ESMO Preceptorship Programme

Metastatic castration sensitive prostate cancer

Dr B. Rakesh Reddy MD DM ECMO

Consultant Medical Oncologist

Mahatma Gandhi Cancer Hospital & Research Institute

Visakhapatnam, India

Prostate – Singapore – 21-22nd November, 2018

ESMO PRECEPTORSHIP PROGRAMME

Case

� 66yr old farmer.

� Diabetic, no other comorbidities

� Presented with Lower urinary tract symptoms – Dysuria, straining to pass urine

� Ultrasound abdomen revealed a prostatic mass;MRI pelvis revealed extraprostatic extension; Serum PSA was 18ng/ml

� Underwent TRUS guided sextant biopsy of prostate mass

� Diagnosed with prostate adenocarcinoma, high risk. Gleason’s score 8 (5+3)

� No metastasis on bone scan, CT abdomen and chest X-ray

ESMO PRECEPTORSHIP PROGRAMME

Treatment

� Post 3 doses of monthly Leuprolide 7.5mg, he was given EBRT

(74Gy in 37 fractions) by IGRT. Leuprolide was continued for a

total of two years.

� He had initial symptom resolution and PSA normalized.

� His tolerance to treatment was good

� Lost to follow up after 4 years of baseline treatment

� 6 years after completion of treatment, he developed lower

urinary tract symptoms and acute onset of severe pain in the left

upper arm.

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Evaluation

� PSA 368 ng/ml

� PSMA PET/CT was done

PSMA avid lesions ( s/o metastasis) in prostate bed, pelvic nodes, para aortic nodes

Multiple dorso-lumabr vertebrae and large destructive lesion in the left proximal humerus

ESMO PRECEPTORSHIP PROGRAMME

Treatment

� Presently 74 years. No other co-morbidities except for well

controlled diabetes. ECOG PS 2.

� Metastatic castration sensitive prostate cancer

� High disease volume - multiple bones involved including

bones outside lumbar vertebrae and pelvic bones

� Treatment options??

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Treatment

� Options considered:

1. castration – medical or surgical.

2. castration + docetaxel or abiraterone

� Treatment given: palliative RT to the humerus lesion; bilateral orchidectomy, 3 weekly Docetaxel (PS improved with pain control prior to starting doce) and monthly zoledronic acid.

� Latest value of PSA is 0.08ng/ml at 5 months of treatment

� Got a total of 6 doses of docetaxel. Patient developed grade 3 neutropenia and grade 2 neuropathy.

ESMO PRECEPTORSHIP PROGRAMME

Questions to consider

� Follow up after treatment of high risk localized

prostate cancer

� Mode of castration

� Addition of docetaxel or abiraterone in first line

treatment of metastatic castration sensitive prostate

cancer

� Low dose abiraterone with food in this setting

ESMO PRECEPTORSHIP PROGRAMME

DISCLAIMER

� CONFLICT OF INTEREST – NONE

� DISCLOSURES – NONE TO DECLARE

ESMO Preceptorship Programme