Clinical Cases in Advanced Prostate Cancer - Episode 2

Case 1: Novel Imaging Used for Nonmetastatic CRPC

Experts in genitourinary oncology share their use of novel imaging in practice for nonmetastatic castration-resistant prostate cancer.

Jorge A. Garcia, MD, FACP: Let’s address the elephant in the room because nowadays you cannot talk about prostate cancer without talking about novel imaging. Over the last few weeks, we saw the recent FDA approval of Gallium-68 PSMA [prostate-specific membrane antigen] PET [positron emission tomography], restricted to 2 institutions on the West Coast. Ganesh, since you are the only urologist here, I want to gauge your thoughts then perhaps extend the question to Mary-Ellen and Patrick. This patient obviously underwent typical staging scans using technetium-99 bone scan and CT scans. Are any of you at your institutions already looking at PSMA PET imaging independent of what sort of metabolite you guys use?

Ganesh V Raj, MD, PhD: I would say that you could clearly envision the day that could be a little more commonly used in a select group of patients in whom you suspect more of a metastatic phenotype. For example, this fellow on the MRI had an index lesion that was possibly invading into the seminal vesicle. But the MRI actually, especially with endorectal coil and a 3 Tesla MRI, gives you a fair bit of information about the lymph nodes, the surrounding bone morphology, and really tells you a little more about the local extension of the disease and the proclivity for metastasis.

If I had a patient with locally extensive disease—and we’ve done this for some of our patients with locally extensive disease—you want to get a sense of whether this patient would benefit from just local therapy or if they need more systemic therapy. When the bone scan and the CT scan are negative, we’ve gotten those patients an Axumin PET scan with insurance approval. We don’t have PSMA PET scan obviously, but we’ve got an Axumin PET scan, and that sometimes helps in deciding whether the patient has locally extensive disease that can be managed with local therapy or if they need more systemic therapy as well.

Jorge A. Garcia, MD, FACP: Mary-Ellen, how about at Dana-Farber [Cancer Institute] and the Boston system? Are you guys already using novel imaging up front?

Mary-Ellen Taplin, MD: Not routinely at this time. As Ganesh said, it’s not unreasonable for somebody if you have a high suspicion of metastasis and their insurance company approves an Axumin scan, but we’re not routinely doing it. I can see a day when we will integrate more novel imaging into early prostate cancer. But of course, we need to prove the clinical benefit. It’s one thing showing scans can pick up disease earlier, but it’s another thing showing that translates into clinical benefit.

Jorge A. Garcia, MD, FACP: Absolutely. Patrick, how about at [The University of Texas] MD Anderson [Cancer Center]?

Patrick G. Pilié, MD: To echo what everyone else has already said, we’re not routinely using it at diagnosis, but certainly in the case of recurrent disease, as well as in select, high-risk clinical pathologic features, potentially up front. But I’ve definitely seen a lot of patients come in who have already had some of these advanced images done outside in the community and bring them in for initial evaluation.

Transcript edited for clarity.