Those of you who have followed my husband's journey with PCa might remember that we were looking at Crescendo trial Ph1. We were told in the UK that his disease was PSMA positive and that he could be eligible for Lu177. We did not wish to wait given the increase in clinical symptoms and decided to fly to India for Lu177 treatment. The FDG PET and GaPSMA scans carried out in India showed considerable discordance with most cancer being FDG positive and extensive marrow involvement. We were advised against trying Lu177 given these facts. Instead, my husband underwent a biopsy of the new liver met the FDG PET identified and one of lymph nodes.
This was to rule out neuroendocrine element. Fortunately, the biopsy did not indicate neuroendocrine disease and his blood test showed CgA of 52.9. In the past it has been 59 and 32.8. The biopsy results show poorly differentiated PCa and the lymph biopsy indicated strong expression of NKx3. The lymph met showed Gleason 9 (this was a note that despite it being a met it had a Gl9 score). As there are no particular indications of why the adenocarcinoma did not respond to the chemo at all, we are left with no particular guidance as to the treatment to be followed next. Abiraterone was never prescribed yet and it is worth a try.
The liver biopsy states, 'CT guided biopsy from FDG Avid left lobe liver lesion shows deposits of Adenocarcinoma.There are atypical cells noted in clusters & sheets. Cells show high N:C ratio, prominent nucleoli & clear cytoplasm. Few mitotic figures are also seen.Background liver shows mild chronic inflammation'.
And the other one: 'The tumor is composed of round to oval cells with pleomorphic nuclei and eosinophilic cytoplasm, arranged predominant in a solid pattern or in an illformed glandular ( acinar ) pattern. Some of the cells show prominent nucleoli. There is no definite intracellular mucin or signet ring cell morphology. There is no well formed papillary pattern seen. There are moderate mitoses seen. Focal area of tumor necrosis is seen. There is no definite evidence of e/o Neuroendocrine differentiation. There are no epithelioid cell granulomas.IHC Result:# Immunohistochemistry Results ( A3 ) :* The tumor cells express NKX-3.1 ( strong ) and are negative for Synaptophysin* The tumor cells negative for Synaptophysin ( No e/o Neuroendocrine differentiation )Final Diagnosis:# Right Inguinal Lymphnode - CT guided Trucut Biopsy (*) In a Known Case of Adenocarcinoma of Prostate on therapy )* Nodal involvement by Metastatic Deposits of Poorly differentiated Adenocarcinoma Consistent with a Known Prostatic Primary ( ^ Please see note )* The tumor cells express NKX-3.1 ( strong ) and are negative for Synaptophysin.'
Any thoughts about what next? Is liver met something to be dreaded? Mobility is worsening slowly and oedema too. So far bloodwork is okay.