ESTRAMUSTINE PHOSPHATE WITHDRAWAL SYNDROME WITH DRAMATIC PAIN RELIEF

A 65-year-old man with hormone refractory prostatic cancer was admitted to our hospital for severe pain of the pelvis and inferior limb due to multiple bone metastases 31 months after initial treatment with luteinizing hormone releasing hormone (LH-RH) agonist depot combined with flutamide. Flutamide was stopped after 2 months because of liver dysfunction. After hospitalization, he was treated with 250 to 375 mg. diethylstilbestrol phosphate intravenously daily and LH-RH. Serum PSA concentration decreased until 13 weeks after treatment and then it gradually increased. Diethylstilbestrol phosphate was stopped after 21 weeks (total dose 41.5 gm.), and the patient started taking 560 mg. estramustine phosphate orally daily. However, PSA level declined for only 2 weeks and then began to elevate. After 6 weeks of estramustine phosphate all hormonal therapy was stopped except for LH-RH. At the current hospitalization the patient was given 180 mg. morphine sulfate daily for pain relief and this dose was increased based on patient complaints to the maximum dose of 960 mg. at 18 weeks. Other treatment for pain relief, including spot irradiation, minor tranquilizers and dexamethasone, were also tried but complete relief of pain was not achieved. The course of treatment, levels of serum PSA and morphine sulfate dose are shown in figure 1. After estramustine phosphate withdrawal PSA concentration declined greatly and the pain was relieved dramatically. Daily dose of morphine sulfate was reduced gradually to a final dose of 0, 8 weeks after estramustine phosphate withdrawal (fig. 2). The patient was discharged home without morphine sulfate and is now followed as outpatient.