Case Overview: A 73-Year-Old Man with Biochemical Recurrence of Prostate Cancer and Metastatic Castration-sensitive High-volume Disease

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Bobby Liaw, MD: We have a case that was given to us to help facilitate some more discussion. This is a 73-year-old man who initially presented in January of 2018 with symptoms of urinary retention, fatigue, and decreased appetite. His personal history is notable for a case of mild alcoholic cirrhosis, based on liver function tests that are abnormal. He has no family history of prostate cancer. Clinically speaking, he’s very active. He’s very involved in his children’s and grandchildren’s activities. He had a prostate biopsy performed, which showed he had a Gleason score of 4 + 4, prostate adenocarcinoma found in 10 out of 12 cores taken. Initial PSA [prostate-specific antigen] at diagnosis was quite elevated, at 150 ng/mL. Also notable was a chronically low hemoglobin of 9.7 g/dL and a chronic baseline ANC [absolute neutrophil count] of 1.9. Additionally, as I mentioned before, he had some baseline abnormal liver function testing.

Following additional staging work-up, it was determined that his disease was localized to the prostate. He underwent robotic radical prostatectomy. Following that, he had a PSA decline to 12 ng/mL from his initial 150 ng/mL. He ended up getting some additional follow-up CT and bone scans after the surgery because of the persistently elevated PSA, which were not revealing for radiographic evidence of residual disease. Time goes on, and in October of 2019, about a year and 10 months after his initial diagnosis, he complained of right hip pain and abdominal pain. Imaging at that time with CT and bone scan showed new spots of disease, unfortunately. There were multiple metastatic bone lesions in the pelvis as well as diffuse liver lesions. Laboratory tests drawn around this time show that his PSA was now more elevated at 90 ng/mL. He remained with his chronic laboratory findings of mild anemia, a hemoglobin of 9.4 g/dL, and an ANC of 1.5. His liver function tests continued to be abnormal.

At this time, he was diagnosed with recurrence of his prostate cancer, with high-volume, castration-sensitive metastatic disease. He had germline genetic testing performed around this time, which was negative for any significant variance. In discussion with his treating physician, the patient was concerned about his quality of life and wished to receive oral therapy so that he could continue to be involved with his grandchildren’s activities. Due to his baseline abnormal liver function tests and his history of alcoholic cirrhosis, he was eventually started on both androgen deprivation therapy [ADT] and apalutamide. At his 1-year follow-up, his PSA levels remained very well controlled and undetectable on the combination of ADT and apalutamide. He’s had follow-up imaging since then showing stable disease and he continues to report a good quality of life.

I want to give some of my initial impressions on this case. For high-risk Gleason score 8 prostate cancer with a very high PSA level at presentation, we’re always going to be concerned about whether there’s going to be any amount of disease that has escaped outside of the prostate primary. His original staging scans showed that there was localized prostate cancer, and this was determined through CT scans and bone scans. These days—certainly on my wish list—we have more sensitive scans that can be done, albeit sometimes it may be difficult due to insurance reasons here in the United States. But if I had my way, I would’ve loved to have gotten him a PSMA [prostate-specific membrane antigen] PET [positron emission tomography] scan. These scans are higher in sensitivity and specificity than conventional imaging, especially surrounding metastatic disease.

There has been a lot of experience in using PSMA PET scans for staging, and it has unfortunately shown that it often changes treatment plans from a curative modality to more of a control modality in up to about 25% of cases. For someone with this type of high-risk, high-volume disease within the prostate—he had 10 out of 12 cores with a PSA of 150 ng/mL—if possible, I would’ve loved to try to get him more advanced imaging, because we may have been in a position to catch some extraprostatic disease earlier. Then there’s the question of whether he would have gotten the same type of treatment, in terms of prostatectomy. It would of course be informed by what the scans show.

But taking what we have so far—a CT scan and bone scan to determine localized disease—for a person with a pretty high-risk prostate cancer, unfortunately, we’re going to find ourselves at a higher likelihood of disease recurrence, or disease left over following the prostatectomy. In his case, his PSA level did drop a fair amount, although it never fully reached a nadir of undetectable, which is ideally what we’d like to see after a successful prostatectomy.

For people who have biochemical recurrence following definitive therapy for prostate cancer, there are some personal differences in how some of these things are managed. Although, for someone with a PSA of 12 ng/mL at its nadir, I may have been a little more inclined to think about starting androgen deprivation therapy even at that time, knowing that there’s still some active disease, that this started as a high-risk Gleason 8 prostate cancer, and that the risk for spread and metastases will unfortunately be a little more likely in his particular case. I probably would have taken a bit more of a proactive stance on trying to control and restage his disease vs keeping him on surveillance alone.

Transcript edited for clarity.

Case: A 73-Year-Old Man With Biochemical Recurrence of Prostate Cancer and Metastatic Castration-sensitive High-volume Disease

January 2018

Initial Presentation

A 73-year-old man presents with urinary retention, fatigue and decreased appetite

Patient History, Lifestyle and Clinical workup

History of mild alcoholic liver cirrhosis

No family history of prostate cancer

Patient is active and is very involved in his grandchildren’s activities

TRUS and biopsy revealed adenocarcinoma of the prostate gland, Gleason score 8 [4+4] with disease in 10/12 cores.

PSA 150 ng/mL; Hb 9.7 g/dL; ANC 1.9

Liver function tests are abnormal

Initial Diagnosis and Treatment

Patient is diagnosed with localized prostate cancer

He undergoes robotic radical prostatectomy with subsequent PSA decrease (12 ng/mL)

CT and bone scans showed no residual disease

October 2019

Presentation at Recurrence

Patient complains of right hip pain and abdominal pain

Imaging with CT and bone scan showed multiple metastatic bone lesions in the pelvis and diffuse liver lesions

PSA 90 ng/mL; Hb 9.4 g/dL; ANC 1.5

Liver function tests continue to be abnormal

Diagnosis of Recurrence

Patient is diagnosed with biochemical recurrence of prostate cancer with high-volume castration-sensitive metastatic disease

Germline genetic testing is negative

Treatment for Recurrence

Patient wishes to receive oral treatment with good quality of life so he can continue to be involved in his grandchildren’s activities

Due to his abnormal liver function tests and desire to receive oral treatment, he is started on ADT + apalutamide

At his 1-year follow-up, the patient’s PSA remains undetectable

Follow-up imaging shows stable disease, and he continues to report a good quality of life