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Thank you for sharing this case .These patients patients exist to challenge our clinical decision making process .We should be respectful for patient's autonomy ,choices, personal and social circumstances and consider all options .Explaining these options and guiding the individual to make the decision that resonate well with him should be considered .If he remains asymptomatic with rising serum PSA and has waited 7 years ( that is , from 2013),there is little justification for any intervention-as any such intervention may change his situation in a different way that may not be favourable. While we admit that the optimal management is currently not available, the Hippocratic dictum "Doctor do no harm" is good !
Comment deleted by Moderator.
Salvage SBRT to prostate and entire pelvic LN area. ADT and abiraterone for 2-3 years.I
I agree with Juan Artigas except ADT plus abiraterone for no more than 1 1/2 years. Long term (2+ years) abiraterone/prednizone can have lasting negative effects on adrenal glands.
I think LHRH antagonist plus Biclutamid for 2 years
I never did like brachy for this nodal result!! I'd suggest ADT and follow his PSA if no geonomics available
The patient has not reached a good nadir following Brachy. He should have been more closely followed up.Despite lack of symptoms it is rapidly progressive disease and the patient will become symptomatic very soon. With non regional lymph nodes this is M1a disease. Hormone treatment would be the corner stone. Having upfront chemo or AR signal blockers like Abiraterone would entail survival advantage. Salvage radiotherapy to the prostate can be considered.
It seems PSA doubling time <24 mo; GS in certain cores 4+3=7. Young, 58 y.o. We do not know what comorbidities; likely to become symptomatic - symptoms control and preserving QoL/sexual function important. Intermittent ADT monotherapy can be considered. If CVD comorbidity and opted for intermitent admin.- antagonist. Meta-analyses have reported increased cardiac toxicity and hypertension with abiraterone. IF CAB desired perhaps apalutamide.
I would give him two treatment paradigm options here. More guideline based: Intermittent LHRHa vs. continuous as mainstay, with radiation oncology consultation for an honest discussion on whether or not radiating the common iliac nodes is something he would allow given 1) prior failure and patient confidence in radiation therapy 2) changes in tradition therapy in the 8 years since his treatment and how it might now reduce his chances of failure and side effects.
He should understand that as soon as failure is again detected, a "less is more" approach is less desirable this time around. If PSA rises then look at ARV-7 testing before choosing anti-androgen, and if mCRPC shows up, then genomic testing for PARP, etc. He was 50 when he was diagnosed and clearly was a minimalist against the idea of RRP so he needs to be more careful about closing in on a cure with more active therapies and be more aggressive.
Surgeons: Is there a role for pelvic node resection in this case?
Philip von Lintel MD
Can avoid ADT ( perhaps a patient specificity ) toxicity ... follow with PSA / PSADT with threshold value in mind . ? suspicion ... Image Ga68 PSMA / RX RT SBRT ( ?+/- surgery ) with target ... for local ablative Rx for ( oligomet disease ) ... vs Lu PSMA
Either ADT alone or if feasible ADT with salvage RT to the prostate and nodes pending review by radiation oncology.
Pending Moderator approval.
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