Interesting Prostate Case

[Haybrant]

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57 yo AA whose PSA was 3 ng/ml for 4 years then slowly rose to 4 then 5.5mng/ml over the course of 2 years. Was referred for biopsy which showed GS 3+4 in 6 cores and 3+5 in 2 cores. So high risk at diagnosis. Gets taken for robot (no bone scan no CTAP is done).

Final path from robot is Gleason 3+4 disease, margins negative, +ECE, no SVI, 11 nodes taken, 1 node positive in the periprostatic fat (which is somewhat interesting), all other nodes negative in the pelvic dissection. Post op PSA is undetectable.

Impressively 1.5 months out from surgery he has no incontinence, minimal if any erectile dysfunction. He is very very concerned about these functions particularly erectile function. If it was just a matter of ECE I wouldn't be opposed to observation in his type of situation. But he obviously has what they are calling a positive node from the prostatic fat.

Appreciate if you have thoughts on management. I believe w positive node ADT is standard and addition of RT based more on other factors such as margin/ECE/Gleason. My initial thought is observe for 3 months if PSA still negative consider ADT alone.

 

[Palex80]

I'd treat.
I suspect that the pathology report may be flawed. pT3a without a postoperative incontinence or erectily dysfuntion sounds fishy to me, especially he is supposed to be margin negative. 🙂

PMID: 25245445

 

[Haybrant]

I'd treat.
I suspect that the pathology report may be flawed. pT3a without a postoperative incontinence or erectily dysfuntion sounds fishy to me, especially he is supposed to be margin negative. 🙂

PMID: 25245445

but. but. robot..

 

[Haybrant]

I'd treat.
I suspect that the pathology report may be flawed. pT3a without a postoperative incontinence or erectily dysfuntion sounds fishy to me, especially he is supposed to be margin negative. 🙂

PMID: 25245445

I dont think im going to do it to be honest, unless PSA is rising after 3 month recheck. I get what youre saying but I cant base the decision on the conjecture and patient specific factors here lead me to lean this way. I had another guy who was similar to this after surgery but his post op PSA was really high. This guy is undetectable.

On further reading the 1-2 positive node group with T3a, GS 7-10, margin negative (considered low risk group) there was 0 benefit to adding RT for cause specific mortality whereas in the intermediate and high risk groups the benefit was quite significant. The same thing fell out from the Rusthoven validation of this study. If he comes back and says he wants to be maximally aggressive thatll be different.

 

[scarbrtj]

Hate to admit it but patient's doc sounds like one hell of a roboticist.

 

[seper]

node positive -- RT is futile


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[medgator]

node positive -- RT is futile


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Not sure I'd be making absolute statements like that.....

http://ascopubs.org/doi/full/10.1200/jco.2014.58.1058
https://www.ncbi.nlm.nih.gov/pubmed/11489709?dopt=Abstract
https://www.ncbi.nlm.nih.gov/pubmed/25245445?dopt=Abstract
https://www.ncbi.nlm.nih.gov/pubmed/24661660?dopt=Abstract

 

[seper]

bad data, not worthy of discussion.
are there any European studies on N+ RT accruing now?


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[medgator]

bad data, not worthy of discussion.
are there any European studies on N+ RT accruing now?


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Given the lack of randomized data for PORT in N2+ NSCLC, do you avoid offering those pts XRT as well?

 

[seper]

no. lung PORT, at least, is supported by secondary analysis of a randomized study.


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[medgator]

no. lung PORT, at least, is supported by secondary analysis of a randomized study.


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Again, an unplanned subgroup analysis of a chemo trial is not exactly the highest quality data but we still offer it.

There is reasonable seer and single institution data to support it imo, and I would offer it to a young pt who is pN+ but is otherwise negative on a metastatic w/u. NCCN felt the existing data was good enough to give ebrt+adt the category 1 recommendation rather than adt alone for upfront therapy, 2B if after surgery.

 

[RadRadRad]

Interesting case

I'd offer up front ADT+RT (see matched pair analysis from Briganti PMID 21354694), with a plan of not keeping him on ADT continuously if PSA remains controlled/undetectable. (this is what I'd do for myself if 57 year old and healthy)

or I'd follow him until PSA rises and offer the same (assuming no evidence of distant mets)

While I recognized that NCCN guidelines recommend upfront ADT in this setting the data is relatively weak (Messing trial was small N and EORTC trial of upfront ADT for node positive (albeit without primary treatment was negative) and ASCO has previously recommended against upfront ADT in 2007 guidelines. Don't like the idea of upfront (with undetectable PSA) committing him to life long (or until hormone refractory) ADT mono therapy particularly if he is highly concerned with ED.

 

[Palex80]

bad data, not worthy of discussion.
are there any European studies on N+ RT accruing now?


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Yes, Wiegel (the guy that ran the German postoperative RT trial on prostate cancer) is running a trial. I recently heard it's recruting very badly...

 

[DoctwoB]

Interesting case

I'd offer up front ADT+RT (see matched pair analysis from Briganti PMID 21354694), with a plan of not keeping him on ADT continuously if PSA remains controlled/undetectable. (this is what I'd do for myself if 57 year old and healthy)

or I'd follow him until PSA rises and offer the same (assuming no evidence of distant mets)

While I recognized that NCCN guidelines recommend upfront ADT in this setting the data is relatively weak (Messing trial was small N and EORTC trial of upfront ADT for node positive (albeit without primary treatment was negative) and ASCO has previously recommended against upfront ADT in 2007 guidelines. Don't like the idea of upfront (with undetectable PSA) committing him to life long (or until hormone refractory) ADT mono therapy particularly if he is highly concerned with ED.