Cases - PROSCA 2019 - Global Congress on Prostate Cancer

Case challenges

Key clinical data from major congresses translated into challenging cases.

 

Curious about the case challenges?
Compare yourself with your peers, and challenge the PROSCA faculty.

You can find the cases already sent hereunder.

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, needs your help!

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, needs your help!

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, needs your help!

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, needs your help!

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?
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?

Join the case discussion

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

Cité Internationale Universitaire de Paris

Mirrors of Medicine

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ISSECAM

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Endorsed by ESTRO