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CASE 1

CASE 1. 65-year-old man No other diseases or previous surgeries July 2005: PSA 11.5 ng/ml; F/T: 9% After prostate biopsy revealing adenocarcinoma: RETROPUBIC NERVE-SPARING RADICAL PROSTATECTOMY HISTOLOGY: Adenocarcinoma pT2b, Gleason 3+3, pN0 (13/13) M0; positive unifocal margin

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CASE 1

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  1. CASE 1 • 65-year-old man • No other diseases or previous surgeries • July 2005: PSA 11.5 ng/ml; F/T: 9% • After prostate biopsy revealing adenocarcinoma: RETROPUBIC NERVE-SPARING RADICAL PROSTATECTOMY • HISTOLOGY: Adenocarcinoma pT2b, Gleason 3+3, pN0 (13/13) M0; positive unifocal margin • PSA after surgery: 0.1 ng/ml • No adjuvant radiotherapy

  2. CASE 1 • October 2005: PSA 0.2 ng/ml • January 2006: PSA 0.5 ng/ml • May 2006: PSA 1.5 ng/ml • Asymptomatic patient • TRUS: negative • Negative bone scan

  3. CASE 1 CASE 1 – First Question • What is the best predictive parameter of clinical progression? • high Gleason score and positive margins • PSA > 0,4 ng/ml followed by another higher value • PSA > 0.4 ng/ml

  4. CASE 1 CASE 1 – First Question • What is the best predictive parameter of clinical progression? • high Gleason score and positive margins • PSA > 0,4 ng/ml followed by another higher value • PSA > 0.4 ng/ml

  5. CASE 1 CASE 1 – Second Question • What parameters, in biochemical recurrence, are highly associated with metastatic disease ? a) State of desease and Gleason Score b) PSA and PSA-DT c)PSA-DT, Gleason Score, Time from RP to BCR

  6. CASE 1 CASE 1 – Second Question • What parameters, in biochemical recurrence, are highly associated with metastatic disease ? a) State of desease and Gleason Score b) Psa and Psa-DT c) PSA-DT, Gleason Score, Time from RP to BCR

  7. CASE 1 CASE 1 – Third Question • What treatment do you suggest in this patient, taken into consideration the risk-benefit analysis ? a) Orchiectomy b) Monotherapy with non-steroidal antiandrogens c) LH-Rh agonists + antiandrogens

  8. CASE 1 CASE 1 – Third Question • What treatment do you suggest in this patient, taken into consideration the risk-benefit analysis ? a) Orchiectomy b) Monotherapy with non-steroidal antiandrogens c) LH-Rh agonists + antiandrogens

  9. CASE 2 • 70-year-old man • BPCO, high blood pressure • May 2000: PSA 9.1 ng/ml • Prostate biopsy reveles adenocarcinoma, Gleason 7 (3+4), cT2aNxM0 • Patient refuses radical prostatectomy and undergoes radiation therapy (DT 70 Gy) • For 3 years PSA levels remain in the range of 0.5-0.8 ng/ml; • Periodical clinical and instrumental evaluations are performed

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

  11. CASE 2 • July 2005: PSA increase (32.6 ng/ml) • Staging of disease: • CT: lung metastatic lesions • Bone scan: L3 osteoblastic lesion • PET: evidence of the previous described lesions plus a pelvic captation

  12. CASE 2 CASE 2 – First Question • What treatment do you suggest in this patient ? a) a new hormonal line b) cortisonics + biphosphonate c) chemotherapy + cortisonics +biphosphonate

  13. CASE 2 CASE 2 – Question • What treatment do you suggest in this patient? a) a new hormonal line b) cortisonics + biphosphonate c) chemotherapy + cortisonics + biphosphonate

  14. CASE 2- evolution • The patient starts chemotherapy with Docetaxel 75 mg/mq (q21) + prednisone 10 mg/die and Zometa 4 mg (q21), obtaining a SD after the III cycles (PSA 28) and a lung PR after the VI cycle (PSA 15). • Stop chemiotherapy after the VI cycle for the appearance of metabolic alterations and diagnosis of diabetes mellitus. (February 2006)

  15. CASE 2- evolution • Periodical follow-up are performed showing clinical and biochemical stability • November 2007: evidence of lung PD PSA: 82 ng/ml PS:1, good metabolic status

  16. CASE 2 –Evolution: Question • What is the further therapeutic option for this patient ? a) Start again hormone therapy b) Start again chemotherapy with Docetaxel and Prednisone c) Metronomic chemotherapy d) Second line chemotherapy with Navelbine

  17. CASE 2 –Evolution: First Question • What is the further therapeutic option for this patient ? a) Start again hormone therapy b) Start again chemotherapy with Docetaxel and Prednisone c) Metronomic chemotherapy d)Second line chemotherapy with Navelbine

  18. Final Question • What are the new sperimental drugs giving the most encouraging results in the treatment of hormone-rafractory prostate cancer ? • satraplatin • bevacizumab, talidomide, gefitinib, inhibitors endothelin-A c) ixabepilone, trastuzumab d) calcitriol e) vaccine therapy

  19. Final Question • What are the new sperimental drugs giving the most encouraging results in the treatment of hormone-rafractory prostate cancer ? • satraplatin • bevacizumab, talidomide, gefitinib, inhibitors endothelin-A c) ixabepilone, trastuzumab d) calcitriol e) vaccine therapy

  20. CASE 3 • 77-year-old man. PS: 1 • Arterial hypertension. Hearth attack in 1995 • August 2003: dysuria and urethral bleeding • Serum 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;

  21. CASE 3 CASE 3 – First Question • What kind of treatment do you suggest ? • Surgery • Radioteraphy • Hormonotherapy

  22. CASE 3 CASE 3 – First Question • What kind of treatment do you suggest ? • Surgery • Radioteraphy • Hormonotherapy

  23. CASE 3 - EVOLUTION • In consideration of the age, he started androgen blockade hormonotherapy • Serum PSA was undetectable for 1 years • October 2004: urinary obstruction, weight loss and bone pain. PS: 2/3

  24. CASE 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

  25. CASE 3 - EVOLUTION • What is the most important neuroendocrine prostate cells marker ? • PSA, PSA Free • CEA, NSE • Chromogranin A CASE 3 – Second Question

  26. CASE 3 - EVOLUTION • What is the most important neuroendocrine prostate cells marker ? • PSA, PSA Free • CEA, NSE • Chromogranin A CASE 3 – Second Question

  27. CASE 3 – EVOLUTION again • 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.

  28. CASE 3 – EVOLUTION again • What treatment do you suggest in this patient, taken into consideration the clinical condition and the comorbidities ? • II-line Hormotherapy • Chemotherapy • Treatment with Somatostatin analogs and dexamethasone CASE 3 – Third Question

  29. CASE 3 – EVOLUTION again • What treatment do you suggest in this patient, taken into consideration the clinical condition and the comorbidities ? • II-line Hormotherapy • Chemotherapy • Treatment with Somatostatin analogs and dexamethasone CASE 3 – Third Question

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