ESMO SUMMIT MIDDLE EAST 2018 Prostate Cancer: Case Discussion Dr Deborah Mukherji American University of Beirut Medical Center Lebanon 6-7 April 2018, Dubai, UAE
CONFLICT OF INTEREST DISCLOSURE Dr Deborah Mukherji Dr Mukherji has received honoraria/speaker fees or travel support from: MSD/BMS/Pfizer/Novartis/Roche/Amgen Astellas/Jannsen/Merk Serono
CASE 1 69 year old fit gentleman • 3 episodes acute urinary retention • Sept 2017 PSA 7.6 (2.87 Mar 2013) • MRI prostate requested •
CASE 1 Prostate biopsy: “cognitive” targeting DIAGNOSIS:1. PROSTATE GLAND, LEFT PERIPHERAL ZONE TARGET, BIOPSY: - PROSTATIC ADENOCARCINOMA, GLEASON SCORE 8 (4+4), INVOLVING 20% OF TISSUE SUBMITTED (3 OUT OF 3 CORES). 2. PROSTATE GLAND, LEFT TRANSITIONAL ZONE, BIOPSY: - PROSTATIC ADENOCARCINOMA, GLEASON SCORE 7 (4+3), INVOLVING 40% OF TISSUE SUBMITTED (1 OUT OF 2 CORES). 3. PROSTATE GLAND, RIGHT TRANSITIONAL ZONE, BIOPSY: - BENIGN PROSTATIC TISSUE
CASE 1: DISCUSSION Use of MRI/targeted biopsy • Staging for locally-advanced disease • Treatment of locally-advanced prostate cancer •
PET-PSMA There is heterogeneous radiotracer uptake in the prostate gland more prominent centrally with extension to both seminal vesicles more on the left with SUVmax up to 5.4. There is also focal increased uptake in the right peripheral zone with SUVmax 3.2 likely related to peripheral zone involvement. There are multiple radiotracer-avid small lymph nodes in the right external iliac, right common iliac, left common iliac, retrocaval, para caval regions measuring up to 1.2 x 0.5 cm with SUVmax 31 (image 143).
CASE 1 DISCUSSION Hormone sensitive metastatic prostate ca detected on PET- PSMA Locally-advanced disease with 3 episodes of retention Options: ADT alone • Surgery • Radiation • Role for systemic therapy? •
CASE 2 70 year-old fit diabetic gentleman PSA 360 on routine blood test (looking back, PSA 12.5 3 years earlier, not investigated) Discussion: • Use of imaging for staging • Need for biopsy with PSA >100?
WORK-UP Bone scan: 3 lesions rib/humerus and T11 MRI prostate: T4N1 Biopsy 1. PROSTATE, RIGHT TARGET ZONE, TRANSRECTAL BIOPSY: PROSTATIC ADENOCARCINOMA, GLEASON SCORE 7 (4+3) IN TWO OF THREE CORES (90%,20%,5%). 2. PROSTATE, LEFT TARGET ZONE, TRANSRECTAL BIOPSY: PROSTATIC ADENOCARCINOMA, GLEASON SCORE 8 (4+4) IN FOUR OF FOUR CORES (100%,100%,90%,30%).
TREATMENT OPTIONS ADT alone • ADT plus docetaxel (STAMPEDE/CHAARTED) • ADT plus abiraterone/prednisone • (STAMPEDE/LATITUDE) Any role for radiation to primary/vertebral mets?
CASE 3 • 70 year-old gentleman presenting with LUTS for 1 year • Minimal improvement on sildosin (alpha-agonist) • PSA 115 • Prostate biopsy and TURP performed • Prostate adenocarcinoma 4+5=9
CASE 3: DISCUSSION • Role of imaging in advanced disease • Palliative TURP
CASE 3: DISCUSSION • Initial management of de-novo metastatic high- grade prostate cancer • ADT • Addition of systemic therapy: docetaxel/abiraterone • Need for local treatment?
CASE 4 63 year-old gentleman • February 2010: Diagnosis Gleason 8 prostate adenocarcinoma PSA 106, no evidence of metastasis on CT/Bone scan Commenced LHRH-agonist plus bicalutamide, EBRT to prostate May 2010 October 2011: Diagnosis of CRPC – treated with intermittent anti-androgen October 2013: Metastatic bone lesions on bone scan – commenced abiraterone plus denosumab, response on bone scan at 6m September 2014: Bone scan negative, maintained on abiraterone plus prednisone October 2015: PSA progression, switched to enzalutamide, no PSA response
CASE 4 PET-Choline (2015) IMPRESSION: PET CT findings are in keeping with active local prostate malignancy with no evidence of metastasis. Gallstones.
CASE 4: DISCUSSION Metastatic CRPC, prior radiation to prostate, maintained on LHRH-antagonist • and denosumab, progressed on abiraterone after initial response and ezalutamide (no response) Previously documeted bone metastasis • PET-choline - uptake in prostate only • ? Local therapy • ? Systemic therapy •
CASE 4 • August 2016: Commenced docetaxel chemotherapy, 10 cycles completed Feb 2017 • March 2017: PET-PSMA: uptake in prostate only
CASE 4 • August 2016: Commenced docetaxel chemotherapy, 10 cycles completed Feb 2017 • March 2017: PET-PSMA: uptake in prostate only • Oct-Nov 2017: 45Gy in 25# to prostate IMRT
CASE 4
PET-PSMA MARCH 2018 Impression: Although there has been mild interval improvement in the radiotracer-avid disease in the prostate gland likely due to treatment effect, there are innumerable new intensely radiotracer-avid enlarged lymph nodes along the iliac chains, retroperitoneum, mediastinum and supraclavicular regions as well as innumerable new tiny lung nodules bilaterally consistent with disease progression.
CASE 4: DISCUSSION • Systemic treatment: Cabazitaxel 20 or 25mg/m 2 ? • Lutetium PSMA therapy radionuclide treatment ? • Germline BRCA testing? • Test for somatic DNA-repair defects? • MSI testing?
Thank you! dm25@aub.edu.lb Contacts ESMO European Society for Medical Oncology Via L. Taddei 4, CH-6962 Viganello – Lugano T. +41 (0)91 973 19 00 F. +41 (0)91 973 19 02 esmo@esmo.org esmo.org
Recommend
More recommend
