UO Oncologia Medica Ospedale S Paolo Polo Universitario ASST Santi Paolo e Carlo Milan Italy FB 73 years old Comorbidities Past duodenal ulcer Diabetes Hypertension ID: 935413
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Andrea Luciani MD,
PhD
U.O. Oncologia MedicaOspedale S. Paolo- Polo UniversitarioASST Santi Paolo e CarloMilan, Italy
Slide2F.B. 73
years oldComorbidities:Past duodenal ulcerDiabetesHypertension
PS 1. GA: ADLs 6/6; IADLs 5/8: he needs help for activities as gionig out, take public transports; MNA is fine; GDS 3/5 MMSE 28/30
Polypharmacotherapy: antihypertensives, antidiabetics, sedative hypnotics.Wife is suffering of ansious-depressive syndrome and she is currently uder psychiatric follow up. He has a son that is living in Modena2
Slide3Access to
emergency room for onset of intensive lumbar and right back pain CT thorax-abdomen: Right Hydronephrosis
destra without any visible stonesPathological tissue at the right seminal
vesicle Multiple pelvic adenopathiesEnlargement of the prostate gland, no cleavage plane with bladderPositioning right nephrostomy with significant reduction of hydronephrosis3
Slide4Prostate
biopsy: Prostatic Adenocarcinoma Gleason 4+5=9, vascular and neural invasionBone
scan: multiple bone metastases at T8, sternum, acetabulum and at the bilateral ribs.
Basal PSA 3.8 ng/mL Starting monthly DEGARELIX4
Slide5PSA 20.5
ng/mL starting BICALUTAMIDE 50 mg/die
Restaging after three
monthsPSA 62 ng/mL, testosterone 9.64 ng/dLCT thorax-abdomen: progression of disease at the adenopathiesBone scan: bone progression, especially at cervical and lumabr levelsPatient with active symptoms, PS ECOG 1 stable. Consultation with pain and palliative service.5
Slide6QUESTION 1.
THE PATIENT HAS A RADIOLOGICAL AS WELL AS BIOCHEMICAL PROGRESSIVE DISEASE. WHICH IS THE PEST THERAPY NOW? AbirateroneEnzalutamideDocetaxel MitoxantroneRadium 223
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Slide7DOCETAXEL
three weekly with primary G-CSF prophylaxis
CT thorax-abdomen: Stable at the prostate glandReduction
of the number of adenopathies Bone stable except for the lesion at the L5Bone scan: significant bone progression with involvement of all spine, all bilateral ribs and sternumImprovement of the syntomps -> Improvement of daily authonomiesPSA 65 ng/mLGA: ADLs 6/6; IADLs stables. Better depression scoresFollow up with Degarelix therapy only7After 8 cycles of chemotherapy (last two months weekly administration due to G3 anemia and G2 fatigue)
Slide8Restaging
after three monthsCT thoracx-abdomen: Stability
at prostate and lymphonodes Increase of the bone lesionsBone scan: Scheletric
progressive diseasePSA 130 ng/mL ABIRATERONE8
Slide9Clinical
worsening. PS 1->2. Autonomous in the ADLs, but needs more
assistance for movements. Need assistance to get outPSA 243 ng/mL
CT thorax-abdome: Stable at prostatic glandSignificant numerical and dimensional increase of the adenopathies Numerical increase of the bone lesionsBone scan: progressive disease at the bone with new lesions at the skullcap , clavicles, lumbar spine, pelvis and at the proximal epiphysis of the right femur STOP ABIRATERONE 9
Slide10PSA 200
ng/mLFatigue G2. Bone scan: partial metabolic remission
CT thorax-abdomen: Onset of a new epatic lesion in S2 compatible with metastasisStability at prostate,
addominen and bone10CABAZITAXEL with a reduced dose for 4 cycles
Slide11PSA 247
ng/mLCT thoracx-abdomen: Significant increase of the of the patic lesions with
onset of new lesions in in S5 and in S6Dimensional and numeric increase of pathological adenopathies Numerical and dimensional
increase of the multiple bone lesionsBone scan: progressive disease PS 2. Still autonomous in ADLs. Worsening of the IADLs He hires a new caregiver. STOP ENZALUTAMIDE after three months RT su L2-L5 (30 Gy in 10 fract)11 ENZALUTAMIDE
Slide12Question 2.
After Enzalutamide therapy the choice of a new treatment could be :
BSCSipuleucel TMitaxantrone Taxotere Flutamide12
Slide13RECHALLENGE with weekly DOCETAXELRestaging after 4 cycles
CT thorax-abdomen: No change in hepatic lesions Partial response in number and dimension of the
pathological adenopathies No change at the bone lesions PSA 190 ng/mLSignificant clinical benefit13
Slide1414
World J Clin Oncol 2015 October 10; 6(5): 99-103
Slide156 cycles of
chemotheapySimultaneus care with palliative serviceCT thorax-abdomen (November 2017): increase
of the hepatic and nodal metastases. PS ECOG 2No significant pain but relevant fatigue. 15
Slide1615 gg
after CT scan exitus of the patientSuspected cerebrovascular event
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Slide17Grazie per l’attenzione
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