Continuing this discussion, the patient underwent first a standard biopsy and then a saturation biopsy which revealed a 67cc gland, BPH, and a low PSA density. In the next step, the panel agreed that MRI should be used in this setting. Finally, the patient’s PSA continues to rise and MRI is performed demonstrating an 11mm R anterior to mid PI-RADS 4 lesion. Two targeted biopsies are performed which return negative. At this point, the discussion turned to the role of transperineal biopsies, which have the ability to better target anterior lesions. Transperineal biopsy revealed multiple cores of 4+3 and the patient proceeded with definitive therapy.
Our 2nd index patient is a healthy 62-year old male with a rising PSA and a negative family history with no prior biopsies and a negative digital rectal exam. Standard biopsy revealed 4 cores of low volume 3+3 and 3+4 disease. The panel discussed definitive therapy with robotic prostatectomy or radiotherapy versus active surveillance. The panel agreed that there is a role for active surveillance in low volume favorable intermediate-risk patients in a motivated patient, with acceptable MRI findings and reassuring genomic testing.
This patient was unable to have an MRI due to anxiety, but a repeat biopsy demonstrated 2 cores of Gleason 3+3 disease. The patient continued to active surveillance and had biopsies every 2 years 2013 (4 cores 3+3/3+4), 2013 (2 cores 3+3), 2015 (negative), 2017 (2 cores 3+4). At that point, the patient underwent genomic testing suggesting he was at high risk of adverse pathology. The committee recommended surgery, where he was diagnosed with pT3 disease and Gl 4+3 with tertiary grade 5 and an intraductal component.
Patient 3 is a 61-year old male with an elevated PSA of 62.0 ng/ml and a nodule on DRE. MRI revealed two PI-RADS 5 lesions and a biopsy returned with high volume Gleason 4+5 and 4+4 with cribiform pattern and extra-prostatic extension. Bone scan and MRI had no metastatic disease or evidence of lymphadenopathy. This panel discussed focused on the need for multimodal therapy in high risk disease. In these aggressive forms or prostate cancer, patients often need surgery +/- XRT or XRT with ADT. Surgery is an option for high risk disease if the patient understands multimodal techniques may be necessary.
Finally, patient 4 was a 56-year old male with an elevated PSA (6.85 ng/ml) with 10 cores positive for Gleason 4+5 disease. Prostate MRI revealed a PI-RADS 5 lesion in the right peripheral zone and a PI-RADS 4 lesion un the left base. Bone scan was positive for metastatic disease with an update in the left acetabulum. The board agreed a referral to medical oncology was appropriate at this time for consideration of systemic therapy. Dr. Garcia suggested he would utilize ADT with abiraterone therapy. Local therapy in the face of metastatic disease should still be performed on clinical trial only or in very select, well informed patients.
Andrew Stephenson, MD, Cleveland Clinic
Ashutosh Tewari, MD, Icahn School of Medicine at Mount Sina
Donna Hansel, MD, Ph.D., University of California at San Diego
Matthew Gettman, MD, Mayo Clinic
Jorge Garcia, MD, FACP, Cleveland Clinic
Daniel Spratt, MD, University of Michigan
Written by: David B. Cahn, DO, MBS Fox Chase Cancer Center Philadelphia, PA @dbcahn at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA