Due to elevated liver enzymes on zytiga - the MO referred my dad to a gastro-ent. He did check the liver manually for inflamation and ordered a few tests - Hepatitis B and Anti HCV for Hepatitis C, both came non reactive, alkaline phosphate which was normal in range at 50, serum protein levels (Albumin, Globulin and A/G Ratio were normal within range, total protein was however lower at 6.3 gm/dl (range: 6.4-8.2). Since my dad has a problem of chronic constipation since the past 10 years and has also had a piles operation done sometime back. The gastro ent. said to get the above tests done and then mentioned that we may have to do a colonoscopy. My dad did a colonoscopy 3 years back wherein one benign polyp was found.
My question is that is it safe to do a colonoscopy due to rectum involvement of his prostate cancer? He had a 68 Ga-PSMA Pet scan in July 2019 upon dx. The report reads:
Intense degree tracer avid heterogeneously enhancing soft tissue lesion is seen involving both lobes of prostate glans (Right > left). The lesion shows extra-prostatic extension along its posterior aspect with loss of fat plane with anterior wall of rectum. The lesion is involving bilateral seminal vesicles. The lesion measures approx. 47 x 38 mm and axial dimension and 52 mm craniocaudally (MAX SUV: 28.7).
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Thanks a lot for your response. How to Wipe it out ? Via surgery or radiation? The MO suggested on diagnosis that the enlarged prostate will shrink with ADT and Zytiga and the problem of constipation should ease...
I'm confused- is he metastatic at all? The ECE doesn't count as a metastasis- only pelvic lymph nodes (stage N1), non-pelvic LNs (stage M1a), bone mets (stage M1b), or visceral mets (stage M1c). Did the PSMA PET reveal any of those? If not, why isn't he having curative therapy?
He is metastatic with mets to several lymph nodes (enlarged bilateral external iliac, internal iliac, common iliac, paraaortic and interaortocaval lymph nodes), only 1 bone met on pubic bone. I mentioned the portion which stated about the rectum wall involvement to ask if colonoscopy would be safe or not.
Not sure why the MO is referring you to a gastro ent when elevated liver enzymes are a known SE of Zytiga, or asking for another colonoscopy after 3 years. Rather you should get a 3p MRI to determine the extent of rectal wall involvement. I would seek out an opinion on radiation treatment similar to that in my profile, HDR-BT + IMRT to depopulate the tumor.
I should have clarified more... my dad has a regular alcohol consumption of a daily glass or two of whiskey... so the Mo said it could be due to the medicine but there is no harm in getting everything checked with a gastro ent. ... the gastro ent mentioned a colonoscopy and we told him we got it done 3 years back so along with the reports we will show him the previous colonoscopy report as well. Regarding the radiation, the MO said it is not determined yet whether there is a benefit in debulking the original tumour via radiation or surgery in case of Mets... some say it’s beneficial in oligomets ... whereas some believe it will just add to the toxicity of zytiga/chemo ... also he was of the opinion the Mets will regress and shrink with treatment - the same would reflect in the next Psma pet scan which he usually would recommend on completion of 8-12 months. For the rectum epe if it is of benefit I will surely ask him about it.
Also, I am a bit confused regarding the definition of oligomets- some state only bone Mets would matter and some say it includes lymph node Mets also. If only bone Mets are included my dad would be considered oligometastastic and maybe I should push the MO for a RO recommendation... any advice would be appreciated.
Reading the PSMA report, he has ECE + bilateral SV involvement, but not metastatic to the bones or soft tissue, thus still treatable as stage 3b advanced PCa. Seek out surgery and radiation opinions. Stay on ADT (Zytiga or other) until your procedure to shrink the tumor.
Unfortunately, he is metastatic with lymph node and bone involvement.
Dad Age 75.5 years, Dx on 24/06/19 - initial PSA - 114 .16 ng/ml, Gleason 4+4=8, perineural invasion with rectum involvement more on right side, PSMA Pet scan - mets to several lymph nodes (enlarged bilateral external iliac, internal iliac, common iliac, paraaortic and interaortocaval lymph nodes), only 1 bone met on pubic bone
12/07/2019- Orchiectomy and Bicalutamide (Casodex/Caluran)
03/08/2019- PSA down to 4.66 ng/ml from 114.16 ng/ml
10/08/2019 - Commence Zytiga generic and prednisone
06/09/2019- PSA down to 0.837 ng/ml
07/09/2019- first 4 mg zometa infusion
07/11/2019- PSA down to 0.103 ng/ml stopped for 2 weeks due to elevated liver enzymes
Thanks a lot. Hope for a curative therapy will make all the difference. I will once again discuss this with the MO during the next visit.
What is the standard of care for oligometastatic for it to be a curative therapy for him ? Radiation to the bone met and the visible lymph nodes? Or dissection/removal of the lymph nodes along with continued ADT and zytiga ? Also does RALP for removal of the main tumour have to be done ?
From what I have read about it on this forum it was contradictory with some saying it would not result in curative therapy and just add to the toxicity due to presence of micro metastasis. Should I go ahead and push the MO for it?
To make these decisions, I would read a lot of trial reports on pub-med, I chose HDR-BT + IMRT + ADT for stage 3b + SV with good results, and if I were oligometastatic, I assume I would have had SBRT to the mets.
The mainstay of OMPC treatment remains systemic therapy, either with androgen-deprivation therapy (ADT) alone or in combination with other agents (docetaxel, abiraterone, etc.). Focal therapies, including resection or radiotherapy (RT), to the primary tumor have demonstrated an improvement in outcomes, including failure-free survival in several retrospective studies.
OMPC, generally defined by the presence of five or fewer metastatic sites on imaging, represents a transitional state between localized and widespread metastatic disease and encompasses a wide spectrum of disease biologies and clinical behaviors.
A growing body of evidence suggests that a subset of patients with OMPC may achieve a deep and prolonged response with multimodality therapy—combination surgery/radiation and systemic therapy—with improvement in disease-specific outcomes, such as time to castration resistance, PFS, and OS.
Local cytoreductive therapies, such as radical prostatectomy with or without pelvic LN dissection and RT, seem to be well tolerated in patients with OMPC.
Pelvic RT has been demonstrated to improve outcomes in patients with high-volume metastatic prostate cancer receiving abiraterone plus aDT.
Participation in clinical trials or institutional registries is strongly encouraged for patients with OMPC who opt for an aggressive multimodality approach.
Hi, no they have not checked for signs of bleeding. The ent did ask him if dad has seen any blood in his stool- which he has not. The doctor recommended Cremaffin Plus syrup in the am and pm . It contains three laxatives: Sodium picosulfate, liquid paraffin, and milk of magnesia. The same has eased his constipation problem.
Since his Hepatitis B and Anti HCV for Hepatitis C, alkaline phosphate and serum protein levels were normal and the colonoscopy report from 3 years ago satisfied him. He said colonoscopy is no longer required. He prescribed him to take 1 Ursodeoxycholic acid 300 mg tablet twice a day for 15 days and to come back with his SGPT, SGOT and T. Bilirubin reports. If the results are fine, we are good to go, else a liver biopsy would have to be done.
We got the results today (2 weeks after stopping Zytiga) which are as follows:
The SGPT, total bilirubin and bilirubin unconjugated has lowered and is now within range, however the SGOT remains elevated (marginally?) and bilirubin conjugated though lowered remains elevated.
1. SGPT
9 Aug 19: 32
6 sep 19: 34
6 Nov 19: 140
21 Nov 19: 54
2. SGOT
9 Aug 19: 27
6 sep 19: 24
6 Nov 19: N/A
21 Nov 19: 41
3. Total Bilirubin
9 Aug 19: 0.49
6 sep 19: 1.03
6 Nov 19: 1.70
21 Nov 19: 0.90
4. Bil. Conjugated
9 Aug 19: 0.18
6 sep 19: 0.41
6 Nov 19: 0.70
21 Nov 19: 0.40
4. Bil. Unconjugated
9 Aug 19: 0.31
6 sep 19: 0.62
6 Nov 19: 1.00
21 Nov 19: 0.50
Any idea if these results are normal or are these worrisome ? Will we be given a go ahead to recommence the zytiga? I am worried that the last PSA of 0.103 would increase without Zytiga
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