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Advanced Prostate Cancer
Center of Excellence
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Yuri Gulevich
May 22, 2018
Sorry, the dates (the indicated years ) were incorrect in the above description. Please find below the text with the corrected dates:
In Dec-16 a blood test of a 60 years old man came up with PSA of 37 ng/mL. The following additional tests have been done within Jan/Feb-17: mp MRT; fusion biopsy (10 out of 12 positive, Gleason 4+4 = 8); bone scan (negative); Ga68 PSMA PET-CT (negative for mets). The resulted clinical diagnosis: T2c, Nx, M0.
The decision was made to treat locally with a robot-assisted radical prostatectomy (RP). As the projected waiting time for the RP was 3 months, we started ADT in order to prevent a possible progression of the PCa during this waiting period: (a) on 22 Feb-17 - Bicalutamid 150 mg was started; (b) on 06 Mar-17 – a 3-month injection of Trenantone (LHRH-analogue) was made and Bicalutamide was discontinued somewhat later on 23 Mar-17. The scheduled RP was shifted to a much earlier date of 21 Mar-17. Hence duration of the neoadjuvant ADT was only one month. Diagnosis after RP: pT3a, pN1 (1 mm micro-metastasis in 1 out of 14 LN’s), Gleason 4 (85%) + 5 (15%) = 9, negative surgical margin. ADT using 3-month Trenantone injections was continued after the RP. PSA data (ng/mL): 12 Apr-17 --- 0.071; from 27 Apr-17 till now --- below 0.008
Thomas McBride
May 25, 2018
We would observe the patient in this situation. PSA is so low and the risks of prolonged ADT in a 60 year old outweighs the clinical benefit vs. prostate cancer. Tough to wholly decide on this not knowing his medical history, presuming he was relatively healthy here. Per Phoenix criteria PSA progression, and per a changing landscape on mCRPC, his life expectancy and comorbidities are hugely relevant at age 60. Additionally, earlier prolonged ADT must be responsible for the ARV-7 mutation, so as time goes on we may have more accurate studies in this post-prostatectomy biochemical failure ---> observation EBRT+/-ADT space (PROS-8 on NCCN guidelines), with regards to how early we should be using ADT. With the PSA at nadir, we would not be using ADT. Would hope for a surgical cure given the path you presented pN1 @ 1mm, and give that time to show up.
Georg Potthast
May 25, 2018
You could continue ADT. Hussain and Dorff had excellent long-term results in this study:
https://www.ncbi.nlm.nih.gov/pubmed/29624463
Eric Khoo
May 31, 2018
Divergence of practice in scenario like this. The true no of lymph node metastasis is unclear in the setting of 1 month of androgen deprivation. In such an ultra low PSA (predominantly suppressed by androgen deprivation), the option of repeat PSA and testosterone in 3-6 months is reasonable. If the PSA rises, there is randomised data to support the use of RT and ADT with PSA 0.2-4, although the study only include N0 patient cohort.
N Engl J Med. 2017 Feb 2;376(5):417-428. doi: 10.1056/NEJMoa1607529.
Radiation with or without Antiandrogen Therapy in Recurrent Prostate Cancer.
Shipley WU1, Seiferheld W1, Lukka HR1, Major PP1, Heney NM1, Grignon DJ1, Sartor O1, Patel MP1, Bahary JP1, Zietman AL1, Pisansky TM1, Zeitzer KL1, Lawton CA1, Feng FY1, Lovett RD1, Balogh AG1, Souhami L1, Rosenthal SA1, Kerlin KJ1, Dignam JJ1, Pugh SL1, Sandler HM1; NRG Oncology RTOG.
Igor Vaz
Jun 06, 2018
i am working in Mozambique where no [brachy] and no Radiation is available, I would continue ADT for 3 months and check the PSA at 3th month. Radiation will be a good option in your settings
Andy Petrovski
Jan 26, 2019
I tend to agree with Thomas McBride above to simply observe the patient without any further treatment.
Certainly NO radiation because of its carcinogenic effect causing high likelihood of long-term very negative sides like rectum ulcers and up to inducing cancers in adjacent parts (e.g. bladder). Thomas Stamey, professor and chairman of Urology at Standford, once said: ""I hope that most physicians will recognize that radiotherapy is no longer a viable option for treatment of prostate cancer. We should not use a therapy that can make 80% of the patients worse than the natural history of the disease."
As demonstrated long ago, PCa thrives in the bone marrow, and several studies confirmed that 80-85% patients scheduled for (and later undergo) radical prostatectomy (RP) have cancer cells in the marrow. Also, numerous other studies have found that RP does not extend life. This is to say that PCa must be treated using a systemic treatment like ADT, especially if there's a suspicion of recurrence.
Remember however that poorly differentiated (high grade) PCa cells produce far less PSA than regular prostate cells, so in the absence of the prostate gland low or barely detectable PSA levels can be misleading.
Apr 24, 2024
Pending Moderator approval.
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Yuri Gulevich
May 22, 2018
Thomas McBride
May 25, 2018
Georg Potthast
May 25, 2018
Eric Khoo
May 31, 2018
Igor Vaz
Jun 06, 2018
Andy Petrovski
Jan 26, 2019
Apr 24, 2024
Pending Moderator approval.