ASCO GU 2017: Challenging Cases in High-Risk, Recurrent, and Advanced Prostate Cancer (ARS) - Radiation Oncologist - Session Highlights
Case Description
65 yo
PSA 7.5, asymptomatic
DRE: palpable nodule, involving the seminal vesicle
TRUS Biopsy: Gleason 4+4, 8/15 positive cores, 20% involvement
Initial Staging: Bone scan negative, CT negative - T3a/N0/M0
It is true that radical prostatectomy provides pathology that can guide further treatment. Furthermore, there is a sub population of patients with better than thought pathology. Finally there is evidence that radical prostatectomy confers a survival benefit compared with radical prostatectomy in high risk patients.However, evidence in favor of radical prostatectomy is of low level of evidence.
Regarding the preferable type of Radiotherapy, high dose rate brachytherapy in addition to IMRT is the best technique to deliver high radiation doses to the prostate with acceptable side effects profile.
Repeat Staging: inferior left pubic ramus metastasis. Biopsy: prostate carcinoma
The standard of care for a M1 patient is androgen deprivation therapy. However, several trials are looking at the effect of local treatment with results pending.
1. HORAD - examines ADT vs ADT+local control with IMRT
2. STAMPEDE - multi arm trial for M1 patients. Examines ADT alone, ADT + docetaxel, ADT + abiratrone and ADT + local control with IMRT.
3. PEACE -1 - examines ADT alone vs. ADT+abiraterone vs. ADT+ IMRT
Case 2 Description
51 y/o
Pre -operative parameters: Gleason 3+4, 3/12 cores, cT1c, PSA 5.4
Post radical prostatectomy pathology: pT3a, Positive Surgical Margins (PSM). PSA undetectable after 6 weeks.
3 trials (SWOG 8794, EORTC 22911, ARO 96-02) have assessed the effect of adjuvant RT in the adverse pathologic feature patient. They have shown overall survival improvement and metastases reduction for aRT. ART is indicated for high Gleason grade, t3b,n+ and PSM. Of note, surgical margin status impact prognosis in high risk patients only. Genomic classifiers can help identify the patients who benefit the most from aRT.
The Patient chose surveillance but presented after a few weeks with PSA increase to 0.54.
salvage RT is given in the post operative biochemical recurrence state. This state is defined as PSA>0.2. Since PSA level is a strong predictor of response to sRT, initiating the sRT at low PSA levels is preferable. Recurrence and metastatic free survival at 10 years after sRT are 35%, 80% respectively.ongoing SAKK RCT examines the effect of radiation dose on survival. Furthermore, RTOG 05.34 trial will examine the effect of pelvic irradiation in addition to sRT.Finally, addition of 6 months ADT had been shown to be beneficial in 2 RCT's.
Presenter: Alberto Bossi, MD
Written By: Miki Haifler, MD, M.Sc, Fox Chase Cancer Center
at the 2017 Genitourinary Cancers Symposium - February 16 - 18, 2017 – Orlando, Florida USA