SUO 2016: Challenging cases - Session Highlights
San Antonio, Texas USA (UroToday.com) Three cases of oligometastatic prostate cancer were used to debate the role of multi-modal therapy, the sequence of such therapy and the role of consolidation surgery/radiation to metastatic sites.
The first case involved a 72 years old patient with decreasing urine stream and pain while walking. He was first examined by an internal medicine physician who did not do a rectal exam. PSA was 2.8 and he was started on alpha blocker for the working diagnosis of BPH. He then saw a urologist that performed a DRE with a fixed prostate and narrowed anus. TRRUS biopsy revealed Gleason 4+4 =8 in 11/12 cores. MRI was not helpful due to hip prostheses. Bone scan identified a metastatic lesion in the 10th rib and CT scan demonstrated a 1.1 cm pelvic lymph node. At that point biopsy the lung was essential to differentiate between a oligometastatic and poly metastatic states. The lesion was found to be a metastasis. The panel recognized this case as a high volume disease according to charted trial. Due to the aggressive nature of the disease and the non oligometastatic scenario the panel agreed that the next step should be chemotherapy with ADT. Another issue discussed was the low PSA for a long time in this patient which mandates a germline genetic testing.
The second case involved a 51 years old patient who presented with left hip pain while standing. He was diagnosed with Gleason 4+4=8 , metastatic prostate cancer he had enlarged iliac lymph nodes and left acetabular metastasis. PSA was 2.5. Since this is an oligometastatic scenario tri modal therapy was started with ADT and chemotherapy. His PSA at 6 months was low (which was shown to be a strong prognostic factor). Subsequently he underwent radical prostatectomy and stereotactic radiation to the bone metastasis. Of not, the role of consolidation therapy was discussed and ir should be offered to good risk patients. LA VA system opens a trial of ADT with chemotherapy, prostatectomy and stereotactic Radiation to the metastatic site. Lastly the role of germline testing was highlighted in young patients with aggressive disease.
The third case described a 47 years old patient with decreasing urine stream and PSA of 487. DRE was abnormal. Biopsy revealed a Gleason 4+4=8 prostate cancer. MRI demonstrated a T4N1M0 disease. CT and bone scan did not reveal metastatic disease. Of note, the patient had a very rich family history of prostate cancer (grandfather, 4 uncles, 3 cousins). The panel agreed that due to the young age and family history germline genetic testing is mandatory. Furthermore, additional imaging must be performed due to the high PSA levels and lack of metastases on standard imaging. PSMA PET was the modality of choice. Part of the panel suggested that prostatectomy to reveal local symptoms is appropriate, while the other part suggested ADT would be more appropriate.
Presented By: Marc A. Dall’Era
Written By: Miki Haifler, MD, M.Sc., Society of Urologic Oncology Fellow, Fox Chase Cancer Center
17th Annual Meeting of the Society of Urologic Oncology - November 30 -December 2, 2016 – San Antonio, Texas USA