Clinical cases INSERIR TÍTULO AQUI · 2018-11-06 · INSERIR TÍTULO AQUI Non Metastatic Prostate...
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Transcript of Clinical cases INSERIR TÍTULO AQUI · 2018-11-06 · INSERIR TÍTULO AQUI Non Metastatic Prostate...
INSERIR TÍTULO AQUI
Non Metastatic Prostate CancerClinical cases
Neal ShoreMedical Director, CPI, Carolina Urologic Research Center
INSERIR TÍTULO AQUICase 1: Mr. Smith Prostate Cancer Patient Aged 63 Years With Rising PSA
History of disease
History of disease
• 6 years ago underwent radical prostatectomy (RP) for Gleason 4+4, iPSA 7.9 ng/mL
• Metastatic evaluation s/p RP NED with BS/CT abdomen/pelvis
• 16 months post-RP, detectable, rising PSA
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Treatment
Treatment
• Salvage RT administered (PSA 0.49 ng/mL)
• PSA 6 months post-RT 0.86 ng/mL
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Clinical progression
Clinical progression
• Started on ADT, when PSA 1.09 ng/mL,3 months later
• PSA nadirs to undetectable level, over the past year PSA values every 3 months: 0.04, 0.15, 0.23, 0.45 ng/mL (testosterone at last visit: 15 ng/dL)
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Summary
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History of disease
• 6 years ago underwent radical prostatectomy (RP) for Gleason 4+4, iPSA 7.9
• Metastatic evaluation s/p RP NED with BS/CT abdomen/pelvis
• 16 months post-RP, detectable, rising PSA
Treatment
• Salvage RT administered (PSA 0.49)
• PSA 6 months post-RT 0.86
Clinical progression
• Started on ADT, when PSA 1.09,3 months later
• PSA nadirs to undetectable level, over the past year PSA values every 3 months: 0.04, 0.15, 0.23, 0.45 (testosterone at last visit: 15 ng/dL)
Case Question 1
Would you have started Mr. Smith on ADT post-salvage RT?
1. Yes
2. No
3. Not then but likely later
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Case Question 2
What would you recommend to Mr. Smith at this time?
1. Fluciclovine or PSMA Ga PET/CT
2. Abdomen/pelvis and bone scan
3. No imaging, repeat PSA 3 months
4. Enzalutamide
5. Something else
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Case 1: Mr. Smith ALTERNATE UNIVERSE
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Alternate universe
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History of disease
• 6 years ago underwent radical prostatectomy (RP) for Gleason 3+3, iPSA 7.9
• Metastatic evaluation s/p RP NED BS/CT abd/pelvis
• 16 months post-RP, detectable, rising PSA
Treatment
• Salvage RT administered (PSA 0.49)
• PSA 6 months post-RT 0.86
Clinical progression
• Started on ADT, when PSA 1.09,3 months later
• PSA nadirs to undetectable level, over the past year PSA values every 3 months: 0.04, 0.15, 0.23, 0.45 (testosterone at last visit: 15 ng/dL)
Case Question 3
Would you have started Mr. Smith on ADT post-salvage RT?
1. Yes
2. No
3. No, and by the way NEVER (unless he develops mets)
4. Not then but likely later
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Case Question 4
What would you recommend to Mr. Smith at this time?
1. Fluciclovine or PSMA Ga PET/CT
2. Abdomen/pelvis and bone scan
3. No imaging, repeat PSA 3 months
4. Enzalutamide
5. Something else
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Case 2: Mr. LAnother Prostate Cancer Patient Aged 65 Years With Rising PSA
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History of disease
History of disease
• 6 years ago underwent radical prostatectomy (RP) for Gleason 4+4, iPSA 7.9 ng/mL
• Metastatic evaluation s/p RP NED BS/CT abd/pelvis
• 16 months post-RP, detectable, rising PSA
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Treatment
Treatment
• Salvage RT administered (PSA 0.46 ng/mL)
• PSA 6 months post-RT 0.75 ng/mL
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Clinical progression
Clinical progression
• Started on ADT 3 months later PSA 1.09 ng/mL
• PSA nadirs to undetectable level, over the past year PSA values every 3 months: 0.04, 0.8, 1.23, 2.45 ng/mL (testosterone at last visit 15 ng/dL)
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Summary
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History of disease
• 6 years ago underwent radical prostatectomy (RP) for Gleason 4+4, iPSA 7.9
• Metastatic evaluation s/p RP NED BS/CT abd/pelvis
• 16 months post-RP, detectable, rising PSA
Treatment
• Salvage RT administered (PSA 0.46)
• PSA 6 months post-RT 0.75
Clinical progression
• Started on ADT 3 months later PSA 1.09
• PSA nadirs to undetectable level, over the past year PSA values every 3 months: 0.04, 0.8, 1.23, 2.45 (testosterone at last visit 15 ng/dL)
Case Question 5
What would you recommend to Mr. L at this time?
1. Fluciclovine or PSMAGa PET/CT
2. Abdomen/pelvis and bone scan
3. No imaging, repeat PSA 3 months
4. Enzalutamide
5. Something else
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Case 2: Mr. L (Cont’d)
• Bone scan mild degenerative joint disease
• CT abdomen/ pelvis
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Case Question 6
What would you recommend to Mr. L at this time?
1. Enzalutamide
2. Node pluck
3. SRS to the node
4. Abiraterone
5. Expectant management
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INSERIR TÍTULO AQUI
Clinical casesPROSPER
Case 1
Clinical Case 1
Age at Trial Entry: 73
Family Hx: none
Medical Hx: CAD, hyperlipidemia, hypercholesterolemia, basal cell carcinoma
PCa Diagnosed: 9/4/1991
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Clinical Case 1
Prior treatment:
– prostatectomy 1991
– EBRT 1993(PSA relapse)
– 12 month histrelin (aLHRH) implant- 2004-current
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Clinical Case 1
PSA: (01/2014) 8.5 ng/mL
CT/Bone scan: negative
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Clinical Case 1
2,5
4,2
8,5
0
1
2
3
4
5
6
7
8
9
set/
13
no
v/13
jan
/14
mar
/14
mai
/14
jul/
14
set/
14
no
v/14
jan
/15
mar
/15
mai
/15
jul/
15
set/
15
no
v/15
jan
/16
mar
/16
mai
/16
jul/
16
set/
16
no
v/16
jan
/17
mar
/17
mai
/17
jul/
17
set/
17
no
v/17
jan
/18
mar
/18
mai
/18
jul/
18
SEP2013
DEC2013
OCT2016
AUG2018
<0.01 <0.01
XTANDI
JAN2014
PSA DT: 2.9 MONTHS PSA
ng/
mL
INSERIR TÍTULO AQUI
Clinical casesPROSPER
Case 2
Clinical Case 2
Age at Trial Entry: 82
Family Hx: Mother-colon cancer
Medical Hx: A. Fib, Diabetes Mellitus, COPD, CABG, Atrial Valve Replacement, HTN, Osteoporosis
PCa Diagnosed: 6/3/2002
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Clinical Case 2
Prior tx:
– LHRH agonist q 3 month; 2011-current
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Clinical Case 2
1,5
2,6
4,9
0
1
2
3
4
5
6
jul/13 ago/13 set/13 out/13 nov/13 dez/13 jan/14 fev/14JUL2013
OCT2013
FEB2014
PSA
ng/
mL
PSA DT: 4.2 MONTHS
Clinical Case 2
1,5
2,6
4,9
0
1
2
3
4
5
6
jul/13 ago/13 set/13 out/13 nov/13 dez/13 jan/14 fev/14JUL2013
OCT2013
FEB2014
PSA DT: 4.2 MONTHS
XTANDI
PSA
ng/
mL
Clinical Case 2
1,5
2,6
4,9
0,93
7,5
0
1
2
3
4
5
6
7
8
jul/
13
set/
13
no
v/…
jan
/14
mar
/…
mai
/…
jul/
14
set/
14
no
v/…
jan
/15
mar
/…
mai
/…
jul/
15
set/
15
no
v/…
jan
/16
mar
/…
mai
/…
jul/
16
set/
16
no
v/…
jan
/17
mar
/…
mai
/…
jul/
17
set/
17
no
v/…
jan
/18JUL
2013OCT2013
FEB2014
JUN2017
JAN2018
• CT: Stable,• BS: New uptake 2
ribs and 2 vertebrae
PSA DT: 4.2 MONTHS
PSA
ng/
mL
XTANDI
Clinical Case 2
1,5
2,6
4,9
0,93
7,5
10,7
0
2
4
6
8
10
12
jul/
13
set/
13
no
v/13
jan
/14
mar
/14
mai
/14
jul/
14
set/
14
no
v/14
jan
/15
mar
/15
mai
/15
jul/
15
set/
15
no
v/15
jan
/16
mar
/16
mai
/16
jul/
16
set/
16
no
v/16
jan
/17
mar
/17
mai
/17
jul/
17
set/
17
no
v/17
jan
/18
mar
/18
mai
/18
jul/
18
set/
18JUL2013
OCT2013
FEB2014
XTANDI
JUN2017
JAN2018
• CT: Stable, • BS: New uptake 2
ribs and 2 vertebrae
OCT2018
ASX, CT chest/abd/pelvis
negative
• (referred for Radium-223 , completed 6 cycles, August 2018) …
• repeat scans unchanged
PSA DT: 4.2 MONTHS
PSA
ng/
mL
