The patient is a 72-year-old man with a PSA score of 80. A biopsy of the prostate reveals Gleason score 10 adenocarcinoma with small-cell components. A bone scan demonstrates extensive metastatic disease, and a CT scan of the abdomen/pelvis demonstrates three hepatic metastases.
The patient was treated with combined blockade with six cycles of carboplatin and etoposide up front. His PSA normalized, and a CT scan of the adenocarcinoma showed that his liver metastases went away completely. He was maintained on combined blockade. After one year, his PSA rises to 40 and his liver metastases comes back. He also develops symptomatic bone pain.
Sartor: To me, that PSA rise indicates that the androgen axis is still intact. So I feel that bringing an additional way to attack the androgen axis, like the abiraterone, is very reasonable. We don’t have a lot of data in this sort of setting—in fact, we have almost none—and I wouldn’t fault anybody who would go with the carboplatin/ docetaxel.
Dreicer: It still may be that what we’ve seen here is just mostly adenocarcinoma, so if at this juncture he’s symptomatic, I think abiraterone is a very reasonable choice. I probably would again give him four weeks of therapy and see whether or not there’s any clinical response.
The patient was treated with abiraterone/prednisone. On that treatment, his PSA dropped from 120 to 30, but a CT scan shows continued progression of the disease in his liver. Do you think the patient has a small-cell component at this point? Do you think he has an adenocarcinoma?
Sartor: Is there a role for measuring chromogranin A or neuronspecific enolase? Would that help determine whether to do a re-biopsy at that point?
Petrylak: I’ve found it to be all over the place, and you can’t really get into a trend. Doing another biopsy is not unreasonable, but at the same point, is it going to alter your therapy that much that you want to delay and arrange for a CT-guided biopsy?
The patient was treated with carboplatin and docetaxel, and responded to treatment. The liver lesions are completely gone, although the cancer did progress into his lymph nodes, so he’s now on cabazitaxel.
|Title||Expiration Date||CME Credits|
|Community Practice Connections™: Personalized Sequencing in Castration-Resistant Prostate Cancer: Bridging the Latest Evidence to the Bedside in Clinical Management||Aug 25, 2018||1.5|
|Community Practice Connections™: 1st Annual School of Nursing Oncology™||Oct 31, 2018||1.5|