08/2008 RRP; Pathology GS7 (3+4); clear nodes; positive margin; no SV invasion;
<Stephen Strum, MD> "clear nodes" does not cut it. Number of nodes from what anatomic nodal areas. Details such as these are critical to appraise STATUS or What's Going On. The bottom line in assessing any biological system in the universe is "You Gotta Do Your Homework". --Stephen Strum, MD along with "What are the facts?
"The facts, maa'm, just the facts." --Jack Webb in Dragnet
Even the (3,4) does not cut it since the amount of grade 4 is so important and can vary from as little as 5% grade 4 to as much as 49%. So, what was it?
>07/2009 SRT 78 Gy
<Stephen Strum, MD> and given your RP findings of a positive margin without waiting to see what the PSA is one month post RP, your MDs went ahead with RT. Given that the RP was in 8/08 and the RT in 7/09, perhaps there was a rise in PSA and you are just not presenting data chronologically.
<Stephen Strum, MD> Present your data in context with what is going on since this the more logical and rational way to understand cause and effect.
<Stephen Strum, MD> you have had a steady rise in PSA with PSADT of about 2 months which is consistent with metastatic disease.
>In spite of the RRP and SRT I have an active sex life with my wife of
>27 years. Consulted with my urologist who wants to start hormone
>therapy immediately. When asked about the benefit of immediate over
>postponed, he is rather ambiguous. My medical oncologist is of the
>opinion that there is no benefit and there is potential harm. What is
>the latest medical opinion about immediate or postponed HT for
>someone with my present status?
<Stephen Strum, MD> Definitely agree with the urologist more than the
fellow medical oncologist. What you do not want is bulky and mutated
PC to deal with. One issue is where is the PC?
I would want the following:
DRE (digital rectal exam) report.
CBC, CMP (comprehensive metabolic panel)
bone resorption markers to include serum b-CTX (C-Terminal
Telopeptide, b-Crosslaps) & urine DpD (deoxypyridinoline) since
these are associated with metastases and also since if one or both of
these markers are high normal or elevated i would want to begin Xgeva
I would want an MRI-A (MRI axial skeleton) to rule out bone mets.
Lecouvet FE, Geukens D, Stainier A, et al: Magnetic resonance imaging
of the axial skeleton for detecting bone metastases in patients with
high-risk prostate cancer: diagnostic and cost-effectiveness and
comparison with current detection strategies. J Clin Oncol
25:3281-3287, 2007; PMID:
PURPOSE: To evaluate the diagnostic performance, costs, and impact on
therapy of one-step magnetic resonance imaging (MRI) of the axial
skeleton (MRIas) for detecting bone metastases in patients with
high-risk prostate cancer (PCa). PATIENTS AND METHODS: Sixty-six
consecutive patients with high-risk PCa prospectively underwent MRIas
in addition to the standard sequential work-up (SW) of bone
metastases (technetium-99m bone scintigraphy [BS] completed with
targeted x-rays [TXR] in patients with equivocal BS findings and with
MRI obtained on request [MRIor] in patients with inconclusive BS/TXR
findings). Panel review of initial and 6-month follow-up MRI
findings, BS/TXR, and all available baseline and follow-up clinical
and biologic data were used as the best valuable comparator to define
metastatic status. Diagnostic effectiveness of MRIas alone was
compared with each step of the SW. Impact of MRIas screening on
patient management and costs was evaluated. RESULTS: On the basis of
the best valuable comparator, 41 patients (62%) had bone metastases.
Sensitivities were 46% for BS alone, 63% for BS/TXR, 83% for
BS/TXR/MRIor, and 100% for MRIas; the corresponding specificities
were 32%, 64%, 100%, and 88%, respectively. MRIas was significantly
more sensitive than any other approach (P < .05, McNemar). MRIas
identified metastases in seven (30%) of 23 patients considered
negative and eight (47%) of 17 patients considered equivocal by other
strategies, which altered the initially planned therapy. Economic
impact was variable among countries, depending on reimbursement
rates. CONCLUSION: MRIas is more sensitive than the current SW of
radiographically identified bone metastases in high-risk PCa
patients, which impacts the clinical management of a significant
proportion of patients.
Tombal B, Rezazadeh A, Therasse P, et al: Magnetic resonance imaging
of the axial skeleton enables objective measurement of tumor response
on prostate cancer bone metastases. Prostate 65:178-187, 2005; PMID:
BACKGROUND: There is currently no technique to image quantitatively
bone metastases. Here, we assessed the value of MRI of the axial
skeleton (AS-MRI) as a single step technique to quantify bone
metastases and measure tumor response. METHODS: AS-MRI was performed
in 38 patients before receiving chemotherapy for metastatic HRPCa, in
addition to PSA, computed tomography of the thorax, abdomen, and
pelvis [CT-TAP]; and Tc-99m bone scintigraphy. A second AS-MRI was
performed in 20 patients who completed 6 months of chemotherapy.
Evaluation of tumor response was performed using RECIST. RESULTS:
Only 11 patients (29%) had RECIST measurable metastases in
soft-tissues or lymph nodes on baseline CT-TAP. AS-MRI identified a
diffuse infiltration of the bone marrow in 8 patients and focal
measurable metastatic lesions in 25 patients (65%), therefore,
doubling the proportion of patients with measurable lesions.
Transposing RECIST on AS-MRI in 20 patients who completed 6 months of
treatment, allows the accurate estimation of complete response (n =
2), partial response (n = 2), stable disease (n = 5), or tumor
progression (n = 11), as it is done using CT-TAP in soft tissue solid
metastases. CONCLUSIONS: MRI of axial skeleton enables precise
measurement and follow-up of bone metastases as it is for other
Pending the results of the above would then make treatment decisions
re ADT (androgen deprivation therapy) and how best to give.
If Combidex were still available would do after a normal MRI-A (MRI
axial skeleton) study. If MRI-A (MRI axial skeleton) could not be
done then I would opt for PET/CT using F18 but NOT FDG isotope.
I would also want baseline testosterone level as well as prolactin
level and given the uncertainty of the Gleason score would want
neuroendocrine (NE) markers that are more often seen with high
Gleason scores of 8-10 such as CGA (Chromogranin A), NSE (Neuron
Specific Enolase) and CEA (Carcinoembryonic Antigen). Read The
Primer on Prostate Cancer by Strum & Pogliano and see page 64
regarding markers in high GS situations.
Assuming all has been done, ADT should be at least ADT with 3 drugs
to include anti-androgen (AA) e.g. Casodex or Flutamide followed one
week later by an LHRH agonist like Lupron or Trelstar or Eligard. I
also use Avodart along with the anti-androgen (AA). I monitor the
CBC, ultrasensitive PSA, CMP (comprehensive metabolic panel) &
testosterone monthly until stable values. My goal in PSA is < 0.05 x
12 months and then off ADT but staying on Avodart.
Our published paper used finasteride (Proscar) but dutasteride
(Avodart) appears to be a more appropriate 5ARI (5-alpha reductase
inhibitor) for higher Gleason score PC.
Hope this helps.
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