Novel Hormonal Therapies in Prostate Cancer - Episode 2
Panelists center their discussion on a real-world patient case of nonmetastatic castration-resistant prostate cancer managed with surgery and adjuvant therapy.
Alan Bryce, MD: We’re going to move on to case No. 1. I’m going to hand this off to Dr Efstathiou.
Eleni Efstathiou, MD, PhD: Thank you very much. Alan and Daniel [Landau], it’s great to be with you. Thank you for having me. Let’s talk about our patients and the cases we deal with every day. This is regarding nonmetastatic castration-resistant prostate cancer. While we were getting ready to get on the meeting, we were discussing the recent [Advanced Prostate Cancer Society] Consensus [Conference] we had in Lugano [Switzerland]. I was tasked to speak with regard to the options we have for this state of disease, but let’s start with the term nonmetastatic. It’s so deceptive as a term and probably not representative of what the current state is, but let’s keep it at that. We can discuss later exactly our thoughts with regard to how these terminologies may be confusing for our patients and sometimes for community practices.
This is with regard to a man who in July 2017 was 59 years old. He is an African American who is referred to urology with an increased PSA [prostate-specific antigen] of 6.8 ng/mL. He does have a medical history that’s positive for seizure disorder but is controlled with long-term treatment with oxcarbazepine. He has a family history from his mother’s side of breast cancer and a brother with pancreatic cancer. That’s a very strong family history. A digital rectal exam is negative with no nodules or duration. A multiparametric MRI shows a volume of 55 cc. There is indeed an indexed lesion that’s PI-RADS 4/5 of 1.6 cm, findings in line with potential seminal vesicle infiltration on the left side.
Two months later, the patient undergoes a mechanical fusion biopsy. In 4 of 12 cores, there’s a positivity with a Gleason score of 3+4, so a group 3 with a 75% involvement in these cores. In the index lesion we had 3 of 3 cores positive for a Gleason group 4, Gleason score 4+4, 8 65% involvement. From a Gleason grading [perspective], we’re looking at a high-risk disease with a bone scan and CT scan, conventional and imaging negative for metastases. Performance status was 0, so he’s doing great. Three months later, the decision was made to move forward with robotically assisted radical prostatectomy and, as expected, extended lymph node dissection. The final pathology meets what was found already and expected from the MRI, a PT3b disease seminal vesicular infiltration with, thankfully, no node infiltration. Here, we don’t have the number of lymph nodes at size. We should assume, based on what he said, that it was extensive. Margins were positive. Based on conventional imaging, there were no metastases, and the final Gleason score was 4+4. The surgical margin was positive to the apex. Eight weeks postoperatively, the patient still has a detectable PSA of 0.18 ng/mL. The baseline serum testosterone that is eugonadal at 380 ng/mL.
The recommendation by the urologist is, upon healing and improvement in incontinence, to move forward with adjuvant radiation to the prostate bed given that we have a positive margin and PT3b disease. In March 2018 we had a PSA that goes to 0.25 ng/mL; in June 2018, 0.67 ng/mL; in September 2018, 2.5 ng/mL; in December 2018, 4.7 ng/mL. We have a consistent and rapid rise of the PSA, and the calculator of PSA doubling time definitely meets a criterion of intense rapidity. In December 2018, a new restaging is done with conventional imaging, and it’s still negative for metastases. At that point, the decision was made to initiate androgen deprivation, and a depot leuprolide of 45 mg for 6 month dosage was given. The patient transferred his care, and the PSA nadir is unknown at that point.
Transcript edited for clarity.