Case Study: Newly Diagnosed High-Risk Prostate Cancer

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Patient Case: Part 1

• In April 2009, a 53-year-old Caucasian male was referred to urology with a PSA of 15
• Family history of prostate cancer
• Comorbid hypertension
• Undergoes traditional sextant biopsies
• Prostatic volume: 68 grams
• 8 of 12 cores positive
• Gleason 4+4
• Metastatic evaluation including technetium bone scan and CT: both negative

The patient is high-risk, but staging negative, and historically this type of patient would have received radiotherapy with androgen deprivation therapy (ADT) based on the possibility of microscopic disease, explains Christopher P. Evans, MD, FACS. Currently, the approach is more multimodal, and assessing pathologic staging can help determine what type of therapy to use, such as adjuvant therapy of radiation, or androgen deprivation for node-positive disease. In terms of stratifying high-risk patients, younger physicians usually send healthier patients to surgery, while advising them they will still likely require radiation later, states Joseph F. Renzulli II, MD, FACS.

Patient Case: Part 2

• In May 2009, he undergoes a radical prostatectomy with bilateral lymph node dissection
• Pathology reveals a pathologic T3c lesion, with seminal vesicle involvement, N0 M0
• Postoperatively, PSA nadir: 0.5
• At 6 months post-operative, PSA is 1.1
• Receives adjuvant radiation therapy to his prostatic bed
• A series of PSAs July 2010, post radiotherapy to the pelvis, PSA: 0.3 July 2011, PSA: 0.5 November 2011, PSA: 1.6
• A re-staging evaluation is negative
• Androgen deprivation therapy initiated in February 2012
• 3 years post-operative. PSA < .01, starts to rise to 0.5 and has a testosterone level in the castration range
• October 2013, PSA: 2.5

The doubling of the patient’s PSA within the first 3 months post-surgery is indicative of metastatic disease, according to Evans. This development, Evans says, would make him doubt that adjuvant radiotherapy will provide any benefit to this patient. In terms of using radiation therapy, Renzulli suggest that it may have been delayed with the goal of improving his continence.

Several factors could trigger the need to look for metastatic disease. Along with a PSA doubling time of less than 10 months, changes in bone scans can prompt further investigations. A baseline bone scan is useful in gauging changes over time, and in ruling out other issues, such as fractures or temporomandibular joint disorders, notes Evans. Finding metastatic disease would drastically change the options for the patient, and therefore is important to detect. From a urology standpoint, explains Evans, it is necessary to be aware of and monitor for changes, to ensure that patients have access to the most appropriate portfolio of treatment options.

The patient’s short duration of response to ADT usually indicates that something has gone awry, adds Celestia S. Higano, MD, FACP. In this situation, she again stresses the need for identifying metastatic disease as soon as possible. According to Higano, one effective way of identifying metastatic disease earlier would be to bypass a regular technetium bone scan but utilize an F18 PET bone scan. Alhough Renzulli concurs with the sensitivity of the PET scan, he adds that it is more challenging to receive insurance approval for that level of imaging.