Roundtable Roundup: Prostate Cancer

CASE SUMMARY

• A man aged 75 years presented with intermittent right hip pain.
• The physical examination was unremarkable except for a prostate nodule on the rectal exam.

Clinical work-up:

• Prostate-specific antigen (PSA): 16.2 ng/mL
• Bone scan and abdominal/pelvic CT scan: negative
• Transrectal ultrasonography biopsy; Gleason 5 + 4, grade group 5
• Negative bone scan and abdominal/pelvic CT scan
• Stage T2N0M0
• ECOG performance status: 1
  

Treatment and follow-up:

• External beam radiation therapy plus androgen deprivation therapy (ADT) was initiated, planned for 24 months. Undetectable PSA level at 6-month follow-up; asymptomatic
• The patient did not return for regularly scheduled PSA follow-up after completion of 24 months of therapy.

Thirty-six months later:

• The patient developed new hip pain and urinary frequency.
• PSA: 29.4 ng/mL
• Testosterone: 300 ng/dL
• Bone scan showed evidence of 2 lesions in left hip (0.8 cm and 1.1 cm)
• Abdominal/pelvic CT showed 2.1-cm left pelvic lymphadenopathy and blastic lesions corresponding to uptake on bone scan.
• Germline and somatic testing are negative for pathogenic alterations.
• The patient started treatment on ADT plus enzalutamide (Xtandi) 160 mg daily. PSA decreased to nadir of 3.9 ng/mL 4 months after starting enzalutamide.
• Bone pain resolved.

• After 8 months on enzalutamide, the patient had a PSA level of 12.6 ng/mL.
• The patient had a vacation planned and declined intense PSA follow-up.
• Four months later, he returned to the office with a PSA level of 48.1 ng/mL. Abdominal/pelvic CT showed enlargement of known pelvic lymph nodes.
• Bone scan showed progressive disease, new lesions.
• New back pain and progressive disease.
• He is now considered metastatic and castration resistant.

• The patient was started on docetaxel 75 mg/m2 intravenously every 3 weeks and prednisone 10 mg daily. Clinically responded with resolution of pain and improved energy, with declining PSA
• Four cycles completed; patient developed worsening bilateral digital neuropathy throughout therapy, so therapy stopped during cycle 5
• Three months later, rising PSA, new back pain, and shortness of breath on exertion
• Abdominal/pelvic CT shows enlargement of known pelvic lymph nodes and 1 new liver lesion (< 2 cm).

“What are you most likely to recommend now that the patient’s disease is progressing, with new liver involvement?”

_REFERENCE

_{1. NCCN. Clinical Practice Guidelines in Oncology. Prostate cancer; version 1.2023. Accessed March 3, 2023. https://bit.ly/41DXvHT}