Consultant Medical Oncologist Mahatma Gandhi Cancer ... · Metastatic castration sensitive prostate cancer Dr B. RakeshReddy MD DM ECMO Consultant Medical Oncologist Mahatma Gandhi

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

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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

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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.

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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

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DISCLAIMER

� CONFLICT OF INTEREST – NONE

� DISCLOSURES – NONE TO DECLARE

ESMO Preceptorship Programme