Cases - Global Congress on Prostate and Bladder Cancer

Key clinical data translated
into case challenges

Curious about the case challenges? Compare yourself with your peers, and challenge the PROSCA & BLADDR faculty.
You can find the prostate & bladder cancer cases already sent hereunder.
BCa Case 2 - Would you suggest a treatment break to Agnieszka who has metastatic UCa?

Agnieszka is a 48-year-old chemistry teacher. She’s heavily inspired by Marie Curie, née Skłodowskaja, winner of 2 Nobel Prizes, and secretly hopes she too might win a Nobel Prize, if only she could find the secret formula for turning lead into gold…

She was diagnosed with metastatic urothelial bladder cancer during investigation of dysuria. Germline testing was negative for mutations. Somatic tumour testing did not show FGFR2 or FGFR3 alterations.

Assessment summary:

  • Medical history: no relevant past medical history
  • CT scan of chest, abdomen and pelvis: diffuse liver and lung metastases
  • ECOG PS: 1
  • Glomerular filtration rate: 90 ml/min
  • PDL1 expression: combined positive score (CPS) 30

A month ago, she received the last of 4 cycles gemcitabine + cisplatin. She has a partial response but has developed significant neuropathy and fatigue and does not want more chemotherapy.

What would you suggest to Agnieszka?

(click on the option you would recommend & compare your answer with your colleagues & expert Petros Grivas)

A. Regular follow-up

B. Start immunotherapy with avelumab

BCa Case 1 - What would you suggest for Stanislaw when there is BCG shortage?

Stanisław is a 66-year-old former miner working in the Wieliczka Salt Mine. He has had a salt overload for the rest of his life, and despite the nagging of his children, he never adds salt to the boiled potatoes.

Diagnostic work-up:

  • Cystoscopy: 1 papillary tumour at right bladder wall, 4.5 cm
  • TURBT with random bladder biopsies:
    • visually complete resection
    • pTa high-grade
    • no CIS
    • muscle present in specimen, no LVI

You are suffering supply constraints for BCG.

 

Which option would you recommend for Stanisław?

(click on the option you would recommend & compare your answer with your colleagues)

A. Re-TUR and cystoscopy after 3 months

B. BCG instillations at standard frequency

C. BCG instillations at reduced frequency

D. BCG instillations at standard frequency but reduced dose

E. Cystectomy

PCa Case 2 - ADT options in a patient with PCa who likes sauerkraut and chocolate

Tomasz is 70 years old. He’s specialised in creating new pierogi recipes, but for reasons he cannot understand, nobody seems to like his pierogi with sauerkraut and chocolate. Tomasz is newly diagnosed with high-risk PCa.

Assessment summary:

  • Medical history: myocardial infarction 1 year ago, treated with 2 stents
  • Present treatment: clopidogrel, amlodipine
  • T3bN0M0 based on CT and bone scan
  • ISUP grade group: 4 (Gleason score 4+4)
  • PSA: 23 ng/ml

He will start external beam radiotherapy with neo-adjuvant and concurrent ADT.

Which ADT option (in combination with EBRT) would you recommend for Tomasz?​

(click on the option you would recommend & compare your answer with your colleagues)

A. LHRH agonist
B. Bicalutamide monotherapy
C. GnRH antagonist

PCa Case 1 - Marek has oligometastatic disease, now what?

Marek is a 61-year-old translator. His specialty is translating Polish into simpler Polish. It is a really tricky language you know.

He was diagnosed with intermediate-risk PCa 6 years ago (PSA 17 ng/ml; ISUP grade group 3) and was treated with radical prostatectomy (pT3aN0M0). He received early prostate bed salvage RT without ADT for biochemical recurrence 2 years ago at a PSA level of 0.25 ng/ml.

Follow-up information today:

  • PSA: 0.5 ng/ml
  • PSA doubling time: 5 months
  • PSMA PET-CT: 1 spot on Th11, biopsy confirmed PCa
  • Asymptomatic and no relevant comorbidities
Which option would you recommend for Marek?

(click on the option you would recommend & compare your answer with your colleagues)

A. Observation

B. ADT monotherapy

C. ADT + additional systemic agent (e.g. docetaxel, abiraterone)

D. Stereotactic RT to bone lesion without systemic agent

E. Stereotactic RT to bone lesion + ADT

F. Enroll in clinical trial

Case 7 - Gustave, an artisanal wine maker, needs your help!

Gustave spends his days with making wine on the Left Bank of Bordeaux. No matter how hard he washes his feet, the smell of mold and grape never goes away. Two years ago, at age 65, Gustave underwent radical prostatectomy for pT3b pN0 cM0 PCa, grade ISUP 5. Gustave’s wife calls you and tells you that he visited his physician for follow-up assessments:

  • PSA: 3.8 ng/ml
  • PSA-DT: 8.8 months
  • Bone scan and CT scan negative

The intended treatment for Gustave was salvage EBRT to the prostate bed + ADT. However, the physician decided to perform fluciclovine PET/CT, which showed positivity in the left common iliac node (5 mm). The treatment plan was revised to include an RT boost to the positive node.

Would you have performed a PET/CT scan before deciding on the treatment plan in this patient with biochemical recurrence after RP?

 

Case 6 - Jérome, a former boatman on a Seine River Cruise, needs your help!

Jérome was trained in the French Navy to sail submarines, but had to quit because of claustrophobia. He spent the rest of his career as the captain of a Seine River Cruise. Two years ago, at age 69, Jérome underwent radical prostatectomy for pT2b pN0 cM0 PCa, with negative margins, but ISUP 4. His first postoperative PSA was negative.

Today, he visits you to discuss a follow-up assessment:

  • Asymptomatic
  • PSA: 2.0 ng/ml (6 months before: 1.2 ng/ml)
  • PSA-DT: 8 months
  • Bone scan and CT scan negative, but PSMA PET/CT: uptake in right acetabulum and positive on biopsy
  • Otherwise fit
  • No relevant comorbidities
Which option would you recommend for Jérome?

 

Case 5 - What would you do?
You edit a major uro-oncology journal and feel very proud that, last month, your journal published a European randomized trial on the treatment of locally advanced prostate cancer that seems to answer some of our most fundamental questions.
This morning, however, you have received an anonymous email from a physician informing you that the randomized trial had never taken place and the data is largely fabricated.

What would you do next?
A) “Assume the “whistleblower” is a disgruntled or jealous former partner of the first author who is set on revenge”
B) “Assume the “whistleblower” is correct and retract the article out of concern for the journal’s reputation”
C) “Challenge the first author with the accusations”
D) “Follow a process laid out by the Committee on Publishing Ethics”
E) “Call the police”

 

Case 4 - Jean-Michel, a journalist at French TV

Jean-Michel is a 68-year-old journalist at French TV specialised in European politics and business. He plays tennis 3 times a week and has an intense sexual life. He was diagnosed with prostate cancer 7 years ago due to high total PSA (6.8 ng/ml at that time) with no significant past history, except a minor surgery for inguinal left hernia 14 years ago. His father was treated for laryngeal cancer at the age of 73.  

At diagnosis, his PCa presented as:

  • Clinical stage: cT2b, prostate MRI negative for extra-prostatic extension and/or seminal vesicles invasion
  • PSA: 6.8 ng/ml
  • Biopsy Gleason score: 3+4 [ISUP grade group 3]
  • Negative bone and pelvic CT scan
  • ECOG performance status: 0

He underwent radical prostatectomy with no pelvic lymph node dissection.

Final pathology:

  • Adenocarcinoma of the prostate
  • Gleason score 3+4 of the left lobe
  • Margins positive on 2 mm at the left apex

Postop PSA was < 0.004 ng/ml.

He regained full urinary continence 4 months after surgery, and was prescribed a treatment with Viagra. An expectant policy was adopted with PSA controls every 3 to 6 months.

Seven years after his surgery, he comes for a second opinion because of a rising PSA.

  • Two years ago: PSA 0.05 ng/ml
  • 18 months ago: 0.09 ng/ml
  • 15 months ago: 0.12 ng/ml
  • 12 months ago: 0.17 ng/ml
  • 8 months ago: 0.19 ng/ml
  • Recently: PSA 0.21 ng/ml, controlled at 0.26 ng/ml
What would you tell Jean-Michel?
A) “Do not panic: your PSA doubling time is so low that you do not need any treatment”
B) “As your PSA is rising with a confirmed value above 0.2 ng/ml you need salvage irradiation”
C) “As your PSA is rising with a confirmed value above 0.2 ng/ml you need salvage irradiation and ADT for 6 months”
D) “As your PSA is rising with a confirmed value above 0.2 ng/ml you need a PSMA PET to detect where it is produced”
Case 3 - Rémi, a cheesemaker from Paris

Rémi, 72 years old, used to be a molecular biologist, but he had to quit because his bacteria plates were always infected with fungi. He changed careers and became a cheesemaker. He’s happily married and otherwise well. Rémi takes statins and no other regular medication.

He presents with a reduced urinary stream, frequency every 2 hours and nocturia x 3 to 4. A PSA test returns with a level of 16.8 ng/ml. DRE reveals a firm normal sized prostate. MRI identifies an index lesion in the left peripheral zone and radiological stage T2b.

Biopsies:

  • 10 cylinders (template): Gleason 3+4 [ISUP grade 2] bilateral in peripheral zone; 8/10 positive
  • 2 cylinders directed to dominant lesion: Gleason 4+5 [ISUP grade 5] in dominant lesion; 2/2 positive

A CT scan for staging identifies an enlarged right obturator lymph node 14 mm diameter and a smaller common iliac node 11 mm. It is otherwise clear and an isotope bone scan is also clear.

Which option would you recommend for Rémi?

*Option C: ADT for 2 years and radical RT to prostate and nodes boosting enlarged nodes to 70+ Gy equivalent dose
**Option D: (boost to enlarged nodes) and prostate, followed by HDR brachytherapy to prostate boosting index lesion and ADT for 2 years

Case 2 - Didier, a critical art critic from Paris

Didier, 69 years old, became an art critic after a failed attempt to become a famous painter. He briefly worked as a nude model, but was never happy with the results from the art students and found himself criticizing them all the time. He underwent radical prostatectomy for localised prostate cancer 2.5 years ago: pT2aNx, pathological ISUP grade group 2 (Gleason score 3+4), positive surgical margins. Didier’s PSA remained undetectable until 3 months ago.

Recent diagnostic work-up:

  • PSA: 0.3 ng/mL (first measurable PSA 3 months ago: 0.2 ng/mL)
  • Comorbidities: 6 months ago angina pectoris, now stable
Which option do you consider most appropriate for Didier?

 

*Option B: PSMA-PET staging + metastases-targeting tx in case of oligo-recurrent disease

Case 1 - François, a baker famous for his macarons

François is a 61-year old baker famous for his butter croissants and rainbow-colored macarons. Personally he prefers the English breakfast, with a lot of sausages. He recently realized he had to wake up twice more in the night for nocturia. He is a former smoker (15 pack/year) with no significant past history, except a pneumonia successfully treated with antibiotics 5 years ago. His mother was treated for breast cancer when she was about 50.

He is diagnosed with prostate cancer:

  • Clinical stage: cT3
  • PSA: 36 ng/ml
  • Gleason score: 4+4 [ISUP grade group 4]
  • Bone scan: 3 spots on the spine
  • CT: locally advanced prostatic mass, few enlarged pelvic lymph nodes, 1 spot on the lung, corresponding to a doubtful metastasis.
  • ECOG performance status: 1
Which treatment do you consider most appropriate for François?

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At the congress, we will discuss several cases. Challenge the expert panel during these patient case sessions.

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