomy (1982)
- Inguinal hernia repair (1999)
Medications:
- Leuprolide depot IM q3mo
- Amlodipine 5 mg daily
- Atorvastatin 20 mg daily
- Pantoprazole 20 mg daily
Allergies:
No known drug allergies
Social History:
- Former smoker (quit 2015, 25 pack-years)
- Occasional wine consumption
- Retired accountant, lives with wife
- No substance abuse history
- Sexually active; partner is premenopausal; plans to use dual barrier contraception
Family History:
- Father: prostate cancer (deceased, age 78)
- Mother: breast cancer, BRCA1+
- Sister: ovarian cancer (alive, BRCA1+)
Review of Systems:
- Fatigue: mild
- Appetite: stable
- Weight: no recent loss
- Pain: mild back pain, managed with acetaminophen
- Urinary: no hematuria, no obstructive symptoms
Physical Exam:
- ECOG: 1
- Vitals: HR 78, BP 128/76, Temp 98.4 degreesF, RR 14, SpO2 99%
- General: Alert, NAD
- CV: RRR, no murmurs
- Lungs: Clear to auscultation
- Abdomen: Soft, NT/ND
- GU: No palpable masses
- MSK: Mild tenderness over L-spine
- Neuro: Intact
Labs (Drawn 06/22/2025):
- CBC: WNL (ANC 2.4, Hb 12.5 g/dL, PLT 175)
- CMP: Cr 1.1 mg/dL, AST/ALT 28/32 U/L, Tbili 0.8 mg/dL
- Testosterone: 0.3 ng/mL
- PSA: 28.3 ng/mL
- HIV/Hep B/C: Negative
- COVID-19 PCR: Negative
Imaging:
- MRI Pelvis w/contrast (06/20/2025): 1.2 cm right peripheral zone lesion; accessible via TRUS for
intratumoral injection
- Bone Scan (06/18/2025): Multiple metastatic lesions to spine and pelvis; stable since March 2025
- CT Chest/Abdomen/Pelvis (06/19/2025): No visceral metastases; stable known lymphadenopathy
Cardiac Clearance:
- EKG: NSR, QTcF 422 ms
- Echo: EF 60%, no valvulopathy
- Clearance: Cardiology approved on 04/15/2025
Assessment:
- Metastatic castration-resistant prostate adenocarcinoma
- BRCA1-positive, declined PARP therapy
- No alternative standard-of-care options available
Plan:
- Proceed with final enrollment screening
- Schedule TRUS-guided biopsy
- Confirm lesion accessibility with interventional radiology
- Begin protocol treatment on or after 07/01/2025