Optimal Management of a Man With Recurrent Prostate Cancer

[Balsam01]

Here is a case summary from Practice Update and it would be interesting to see the opinions of the more well-informed minds on this forum regarding this case. As a completely uninformed mind, I would have opted for RP from the get-go but QOL matters more here due to age.

Written by Jeffrey J. Tosoian MD, MPH

58 year-old male diagnosed with GS 3+4=7 PCa in 2013. He underwent brachytherapy with a PSA nadir of 2-3 ng/ml. PSA gradually increased to 10 ng/ml by 2017. He was asymptomatic and imaging with CT and bone scan were negative, so his team opted to continue monitoring PSA.

Ultimately he presented again in 2020 with PSA of 42 ng/ml. Repeat biopsy of the radiated prostate confirmed GS 4+3=7 and 3+4=7 PCa in multiple cores. He underwent PSMA-PET showing uptake in the prostate and left common iliac lymph nodes.

He continues to have no symptoms.

Seeking input regarding optimal management in this case.

[lewicki]

Interesting reply.While at Karmanos cancer in Detroit my PSA went to 747 while on trial ESK981 before it was stopped. Unusual?

[Tall_Allen]

Salvage SBRT to prostate and entire pelvic LN area. ADT and abiraterone for 2-3 years.

[Blackpatch in reply to Tall_Allen]

Any particular reason for abiraterone as opposed to other later generation options?

Also, isn’t 2-3 years a bit long? If two years of bicalutamide was effective in RTOG9601, wouldn’t your much more effective ADT regime do the job faster, reducing CV impact?

Just curious about your logic...

[Tall_Allen in reply to Blackpatch]

NCCN guidelines say "EBRT with neoadjuvant, concurrent, or adjuvant ADT is the preferred option for patients with clinical N1 disease. Abiraterone can be added." (MS-24)

No, 2-3 years is not too long for known N1 disease. Touijer showed that long-term use is better.

RTOG 9601 had nothing to do with this situation. It was only among men who were recurrent after a prostatectomy and lymphadenectomy and had no cancer in their lymph nodes.

[Bab52413 in reply to Tall_Allen]

Hey Tall Allen. Got some very disturbing news and want to know your thoughts.

My Surgery for prostate removal was Sept of 2019. Had Radiation 40 treatments from Feb 20 to April 20... All was looking well or supposedly.

Have had a growth develop on my right collarbone got a Bone scan and they say I got cancer in shoulder ribs skull jaw and upper thigh bones and spine.

Going in for a CT scan to see if it is in my organs.

Dr says with the IV chemo I may still have good probability of surviving the 5 year mortality rate.

Your thoughts and if you have any insight what should I do next? Is there hope or am I grasping at straws? Looking for truth.

Thank you

[Tall_Allen in reply to Bab52413]

I'm so sorry to hear that. Yes, early chemo is almost certainly your best first treatment. Fortunately, this is coming at a time when there seem to be new medicines every day.

You might ask for a biopsy of the collarbone metastasis. They can do cell histology, IHC, and genomics on the off chance that they find something actionable.

[Bab52413 in reply to Tall_Allen]

Thank you

[ragnar2020]

Hide sight is always twenty twenty. I have numerous friends and acquaintances who used brachytherapy as their primary treatment and have enjoyed a long period prior to BCR if at all. However, when BCR begins, I agree with Tall Allen that salvage radiation with SBRT or PBT and hormone therapy is probably warranted. Get some multiple opinions soon.

Jeff

[MateoBeach]

Yes, as T_A says: SRT to Prostate and bed and extended field to pelvic lymph node fields with ADT for 1-2 years. Go for the possible cure!

[Cooolone]

So... First, just the Gleason Score and PSA levels at the time aren't enough information to properly get a good picture of the patient at the time. What about general health, family history, PSA history, co-morbidity's, etc.

A patient that had seeds (what type), and then a nadir that is considered detectable, was put on an AS program until PSA reached 10ng 4 years later. Then continued no action for an additional 3 years until a PSA test indicated a rise to 42...?

So the patient was diagnosed and treated in 2013 and remained persistent in PSA readings, that increased over the next 7 years with no action!

Am I reading that correctly?

And the question presented then, is what "optimal" management may be appropriate in this example?

Might not like my answer, but it is to immediately seek a different team providing my care!!! Get to a Major Cancer Center and one of Excellence! Watching and waiting when Gleason type 4 tissue has been identified is not an option. Especially in a recurrent setting. There are studies which show great benefit and result from early salvage therapy (not to be confused with adjuvant). So I'm not sure why any care provider would recommend waiting, watching, especially when at 10ng. The additional delay to >40ng PSA without any action, is borderline malfeasance!

I'm not compassionate to "we made a mistake" in a setting line this, when the situation does not follow even standard of care guidance! Maybe harsh, but I've always been a cynic, so take it where it's coming from!

Best Regards!