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Advanced Prostate Cancer
Center of Excellence
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Jeffrey Tosoian
Jun 09, 2015
This patient is presenting with metastatic prostate cancer (mPCa) with distant metastases to the bone, leading to significant symptoms. Plain films have demonstrated vertebral fractures, and MRI may be helpful in identifying the site of symptomatic lesions and any lesions that may cause impending problems.
As you mention, immediate therapy is necessitated by impending cord compression. Intravenous steroids should be initiated in order to decrease swelling and inflammation. Immediate androgen deprivation therapy (ADT) should be initiated by either bilateral orchiectomy, GnRH antagonists (e.g. degarelix), or inhibitors of androgen synthesis (e.g. ketoconazole). Bilateral orchiectomy and ketoconazole produce castrate testosterone levels usually within 12 hours, while GnRH antagonists take up to 3 days. Notably, LHRH agonists should not be used, as testosterone flare may acutely worsen compression.
Early involvement of neurosurgery, radiation oncology, and medical oncology is merited as well. If the patient is deemed to have spinal instability, bone protrusion into the cord, or neurologic compromise from metastasis, these would be indications for surgical intervention. Otherwise, immediate radiation therapy should be implemented in addition to ADT.
Finally, while the patient is anticoagulated for atrial fibrillation, I would think the risk of a bleed in his current condition outweighs the minimal daily risk of embolic event secondary to AF. After consultation with either his managing physician or specialists at your institution, it may be prudent to hold his anticoagulation at least until a multidisciplinary plan of care is established.
Paul Pomerantz
Apr 16, 2017
I generally agree with the above assessment however severe back pain with related Mets does not automatically mean cord compression. It might be of benefit to obtain an MRI to see if there is a cord compression which would certainly warrant either neurosurgical or radiation oncologyinvolvement. Bilateral orchiectomy certainly would provide the quickest route to castrate levels however the other methods suggested would work as well. If LHRH agonist were to be used first line anti-androgen such as bicalutamide could be started immediately.
Dec 09, 2024
Pending Moderator approval.
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Jeffrey Tosoian
Jun 09, 2015
Paul Pomerantz
Apr 16, 2017
Dec 09, 2024
Pending Moderator approval.