Clinical Cases in Advanced Prostate Cancer - Episode 1

Case 1: MRI/TRUS Fusion Biopsy for Nonmetastatic CRPC

Jorge A. Garcia, MD, FACP, describes the case of a 57-year-old African American man with nonmetastatic castration-resistant prostate cancer, and Ganesh V Raj, MD, PhD, reviews how the MRI/TRUS fusion biopsy is becoming a mainstay in diagnosis.

Jorge A. Garcia, MD, FACP: Thank you for joining us for this Targeted Oncology® Virtual Tumor Board®, which is aimed at addressing major changes in the treatment of patients with castration-resistant prostate cancer. In today’s presentation, my colleagues and I will review 2 clinical cases and discuss an individualized approach to treatment for each of these patients. We also plan to review key clinical trials that impact our decision and management.

I am Dr Jorge A. Garcia, a GU [genitourinary] medical oncologist and the chair of the Solid Tumor Oncology Division at University Hospitals/Seidman Cancer Center at the Case Comprehensive Cancer Center in Cleveland, Ohio.

Today, I am joined by 3 outstanding faculty: Dr Patrick G. Pilié, an assistant professor of medicine in the Department of Genitourinary Medical Oncology at The University of Texas MD Anderson Cancer Center in Houston; Dr Ganesh Raj, a professor of urology from the University of Texas Southwestern Medical Center in Dallas; and Dr Mary-Ellen Taplin, a GU medical oncologist at Dana-Farber Cancer Institute and a professor of medicine at Harvard Medical School in Boston, Massachusetts.

Thank you all for joining me today. In the setting of such a different environment, virtual meetings are a great opportunity for us to review and dissect the clinical data that have changed some of the treatment options for our patients with castration-resistant disease.

It’s important for us and our audience to recognize that we want to be as candid as we possibly can. We’re going to be data-driven. Let’s go ahead and review the first case.

This is a case of a 57-year-old African American male who in October of 2016 was referred to urology with a PSA [prostate-specific antigen] of 6.8 [ng/mL]. His past medical history was known for seizure activity, although the etiology of that was not well understood. He was, however, controlled with seizure medications. His family history was positive for breast cancer in his mother and sister. Both had breast cancer, but none of them have died from breast cancer.

He also had a history of pancreatic cancer in one of his brothers. At the time his digital rectal examination was read as normal. His multiparametric MRI of the prostate revealed a gland of 58 cc, and an index lesion in the left peripheral zone read as a PI-RADS [Prostate Imaging Reporting and Data System score] 4/5, around 1.8 cm. There were also questionable seminal vesicle invasions, specifically in the left seminal vesicle.

One month later, in November 2016, he underwent an MRI/TRUS [transrectal ultrasound] fusion biopsy. He had a systematic biopsy. He had 4 positive cores out of 12. All of them with Gleason Group 3 (3 + 4), 75% involvement. The index lesion biopsy was 3 out of 3 positive cores with a Gleason Group 4 (4 + 4), with 70% involvement.

At the time, he underwent a baseline staging with a whole-body bone scan and a CT scan of the chest, abdomen, pelvic region, all of which were negative for metastatic disease. His functional capacity at the time was also stated as an ECOG performance status of 0.

Before we go on in this case, let me ask Dr Raj, from the urology perspective, where do you see the use of MRI in North America presently?

Ganesh V Raj, MD, PhD: MRI for prostate has become a lot more widespread. Almost every patient prior to undergoing a radical prostatectomy with a diagnosis of prostate cancer will have had an MRI. A significant number of them are now getting it for an elevated PSA. Not all insurances pay for it up front. A vast majority of patients will come in with an elevated PSA. Patients who have had either a prior negative biopsy and/or have an extraordinarily strong family history like this fellow had, would be eligible for an MRI prior to biopsy. The MRI/TRUS fusion biopsy has taken a lot of the guesswork out of the biopsy. Rather than randomly taking 12 cores and hoping you hit something, you’re actually identifying targeted lesions and able to identify tumor within the targeted lesion that is more likely to represent the worrisome malignancy.

This patient, for example, had 4 out of 12 cores of systematic biopsies. Most of them showed Gleason 7. Those are more intermediate-risk prostate cancers. A lot of people would say, “Depending on the age of the patient and the characteristics, you could opt for a more conservative management or not even detect cancer based on a systemic biopsy.”

But having the MRI prior to the biopsy helps identify, in this patient for example, a much more aggressive form of cancer. In many patients, it helps identify small index lesions, especially the ones anteriorly in the prostate that you would normally have missed in the prostate biopsy. To me, the MRI/TRUS fusion biopsy has become much more of a mainstay in the way we image prostate cancers and care for patients with an elevated PSA.

Transcript edited for clarity.