Research Article Radiotherapy Suppresses Bone Cancer Pain ...
Preceptorship on Prostate Cancer · Sep.07 A ue (ng / mL) Goserelin 10.8 µg sc, 12/12 weeks Bone...
Transcript of Preceptorship on Prostate Cancer · Sep.07 A ue (ng / mL) Goserelin 10.8 µg sc, 12/12 weeks Bone...
Andreia Freire Coelho Medical Oncology Resident, Hospital S. João, Oporto - Portugal
Preceptorship on Prostate Cancer16th-17th October, Lugano - Switzerland
A (Re)challenging Case
Identification:
Male
66 years-old
Retired factory worker
ECOG PS 1
Clinical background:Atrial fibrillationDiabetes mellitus type 2Arterial hypertensionHabits:- Tobacco: ex-smoker- Alcohol: marked ingestion
No allergies
Usual medication:Sulphonylurea 60 mg, 2/dayLosartan 50 mg + HCTZ 12,5 mg, 1/dayCarvedilol 6.25 mg, 2/dayAcetilsalicilic acid 150 mg, 1/dayTramadol 100 mg, 2/dayMetamizole 575 mg, 1/day
Familiar background:No history of cancer cases
May – September 2007:
Hip pain with walking claudication
Bone scan (08.07): diffuse bone metastization
PSA ↑: 801 ng/mL
DRE: enlarged heteregenous prostate, stiff nodules
Prostate biopsy: adenocarcinoma, Gleason 7 (3+4)
TAC-CT (09.07): bone metastasis only
cT4NxM1, stage cIV - mPC
66 years old, ECOG PS 1 (bone pain)
Bone metastasis only
Gleason 7
Baseline:
PSA: 801 ng/mL
LDH: 272 U/L
ALP: 332 UI/L
Hb: 11,4 gr/dL
2
Sep.07
PSA
val
ue
(ng/
mL)
Goserelin 10.8 µg sc, 12/12 weeks
Bone pain resolution
No walking limitation
Dec.08
Moderate-severe bone pain
Marked walking limitation
Bone scan and TAP CT: ↑ bone metastasis
Feb.09
0,2
18,551,5
83,2>100
801,4
59,1
PFS: 18 months
Jan.08
Metastatic Hormone Sensitive Prostate Cancer (mHSPC)
Goserelin 10.8 µg sc, 12/12 weeks
Bicalutamide 50 mg po, 1/day
May.09
Met
asti
cca
stra
tio
nre
sist
ant
pro
stat
eca
nce
r…
Dec.07
14,2
Nov.08
ECOG PS 0
Mar.09
ECOG PS 2
3
Docetaxel 75 mg/m2 iv, 21/21 days + Prednisolone 5 mg po, 2/dayEnzalutamide 160
mg/day, 28/28 days
Jun.09 - 1st Treatment
9 cycles, G1 diarrhea
Feb.11 - 1st Rechallenge
11 Cycles, G1 asthenia
Oct.12 – 2nd Rechallenge
7 Cycles, G1 neuropathy
Sep.13 - 3rd Rechallenge,
6 cycles, G2 neuropathy
Jan.14 - Treatment begins
6 cycles, G1 myalgias
Bone pain ↓↓
Minor walking limitation
ECOG PS 1
No bone pain
Minor walking limitation
ECOG PS 1
No bone pain
Minor walking limitation
ECOG PS 1
No bone pain
Minor walking limitation
ECOG PS 1
No bone pain
Minor walking limitation
ECOG PS 1
Zoledronic ac. 4 mg iv, 21/21 days Zoledronic ac. 4 mg iv, 3/3 months
Aug.12 - Bone scan: ↑
bone metastasis
Sep.13 - TC and
Bone scan: ↑ bone
metastasis
Dec.13 - Bone scan: ↑ vsflare of bone metastasis?
Fungal right cornea ulcerby foreign object
An
talg
icR
th, 3
0 G
y, 1
2 f
rP
SA v
alu
e(n
g/m
L)
>100
<0,050,81
13,552,52
4338
70257
386
905
Jun.09 Sep.10 Oct.12 May.13 Sep.13 Jan.14
Metastatic Castration Resistant Prostate Cancer (mCRPC)
Dec.09 Feb.11 Sep.11
7,39
Sep.12 Mar.13 Oct.13 Dec.13
700
32.8
May.14
1,13
Aug.14
Mar.13 - TC and Bone
scan: stable bone
metastasis
3
PFS: 20 months PFS: 19 months PFS: 11 months PFS: 3 months PFS: 8 months
Elder patient
ECOG PS 0-1
2007: mPC (bone metastasis only, Gleason 7)
OS: 7 years
mHSPC
AD (LHRH Ag +/- AA)
PSA ↓ 50%
PFS: 18 months
mCRPC
Docetaxel Rechallenges:
Progresion ≥ 6 months after stopping Docetaxel
1st, 2nd: PSA ↓, stable disease
3rd: PSA ↑ (3 months) - progresion (docetaxelresistance)?
Minor toxicity
Serious infection intercurrence
PFS: 20 » 19 » 11 » 3 months
Enzalutamide
Still good response
PSA ↓ 50%
PFS: 8 months
4
Rechallenge:
- Progresion ≥ 6 months after stopping Docetaxel
- 50% responders
- Posible preditive factors:
. Time from previous cycle to progresion
. Time slope-log PSA
- Benefit on OS?: unclear
- Cabazitaxel
Benefit on OS after Docetaxel treatment
5
Drug sequence may affect response to subsequent therapies
Lack of prospective trials
Decisions driven by clinical and biological parameters and drugs availibility
Discu
sion
Top
ics
Cth with Docetaxel: standard of care in mCRPC
Progresion after 1st line Docetaxel: what’s next?
Cross resistance: AR targeted pathway agents ↔ Taxanes
mCRPC treatment: Which is the best sequencing therapy and when
to switch? We don´t all do the same…
Abiraterone, enzalutamide
- Benefit on OS after Docetaxel treatment
Thank you for your attention