1 Andrea Luciani MD, PhD - PowerPoint Presentation

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Andrea Luciani MD,

PhD

U.O. Oncologia MedicaOspedale S. Paolo- Polo UniversitarioASST Santi Paolo e CarloMilan, Italy

F.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

Access 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

Prostate

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

PSA 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

QUESTION 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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DOCETAXEL

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)

Restaging

after three monthsCT thoracx-abdomen: Stability

at prostate and lymphonodes Increase of the bone lesionsBone scan: Scheletric

progressive diseasePSA 130 ng/mL ABIRATERONE8

Clinical

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

PSA 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

PSA 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

Question 2.

After Enzalutamide therapy the choice of a new treatment could be :

BSCSipuleucel TMitaxantrone Taxotere Flutamide12

RECHALLENGE 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

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World J Clin Oncol 2015 October 10; 6(5): 99-103

6 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

15 gg

after CT scan exitus of the patientSuspected cerebrovascular event

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Grazie per l’attenzione

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