Father,56, metastatic prostate ca, completed triplet therapy just now but experiencing pain

[Helllfire]

Hi everyone ,

My father ,56 age ,is diagnosed with metastatic ca prostate , Gleason score 4+5, with mets to bones and nodes in august 2022, he started with bl orchidectomy and Abiraterone 1000mg with prednisolone and chemo.He completed 6 cycles of docetaxel chemo now .He has tolerated treatment very well . Triplet therapy , all three treatment stated within 25 days of diagnosis.

He is also taking tapentadol 50 TDS(opioid ) and paracetamol 650mg tds for pain management as he was having pain in lower back since start . This painkillers were effective till now , but now he is having pain in his left thigh just below hip joint ( upper side of thigh ).Taking treatment in Tata hospital Mumbai . 

Diagnostic psa was 375 , before 1st chemo was 32 . Before 4 th chemo , psa was 9. I was hoping that his pain in lower back will be gone after this treatment , but instead he stated experiencing left thigh pain despite above painkillers now.

What do u think reason of his pain and how should I proceed further ?Maybe I was thinking to ask for more chemo cycles as I heard fairly healthy patient can be given upto 9 cycles.But after his 6th last chemo , he is experiencing pain in left thigh , I am fearing it might be tolerance to chemo drug and other bad things . Will be doing post treatment chemo blood investigations in next 5 days .

Please help me how should I move furthur on this pain issue

[rsgdmd]

Is he taking any kind of medicine for his bones, Xgeva, Prolia, Zometa or similar?

[Helllfire in reply to rsgdmd]

No, doctor previously said denosumab is used in Hormone resistant setting , no need as of now. Should I ask for it ?

[rsgdmd in reply to Helllfire]

I'm hormone sensitive, but osteopenic & have some bone mets, so I'm on denosumab. The reason I asked is that one, uncommon, side effect is fracture of thigh bone, which is preceeded by severe pain.

[Helllfire in reply to rsgdmd]

That's scary , I will have to ask for dexa bone scan for father to see this possibility and for Denosumab . Thanks for ur differential .

[gsun in reply to Helllfire]

I am sensitive as well and am on denusomab.

[Finlay66]

I had 10 cycles of Docetaxol. To be honest I think the sweet spot in terms of effectives is probably 6 -8 cycles. I have had Zometa with each cycle and I think it has helped to reduce bone pain.

[Helllfire in reply to Finlay66]

Thanks for reply . I am also thinking to ask for more chemo cycles if beneficial . Can u please tell me what criteria or basis your doctor had more than 6 cycles?, it will help me to ask for more cycles.

Also have to ask if Zometa or denosumab will do based on bone scan.

[Finlay66 in reply to Helllfire]

To be honest. I don't know. It was perhaps based on the severity of the disease. What I do know is after 8 cycles, the Oncologist was suggesting diminishing returns. I'm to carry with Zometa infusions after chemo has finished.

[Tall_Allen]

Often there is a pain flare for a short time after chemo caused by inflammation. Prednisone may help. Or it may be caused by neuropathy from the chemo, in which case gabapentin may help. He's had a wonderful response to chemo, so it probably is NOT a new metastasis in his femur. An NaF(18) PET/CT can find it, if it is. Discuss with his oncologist.

[Helllfire in reply to Tall_Allen]

Thanks you Sir for ur reply . His Hb is 9.8 after 5 cylces, Earlier he had no problems similar to peripheral neuropathy, but now have to ask doc . He is already taking prednisolone 10mg daily due to chemo and abiraterone. But I will ask doctor as per ur suggestions. He has done Fdg and PSMA PETCT previously , I had to check availability of NaF PET availability. Thanks once again .

[Hidden]

Sending prayers and love 🙏❤️

[Helllfire in reply to Hidden]

Thanks and prayers for you too , 🙏🏻🙏🏻

[Hidden in reply to Helllfire]

Thank you . 🙏

[Helllfire]

Can anyone will tell me what type or name of bone scan I have go for father ?

Father had bone mets over vertebra and many major bones overall. Doctors have Never asked for bone scan for him.

[anony2020 in reply to Helllfire]

PSMA is more sensitive. That's only from a layman. Dont mind me. 😊

[Helllfire in reply to anony2020]

Actually I am asking regarding Dexa Bone Scan for osteoporosis signs in bones due to ADT .

[RusLand in reply to Helllfire]

Hi, Helllfire! PAT/CT with PSMA will show you and all the bones of your father better than the SPECT! If you have such an opportunity, it is better to undergo PET with PSMA in comparison with previous studies on PET with PSMA.. In this case, there will be a very reliable dynamics! And by the way, what is your dad's FDG status?

[Helllfire in reply to RusLand]

Thanks Rusland, After diagnostic spine MRI(done for lower back pain )then PSA test , my father has initial PET with 3.0 mCi-F18-FDG and next with PSMA tracer 7.0 mCi Psma PETCT.

All the lesion in prostate , regional lymph nodes , bone mets are PSMA avid.

No FDG avid lesion in prostate, nodes and bones. Weakly metabolic to say in nodes and bones.

I hope if this situation remains as similar to current, later in CRPC setting he may be a good candidate for Lu177Therapy .

[RusLand in reply to Helllfire]

Hello,Helllfire! Yes, it was therapy with PSMA that I had in mind and I already see that you have read my publications on this topic ..)) If your dad is FDG-negative and PSMA-positive, then this means a high expected assessment of the therapeutic effectiveness of treatment with the isotope 177Lu or 225Ac, or a combination of them! In this situation, the PSA dropped from 375 to 9 (!!!) after only three courses of introduction.. If I were you, I would continue Docetaxel therapy for at least 6 courses with the possibility of adding three more courses with good tolerability! The resulting pain in the bones during chemotherapy, as well as during PSMA therapy, should be perceived as a therapeutic effect! When mts is formed in the bones, as a rule, there is resorption (destruction) of the spongy part of the bone tissue, which is produced by osteoclasts.. And during treatment, when malignant cells are destroyed, the reverse process of modeling (restoration) of these destroyed areas begins, which is produced by osteoblasts.. Osteoclasts destroy osteocytes (the main cells of bone tissue) within 2-3 weeks.. Osteoblasts are reborn into full-fledged osteocytes within 2-3 months! In the case when the restoration of bone tissue begins, taking Denosumab or Zolendronic acid is useless for the reason that these drugs block the work of osteoclasts exclusively!!! It is best to take additional Calcium and vitamin D in doses in consultation with your doctor! Both in the first and in the second case, during these processes, blood circulation is simultaneously disrupted due to the destruction of blood vessels (inflammation) and there is an impact on nerve endings (pain).. The main marker of a decrease in metabolic activity in malignant foci is a decrease in total PSA! You're doing great with this! And if you track the dynamics of PET in the future/CT with PSMA in comparison with the pre-existing (control) study, then this is SUVmax in these very foci! Therefore, go through the maximum possible number of Docetaxel courses (9 - 10), finish this reptile to the lowest PSA values and only then make a comparative PET with PSMA.. This is my subjective opinion, what would I do in your place! Sorry for the many letters! )) And God bless us all!

[Helllfire in reply to RusLand]

Sorry for delayed reply. And many thanks for ur detailed reply. This should definitely help me to connect with my doctor.

One possibility I am exploring is Avascular necrosis of femur due to daily dose of 10mg prednisolone. Doing MRI scan today to see if this is the possibility . Praying God not to turn into this AVN.

Thanks for reply . God bless you.

[anony2020]

Sorry

[Helllfire in reply to anony2020]

No need to be sorry. In fact I am thankful for ur concern . Sharing is Caring .

[Helllfire]

Father blood investigation results after 6 chemo and triplet therapy with ADTsurgery and Abiraterone 1000mg ,completed 4 months of treatment now.

Hb- 8.7, WBC -7.59, Platlets 160, Triglycerides -216 , Phosphorus 2.10,

Alkaline phosphate -865

PSA- 2.287

Diagnostic PSA was 385 and alkaline phosphate was 6795 . His Hb after 5 cycles was 9.8,but reduced to 8.7after 6 cycles.

He is experiencing pain in left hip area since 8days. . Due to this his Gait is totally changed . Did MRI today , waiting for results .

Taking prednisolone 10mg daily. And He is also taking 250mg Calcium citrate maleate daily with no zolendronic acid neither denosumab.His hip pain is main concern now.

What should be way further for 3 more chemo cycles or stopping now and reserving docetaxel for next time(to avoid tolerance now)

[Helllfire]

Just wanted to give heads up, mri result not shown any signs of AVN. Also the positive lymph nodes are regressed in size, and bone are sclerotic now.

The pain in left groin area is also reduced without any efforts. My doctor said no new mets possibility due to treatment undergoing and no AVN suggested by MRI.

Doctor said likely cause may be due to start of Atorvaststin , which has side effect of pain in thigh region . Which is eventually weaning off.

[Rrrspc]

hello Helllfire,

My father currently in a pretty similar situation and feel a high pain in his back which go through the leg. He just started his treatment and currently on a second course of chemo.

Pain is the biggest problem right now, we are thinking if radiation can help..

Thank for any feedback

[Helllfire in reply to Rrrspc]

Sorry for late reply. Regarding my father's case , his pain was attributed to start of atorvastatin which has side effect of pain in thigh region. But due to overthinking of possibility of AVN of femur , we did MRI which was good ,no such signs . The pain was gone in 7 days later .But I think for ur case u should give time to chemo drugs to act on . But of course always consult your doctor regarding your any issues . By any chance are u on any other treatment like abiraterone or darulotamide ? If yes then they and chemo will help if pain is due to metastatic lesions. If still pain persists even after some time , I think consulting your doctor for MRI, he can evaluate for any degenerative age related possibilities. Please update ur profile and timeline so that members can also provide their insights.