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Published in Advanced Prostate Cancer

Expert Opinion / Cases · February 11, 2021

Optimal Management of a Man With Recurrent Prostate Cancer

Jeffrey Tosoian MD, MPH

 

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Jeffrey Tosoian MD, MPH

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  • Emmanuel Abara

    Feb 12, 2021

    Thank you for sharing this case .These patients patients exist to challenge our clinical decision making process .We should be respectful for patient's autonomy ,choices, personal and social circumstances and consider  all options .Explaining these options and guiding the individual to make  the decision that resonate well with him should be considered .If he remains asymptomatic with rising serum PSA  and has waited  7 years ( that is , from 2013),there is little justification for any intervention-as any such intervention may change his situation in a different way that may not be favourable. While we admit that the optimal management is currently not available, the Hippocratic dictum "Doctor do no harm" is good !
  • Comment deleted by Moderator.

  • Juan Artigas

    Feb 12, 2021

    Salvage SBRT to prostate and entire pelvic LN area. ADT and abiraterone for 2-3 years.I

  • Craig Knox

    Feb 13, 2021

    I agree with Juan Artigas except ADT plus abiraterone for no more than 1 1/2 years. Long term (2+ years) abiraterone/prednizone can have lasting negative effects on adrenal glands.

  • Waleed Ragab

    Feb 13, 2021

    I think LHRH antagonist plus Biclutamid for 2 years

  • jake jason

    Feb 13, 2021

    I never did like brachy for this nodal result!!  I'd suggest ADT and follow his PSA if no geonomics available

  • Abdelhamid Sabaa

    Feb 14, 2021

    The patient has not reached a good nadir following Brachy. He should have been more closely followed up.Despite lack of symptoms it is rapidly progressive disease and the patient will become symptomatic very soon. With non regional lymph nodes this is M1a disease. Hormone treatment would be the corner stone. Having upfront chemo or AR signal blockers like Abiraterone would entail survival advantage. Salvage radiotherapy to the prostate can be considered.

  • Teodor Burtea

    Feb 19, 2021

    It seems PSA doubling time <24 mo; GS in certain cores 4+3=7. Young, 58 y.o. We do not know what comorbidities; likely to become symptomatic - symptoms control and preserving QoL/sexual function important. Intermittent ADT monotherapy can be considered. If CVD comorbidity and opted for intermitent admin.- antagonist. Meta-analyses have reported increased cardiac toxicity and hypertension with abiraterone. IF CAB desired perhaps apalutamide.

  • Thomas McBride

    Feb 21, 2021

    I would give him two treatment paradigm options here.   More guideline based: Intermittent LHRHa vs. continuous as mainstay, with radiation oncology consultation for an honest discussion on whether or not radiating the common iliac nodes is something he would allow given 1) prior failure and patient confidence in radiation therapy 2) changes in tradition therapy in the 8 years since his treatment and how it might now reduce his chances of failure and side effects.  
He should understand that as soon as failure is again detected, a "less is more" approach is less desirable this time around.  If PSA rises then look at ARV-7 testing before choosing anti-androgen, and if mCRPC shows up, then genomic testing for PARP, etc.  He was 50 when he was diagnosed and clearly was a minimalist against the idea of RRP so he needs to be more careful about closing in on a cure with more active therapies and be more aggressive.

Surgeons: Is there a role for pelvic node resection in this case?

  • Philip von Lintel MD

    Feb 21, 2021

    Can  avoid ADT ( perhaps a patient specificity ) toxicity ... follow with  PSA / PSADT with threshold value in mind . ? suspicion ...  Image Ga68 PSMA / RX RT SBRT ( ?+/- surgery ) with target ... for local ablative Rx  for ( oligomet disease ) ... vs Lu PSMA

  • Paul Pomerantz

    Mar 01, 2021

    Either ADT alone or if feasible ADT with salvage RT to the prostate and nodes pending review by radiation oncology.

  • Prasanta Kumar Pradhan

    Apr 03, 2022

    Completely agree with Philip Von Lintel

  • Paul Pomerantz

    Apr 04, 2022

    As he is a relatively young individual with what sounds like good performance status would suggest aggressive therapy which might include cryotherapy of the prostate to salvage and radiation to the pelvic lymph nodes. I’m not sure you could give salvage radiation to the prostate that has been adequately treated with breakage prior without causing some significant downsides.

  • Nov 21, 2024

    Pending Moderator approval.
    Delete

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