Metastatic Hormone-Sensitive Prostate Cancer Progression to CRPC

Case: Met HSPCa Progressing to mCRPC

June 2016

H&P

• A 64-year old gentleman referred to a medical oncologist with lower back pain
• Initial work-up included:
  • PSA of 79.5 ng/ml
  • WBS showing 3 bone metastasis — 1 Right pelvic area and 2 in lumbar spine
  • CT Chest/Abdomen and Pelvis showed no pelvic lymph nodes and no evidence of visceral disease
  • TRUS/Bx revealed adenocarcinoma of the prostate gland with a Gleason score of 9 [5+4]
• PMH: HTN, Hyperlipidemia - both controlled on oral medications and a family history of colon cancer
• His KPS is 90% and the remaining of his blood work is unremarkable

Pt was started on ADT with LHRH agonist-based therapy and abiraterone + prednisone. He also was placed on monthly zoledronic acid.

• During therapy minimal AEs that included G1 fatigue, hot flashes and muscle aches
• Nadir PSA at 6 months was 0.9 ng/mL

August 2017

• Despite a Testosterone level < 50 ng/dL, patients PSA began to rise
  • PSA August 1.56 ng/mL
  • PSA November 4.4 ng/mL
  • Patient remain completely asymptomatic

February 2018

• Patient is complaining of new back pain (L spine radiating to right hip area) for which he takes over the counter NSAIDs
• PSA now is 6.5ng/mL
• Repeat WBS and CT C/A/P demonstrated 2 new lesions in L spine. No epidural disease or fractures and no evidence of visceral disease.
• Patient is diagnosed as minimally symptomatic Metastatic castration-resistant and abiraterone + prednisone was discontinued.
• Radium 223 therapy was initiated — 6 cycles were completed with improvement of bone pain and minimal AEs that included G1 fatigue and G1 anemia.
  • PSA during therapy ranged from 6.5 to 8.9ng/mL

September 2018

• Patient now is experiencing anorexia, fatigue and progressive abdominal pain
• WBS showed stable disease however CT C/A/P now showed progressive liver metastases
• PSA is now 10.7 ng/ml
• Hemoglobin is 10 g/dL, ANC is 3900 and Platelets are 331,000
• Normal Liver function tests (ALT/AST, Alk Phos, TBili) and LDH of 565

Patients is started on Docetaxel-based chemotherapy (75mg/m2 on 21-day cycles)

Patient completes 6 cycles of therapy with expected AEs including G1 fatigue, G1 alopecia and G1 peripheral neuropathy. His scans at the completion of chemotherapy showed SD with tumor burden reduction in liver lesions and SD in bones. His Hemoglobin level at the completion of chemotherapy is 12.1 g/dL and his ANC and platelets are also within normal limits.