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I think it is a strange case, I'm not used to see patients with metastatic disease and such a low PSA level with a Gleason 4+3...
I would rather repeat the prostate biospy before taking any decision.
Nevertheless I think treatment of the primary tumors in oligometastatic patients may play a favorable role in patient's outcome
I would offer this patient a passibility of radical treatment with 3 mts. neo-adjuvant MAB + 3x12Gy HDR 3D Real Time Brachytherapy to the prostate + 50Gy/10fr ext. beam to the bone leasion + consecutive MAB for 21 mts. The final decision should of course be made in compliance with patient's expectations.
There is a role, as suggested by 2 radiation studies (PRO-7 and SPCG-7) and the recent Eur Urol papers by Culp (2014) and Fossati (2015), all of which demonstrate a survival advantage from treating the primary in oligometastatic prostate cancer. The survival advantage appears to be greater for surgery, probably explicable by the self-seeding hypothesis. However, as Chapain wrote in his editorial in Eur Urol on the subject in 2014, this ought to be done in the context of a trial as it is not mainstream treatment and further knowledge on this subject is needed. According to www.clinicaltrials.gov there are 7 trials on oligometastatic ca prostate ongoing in the US, 6 of which are still recruiting and one of which includes surgery. A multi-centre European study (TRoMbone) addressing this issue is set to start recruiting sometime later this year.
juan carlos velez roman
ADT with analogues LHRH + radioterapy 3D or IMRT a prostate for control de primary
Optional Radical Prostatectomy + extendend linphadenectomy and Adt
Jacques Planas: Why would you rebiopsy the patient? How would this alter your management?
Christopher Eden: I agree with you. We have a limited series of RARP in this setting (unpublished data) over the last few years and the patients have fared well thus far (obviously, limited follow-up). This is an interesting topic and will likely see a growing body of literature and pursuant interest from urologists over the next few years. The clinical trials are good evidence of this.
This is a very unusual case, with early metastatic disease and a very low PSA. On Pathology were there any neuro endocrine features? Did the patient have a family history suggestive of BRCA- in my experience there may be a discrepancy between PSA and cancer among BRCA carriers
Radical prostatectomy and radiotherapy for bone metastasis
@David Margel: There were no neuroendocrine features on any of his biopsies. He was not tested for BRCA, however, that is an interesting potential corollary.
I think Robot assisted RP then SRS to bone met, agree 50Gy/10 as per Belgian trial then hold off with ADT for moment and watch PSA, participation in trial given 'unusual' clinical scenario
I agree this is an unusual PSA value for metastatic disease. I could consider templates review by pathologist or even a new rebiopsy targeted to the abnormal area in MRI.
Pending Moderator approval.
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