CASE 1

65-year-old man65-year-old man

No other diseases or previous surgeriesNo other diseases or previous surgeries

July 2005:July 2005: PSA 11.5 ng/ml; F/T: 9% PSA 11.5 ng/ml; F/T: 9%

After prostate biopsyAfter prostate biopsy revealing adenocarcinoma: revealing adenocarcinoma: RETROPUBIC NERVE-SPARING RADICAL RETROPUBIC NERVE-SPARING RADICAL PROSTATECTOMYPROSTATECTOMY

HISTOLOGY:HISTOLOGY: Adenocarcinoma pT2b, Gleason 3+3, pN0 Adenocarcinoma pT2b, Gleason 3+3, pN0 (13/13) M0; positive unifocal margin(13/13) M0; positive unifocal margin

PSA after surgeryPSA after surgery: 0.1 ng/ml : 0.1 ng/ml

No adjuvantNo adjuvant radiotherapy radiotherapy

October 2005October 2005: PSA 0.2 ng/ml: PSA 0.2 ng/ml January 2006January 2006: PSA 0.5 ng/ml: PSA 0.5 ng/ml May 2006May 2006: PSA 1.5 ng/ml: PSA 1.5 ng/ml

Asymptomatic patient

TRUS: negative

Negative bone scan

CASE 1

What is the best predictive parameter of clinical What is the best predictive parameter of clinical progression?progression?

a)a) high Gleason score and positive marginshigh Gleason score and positive margins

b)b) PSA > 0,4 ng/ml followed by another higher value

c)c)PSA > 0.4 ng/mlPSA > 0.4 ng/ml

CASE 1 – First QuestionCASE 1 – First QuestionCASE 1

What is the best predictive parameter of clinical progression?What is the best predictive parameter of clinical progression?

a)a) high Gleason score and positive marginshigh Gleason score and positive margins

b)b) PSA > 0,4 ng/ml followed by another higher value

c)c) PSA > 0.4 ng/mlPSA > 0.4 ng/ml

CASE 1 – First QuestionCASE 1 – First QuestionCASE 1

What parameters, in biochemical recurrence, What parameters, in biochemical recurrence, are highly associated with metastatic disease ? are highly associated with metastatic disease ?

a) State of desease and Gleason Scorea) State of desease and Gleason Score

b) PSA and PSA-DTb) PSA and PSA-DT

c)c) PSA-DT, Gleason Score, Time from RP

to BCR

CASE 1 – Second QuestionCASE 1 – Second QuestionCASE 1

What parameters, in biochemical recurrence, What parameters, in biochemical recurrence, are highly associated with metastatic disease ? are highly associated with metastatic disease ?

a) State of desease and Gleason Scorea) State of desease and Gleason Score

b) Psa and Psa-DTb) Psa and Psa-DT

c) c) PSA-DT, Gleason Score, Time from RP to BCR

CASE 1 – Second QuestionCASE 1 – Second QuestionCASE 1

What treatment do you suggest in this What treatment do you suggest in this patient, taken into consideration the risk-patient, taken into consideration the risk-benefit analysis ?benefit analysis ?

a) Orchiectomya) Orchiectomy

b) Monotherapy with non-steroidal antiandrogensb) Monotherapy with non-steroidal antiandrogens

c) LH-Rh agonists + antiandrogensc) LH-Rh agonists + antiandrogens

CASE 1 – Third QuestionCASE 1 – Third QuestionCASE 1

What treatment do you suggest in this What treatment do you suggest in this patient, taken into consideration the risk-patient, taken into consideration the risk-benefit analysis ?benefit analysis ?

a)a) Orchiectomy Orchiectomy

b) Monotherapy with non-steroidal antiandrogensb) Monotherapy with non-steroidal antiandrogens

c) LH-Rh agonists + antiandrogensc) LH-Rh agonists + antiandrogens

CASE 1 – Third QuestionCASE 1 – Third QuestionCASE 1

CASE 2

70-year-old man70-year-old manBPCO, high blood pressureBPCO, high blood pressureMay 2000May 2000: PSA 9.1 ng/ml: PSA 9.1 ng/mlProstate biopsyProstate biopsy reveles adenocarcinoma, reveles adenocarcinoma, Gleason 7 (3+4), cT2aNxM0Gleason 7 (3+4), cT2aNxM0Patient refusesPatient refuses radical prostatectomy and radical prostatectomy and undergoes undergoes radiation therapy (DT 70 Gy)radiation therapy (DT 70 Gy)For 3 years PSAFor 3 years PSA levels remain in the range of 0.5- levels remain in the range of 0.5-0.8 ng/ml; 0.8 ng/ml; Periodical clinical and instrumentalPeriodical clinical and instrumental evaluations evaluations are performedare performed

July 2003July 2003: PSA 2.2 ng/ml: PSA 2.2 ng/mlOctober 2003October 2003: PSA 4.1 ng/ml: PSA 4.1 ng/mlJanuary 2004January 2004: PSA 7.2 ng/ml: PSA 7.2 ng/mlPatient refuses surgical treatment.Patient refuses surgical treatment.The patient receivesThe patient receives LHRH in combination with LHRH in combination with Casodex, achieving a PSA decline to 0.5 ng/ml.Casodex, achieving a PSA decline to 0.5 ng/ml.Periodical follow-up are performed. Periodical follow-up are performed. March 2005March 2005: PSA increases to 13.5 ng/ml; no : PSA increases to 13.5 ng/ml; no metastases. metastases. The antiandrogen therapy is stoppedThe antiandrogen therapy is stopped, resulting , resulting after 2 months in a withdrawal effect on his after 2 months in a withdrawal effect on his PSA level (2.5 ng/ml)PSA level (2.5 ng/ml)

CASE 2

July 2005:July 2005: PSA increase PSA increase (32.6 ng/ml)(32.6 ng/ml)

Staging of diseaseStaging of disease::

CT: CT: lung metastaticlung metastatic lesions lesions

Bone scan: Bone scan: L3 osteoblasticL3 osteoblastic lesion lesion

PET: PET: evidence evidence of the previous described of the previous described

lesions plus a pelvic captationlesions plus a pelvic captation

CASE 2

What treatment do you suggest in this What treatment do you suggest in this patient ? patient ?

a) a new hormonal linea) a new hormonal line

b) cortisonics + biphosphonate b) cortisonics + biphosphonate

c) chemotherapy + cortisonics +biphosphonate c) chemotherapy + cortisonics +biphosphonate

CASE 2CASE 2 – First QuestionCASE 2 – First Question

What treatment do you suggest in this What treatment do you suggest in this patient? patient?

a) a new hormonal linea) a new hormonal line

b) cortisonics + biphosphonate b) cortisonics + biphosphonate

c) chemotherapy + cortisonics + biphosphonatec) chemotherapy + cortisonics + biphosphonate

CASE 2CASE 2 – QuestionCASE 2 – Question

The patient starts chemotherapyThe patient starts chemotherapy with with Docetaxel 75 mg/mq (q21) + prednisone 10 Docetaxel 75 mg/mq (q21) + prednisone 10 mg/die and Zometa 4 mg (q21), obtaining a mg/die and Zometa 4 mg (q21), obtaining a SD SD after the III cycles (PSA 28) and a lung PR after after the III cycles (PSA 28) and a lung PR after the VI cycle (PSA 15).the VI cycle (PSA 15).

Stop chemiotherapy after the VI cycleStop chemiotherapy after the VI cycle for the for the appearance of metabolic alterations and appearance of metabolic alterations and diagnosis of diabetes mellitus. diagnosis of diabetes mellitus. (February 2006)(February 2006)

CASE 2- evolution

Periodical follow-upPeriodical follow-up are performed are performed showing clinical and biochemical showing clinical and biochemical stabilitystability

November 2007November 2007: : evidence evidence of lung PDof lung PD

PSA: PSA: 82 ng/ml82 ng/ml

PS:1, good metabolic statusPS:1, good metabolic status

CASE 2- evolution

What is the further therapeutic option for What is the further therapeutic option for this patient ?this patient ?

a) Start again hormone therapy a) Start again hormone therapy b) Start again chemotherapy with Docetaxel b) Start again chemotherapy with Docetaxel

and Prednisoneand Prednisonec) Metronomic chemotherapyc) Metronomic chemotherapyd) Second line chemotherapy with Navelbined) Second line chemotherapy with Navelbine

CASE 2 –Evolution: QuestionCASE 2 –Evolution: Question

What is the further therapeutic option for What is the further therapeutic option for this patient ?this patient ?

a) Start again hormone therapy a) Start again hormone therapy

b) Start again chemotherapy with Docetaxel b) Start again chemotherapy with Docetaxel andand

PrednisonePrednisone

c) Metronomic chemotherapyc) Metronomic chemotherapy

d)d) Second line chemotherapy with NavelbineSecond line chemotherapy with Navelbine

CASE 2 –Evolution: First QuestionCASE 2 –Evolution: First Question

What are the new sperimental drugs giving What are the new sperimental drugs giving the most encouraging results in the treatment the most encouraging results in the treatment of hormone-rafractory prostate cancer ?of hormone-rafractory prostate cancer ?

a)a) satraplatin satraplatin b)b) bevacizumab, talidomide, gefitinib, inhibitors bevacizumab, talidomide, gefitinib, inhibitors

endothelin-Aendothelin-Ac)c) ixabepilone, trastuzumabixabepilone, trastuzumabd) d) calcitriolcalcitriole)e) vaccine therapyvaccine therapy

Final QuestionFinal Question

What are the new sperimental drugs giving What are the new sperimental drugs giving the most encouraging results in the treatment the most encouraging results in the treatment of hormone-rafractory prostate cancer ?of hormone-rafractory prostate cancer ?

a)a) satraplatin satraplatin b)b) bevacizumab, talidomide, gefitinib, inhibitors bevacizumab, talidomide, gefitinib, inhibitors

endothelin-Aendothelin-Ac)c) ixabepilone, trastuzumabixabepilone, trastuzumabd) d) calcitriolcalcitriole)e) vaccine therapyvaccine therapy

Final QuestionFinal Question

CASE 3

77-year-old man. PS: 1Arterial hypertension. Hearth attack in 1995 August 2003: dysuria and urethral bleedingSerum PSA 23 ng/ml. Chromogranin A 20; NSE 3,4

transrectal ultrasound guided A needle biopsy was performed

HISTOLOGY: Adenocarcinoma cT2b, Gleason 5+5, perineural invasion; N0 M0;

What kind of treatment do you suggest ?What kind of treatment do you suggest ?

a)a) SurgerySurgery

b)b) RadioteraphyRadioteraphy

c)c) HormonotherapyHormonotherapy

CASE 3CASE 3 – First QuestionCASE 3 – First Question

What kind of treatment do you suggest ?What kind of treatment do you suggest ?

a)a) SurgerySurgery

b)b) RadioteraphyRadioteraphy

c)c) HormonotherapyHormonotherapy

CASE 3 – First QuestionCASE 3 – First Question CASE 3

In consideration of the ageIn consideration of the age, he started , he started androgen blockade hormonotherapyandrogen blockade hormonotherapy

Serum PSA was undetectableSerum PSA was undetectable for 1 for 1 yearsyears

October 2004October 2004: urinary obstruction, : urinary obstruction, weight loss and bone pain. PS: 2/3weight loss and bone pain. PS: 2/3

CASE 3 - EVOLUTIONCASE 3 - EVOLUTION

Imaging studies revealed multiple bones metastases.

PSA 18,0 ng/ml; Chromogranin A 450; NSE 22

A fine-needle aspiration biopsy of the bone revealed metastases of a neuroendocrine tumor which was strongly positive for NSE and Chromogranin-A

CASE 3 - EVOLUTION

What is the most important What is the most important neuroendocrine prostate cells marker ?neuroendocrine prostate cells marker ?

a)a) PSA, PSA FreePSA, PSA Free

b)b) CEA, NSECEA, NSE

c)c) Chromogranin AChromogranin A

CASE 3 – Second QuestionCASE 3 – Second Question

CASE 3 - EVOLUTION

What is the most important What is the most important neuroendocrine prostate cells marker ?neuroendocrine prostate cells marker ?

a)a) PSA, PSA FreePSA, PSA Free

b)b) CEA, NSECEA, NSE

c)c) Chromogranin AChromogranin A

CASE 3 – Second QuestionCASE 3 – Second Question

CASE 3 - EVOLUTION

A transurethral prostatectomy (TUR-P) was performed in order to relieve the obstructive symptoms

pathological examination of the resected specimen showed a small cell carcinoma of the

prostate.

CASE 3 – EVOLUTION again

What treatment do you suggest in this patient, What treatment do you suggest in this patient, taken into consideration the clinical condition taken into consideration the clinical condition and the comorbidities ?and the comorbidities ?

a)a) II-line HormotherapyII-line Hormotherapyb)b) ChemotherapyChemotherapyc)c) Treatment with Somatostatin analogs and Treatment with Somatostatin analogs and

dexamethasonedexamethasone

CASE 3 – Third QuestionCASE 3 – Third Question

CASE 3 – EVOLUTION again

What treatment do you suggest in this patient, What treatment do you suggest in this patient, taken into consideration the clinical condition taken into consideration the clinical condition and the comorbidities ?and the comorbidities ?

a)a) II-line HormotherapyII-line Hormotherapyb)b) ChemotherapyChemotherapyc)c) Treatment with Somatostatin analogs and Treatment with Somatostatin analogs and

dexamethasonedexamethasone

CASE 3 – Third QuestionCASE 3 – Third Question

CASE 3 – EVOLUTION again