Progressing Prostate Carcinoma

Abstract

In the Karnell Cancer Center Grand Rounds, we present a patient who underwent radical prostatectomy with bilateral pelvic lymphadenectomy, but had positive margins and subsequently developed local recurrence and then systemic disease. Pathologic and radiologic aspects of his disease are discussed. Therapeutic options at different stages of the disease are examined from the point of view of the urologist, radiation oncologist, and medical oncologist.The surgical portion of the discussion focuses on the selection of initial therapy. Both the selection of surgical candidates and choice of pre-or post-operative therapy in patients can be aided by prognostic tools looking at several variables, including prostate-specific antigen (PSA) level, Gleason score of the tumor, seminal vesicle invasion, extracapsular invasion, and lymph node involvement. Low-risk patients can be treated with monotherapy, such as radical prostatectomy, external beam radiation therapy, prostate brachytherapy, or cryosurgical ablation of the prostate. Higher risk patients may require adjuvant and possibly neoadjuvant therapy in addition.The radiation portion of the discussion focuses on the use of radiation therapy as salvage for relapsing disease.Of particular importance is the point that treating highrisk patients whose PSA levels have started to rise but are less than 1 ng/ml results in a long-term PSA control rate as high as 75%, but that limiting the use of salvage radiation therapy to patients with high PSA levels or biopsy confirmation of local recurrence in the face of a negative bone scan results in biochemical long-term control of less than 40%.In the medical oncology part of the discussion, the major focus is on the use of chemotherapy to treat patients whose disease has become resistant to hormonal therapy. Mitoxantrone plus a corticosteroid has been found to offer significant palliation for such patients. Combination therapy with estramustine plus taxanes, other microtubule inhibitors, or other agents such as topoisomerase II inhibitors, has been found to cause shrinkage of measurable soft tissue disease and diminution of serum PSA levels. The development of effective hormonal and chemotherapeutic drugs for treatment of metastatic disease has led to new interest in adjuvant and neoadjuvant therapy of high-risk patients.

Prostate cancer: palliative care and pain relief

“…Corticosteroids may be the treatment of choice in less ambulatory patients who have a short life expectancy, although they also have an accepted role in antitumour treatment effects. [26][27][28] Most patients will be started on 4 mg dexamethasone daily, even though there are no established evidence-based guidelines for doses of corticosteroids. 29 Other symptoms include nausea and constipation, both of which can be effectively treated by a variety of antiemetics and laxatives, respectively.…”

Phase I Trial on sms‐D70 Somatostatin Analogue in Advanced Prostate and Renal Cell Cancer

“…1−3 Although most of the patients initially respond to the treatment, the great majority eventually relapse with androgen-independent disease. 4,5 Chemotherapy with mitoxantrone, 6 as well as with radioisotopes 7,8 may palliate the pain; but not a single agent nor combination of agents has yet been proven to prolong survival 9 despite numerous studies on this field. 10−16 Renal cell cancer is biologically and clinically entirely different from prostate cancer, but, again, no therapies with significant activity are currently available in the metastatic phase of the disease, in particular for those patients who have disease refractory to interferon (IFN).…”

“…Various kinds of hormone manipulations create the cornerstone of treatment of metastatic prostate cancer 1–3. Although most of the patients initially respond to the treatment, the great majority eventually relapse with androgen‐independent disease 4,5. Chemotherapy with mitoxantrone,6 as well as with radioisotopes7,8 may palliate the pain; but not a single agent nor combination of agents has yet been proven to prolong survival9 despite numerous studies on this field 10–16.…”