70/M
PSA 100
Bone scan shows multiple areas of avidity
What are the policies that you follow regarding histological diagnosis before starting hormonal treatment?
TRUS guided Biopsy not feasible?
Its feasible, but someone raised the issue about whether its required at all - could it be anything else? Is it inappropriate to treat without a histological diagnosis in this case?
I seriously dont know when we can omit obtaining a histological proof of malignancy before initiating treatment. This case can be benefitted in a clinical trial - in which case they will require a histological proof. Assuming the guy is poor and a clinical trial is not going to be in the horizon and the treating clinician is 100% certain of the diagnosis and gets a informed consent from the patient about proceeding with the treatment / patient refuses biopsy I think we can proceed without biopsy .. other than that a biopsy is needed if for nothing else but confirming the diagnosis.
NEVER!
Better the 'needless' biopsy to confirm the obvious, than to needlessly look stupid when the clip-clop turns out to come from a zebra not a horse!
The only acceptable time to proceed without a biopsy is when attempt at biopsy is hazardous to health. PRCA diagnosis is obvious when >1000, not 100. PSA 100 is not always associated with metastases from PRCA either. (I wouldn't bet against it being PRCA, but my experience is that these assumption break SOP and are the progenitor of gross errors in management).
Andrew, santam and others
Thanks a lot. I was a bit in two minds about this situation. The suggestion of not performing a biopsy actually sounded quite reasonable to me when I thought about it in the light of a 100 PSA and osteoblastic lesions on a bone scan, but I couldn't find any guidelines on it. I wanted to know if some people go ahead without biopsies before treatment in a situation like this… this is not my patient… so just for my understanding.
What are the other possibilities with high PSA? >100 ? Although remote?
I agree with Andrew, biopsy is must. Although most likely the patient has metastatic disease but you still want to know what you are treating.
Re: Adjuvant. PSA is one of the best tumor markers we have in Oncology. Still we do see spurious results which do not fit well in the clinical scenario. Key rule to remember don't treat the report on paper. Treat the patient.
As you know PSA can go up due to 6 non cancerous causes: 1) Prostatitis, 2) DRE , 3) Intercourse(ejaculation), 4) Prostate Biopsy, 5) BPH and last but not the least which I always forget 6) Bicycle riding. But can it go >100 ? Dont think so. I have not seen that yet in my limited experience.
Actually, Indranil's question is more pertinent for people sitting at peripheries with lack of multimodality facilities,
where u can get PSA with outsourced labs, bone mets being seen with digital X-Rays but no backup of Surgeon/ radiologist for biopsy/ FNAC. Even in gud setups, its difficult to get an ideal multi quadrant biopsy done due to complications especially bleeding post procedure,, it usually is a costly procedure, n may turn out to b costlier if complications arise.
If we dont think "medicolegally", I really dont think we justify ourselves putting a metastatic pt thru this traumatic procedure.
An unique 3rd world consideration :-D
I understand your concerns suruchi, however Prostate biopsies are not that painful and difficult "if done properly". Doing a head neck cancer biopsy is equally traumatic and dangerous. It is just that we do not see that many PRCA our exposure is less in this area, however as per the new data life expectancy of Indian men/women has gone up so we will be seeing more PRCA cases in future http://www.worldlifeexpectancy.com/global-health-comparison-index-india.
There are very special emergent life threatening situations (eg., SVCO) where we may be forced to go without a biopsy but not for this man.
Q1. If this same guy had a partial collapse of T8 and spinal cord compression, how would you treat him? Objectively the situation would still be an elderly male with high PSA and bone mets.
Q2. If the prostate biopsy from a regular indian urology center turns out negative, what should be done first? Repeat biopsy? Slide Review? Look for a primary elsewhere for bone mets?
"The commonest bone tumor in elderly population is Multiple Myeloma " . One should try every attempt to get the pathology. However Multiple myeloma will not light up on Bone scan. So if thats the case, then look for other possible cancers like 1) Lung, 2) Prostate 3) GI etc.,
Interestingly I saw a 86 years old guy today with multiple osteoblastic bone lesions, PSA=89.4. Clinically the prostate is hard,nodular, quite big (4x4cm), I could not reach the base. The bone mets were picked becoz he had some ongoing low back ache. Now this elderly gentle man was sent to us for RT with no tissue diagnosis. We have requested for a biopsy. The reason being lets assume it comes out to be neuroendocrine carcinoma of prostate then what do we do? The treatment is entirely different. The chances of this happening very lot but they are not zero either.
For the case situation where the patient present with T8 collapse/cord compression: One can discuss with the patient and go ahead and treat like we do in some emergent situations where one has to go by clinical judgement.
On an average you need atleast 3-4 working days for the pathology to be ready. During this time you are expected to rule out other possible primaries as well. But if your index of suspicion is in favor of a particular site then that should be ruled out first. It is always good to review difficult cases with colleagues and the same applies to pathologists when it come to slide review.
Sorry for nitpicking here but cant help :-)
However Multiple myeloma will not light up on Bone scan
A very common misconception that as its an osteolytic leison it wont light up. The thing is that osteolytic lesion is filled with plasma cells and bone per se never takes up the radionuclide. While its less sensitive than plain xrays about 40% of MM scans are positive on bone scan (its the poor positive and negative predictive value that makes its utility limited as a diagnostic modality). If there is a fracture it will light up like a christmas light.
A reference ? here you go
http://radiology.rsna.org/content/231/1/11.full
Good point and nice paper, thanks Santam
Nikhilesh - how would multiple myeloma give rise to a PSA of 100? I don't think that neuroendocrine ca gives rise to a PSA of 100 either.
I agree with everyone's insistence for a biopsy for everyone's peace of mind. I am just trying to think whether there is even a single differential diagnosis in this man's case.
Iam not saying PSA will be high in MM. What Iam trying to convey is if you get a elderly patient with multiple bony lesions then MM is on top of the list as differentials followed by other sites. Your patient most likely has PRCA rather than anything else but Iam not comfortable treating without pathology.
http://www.ncbi.nlm.nih.gov/pubmed/20664477 nice guideline for Neuroendocrine tumors.
Hi, I Don't known if the last nail has been hit to the coffin concerning this topic, but I thought of tumbling a few more skeletons from the coffin before that.
85yr Male, KPS=30-40, Known Diabetes and Hypertensive on treatment,
Was referred from NIMHANS as he had high PSA.
Patient was referred to NIMHANS by a local doctor because of fever, delirium and paraperesis since 15 days
NIMHANS evaluation:
Had past history of Chikungunya fever 3yrs back which was treated at a local hospital
CBC = Hb (6gm%) , TC & DC - Normal , Plt = 27000/mm3. RFT = Normal.
Antibodies against Malaria, Dengue , Leptospira & Chikungunya = Negative
widal = Negative
RA Factor = Negative
CRP = Positive
CT BRAIN - Diffuse cerebral atrophy with multiple lacunar infarcts in brainstem. Probably age related degeneration.
MRI SPINE - Lytic lesion in L1 Vertebrae body, Intervertebral disc desiccation at multiple vertebral levels, with associated compression of thecal sac at L4-L5 level.
PSA - 2926 ng/ml.
Withe the above background information the patient was referred to us.
We did a urgent BONE Scan - Reported as SUPERSCAN . Disseminated metastasis
This is somewhat similar to the case profile alluded to by Indranil earlier , but with associated THROMBOCYTOPENIA
(Reason for thrombocytopenia not yet ascertained inspite of investigations . Inspite of daily multiple platelet transfusions , patient's Plt count as of today is 18000/mm3).
An opinion of Hemato-oncologist was taken. Advised to do
Bone marrow biopsy !!! {to r/o the cause for thrombocytopenia}
Prostatic Biopsy !!!! {to confirm the primary}
So Now the patient has to undergo "TWO BIOPSIES" . The song Dene Wala Jab Bhee Deta, Deta Chhappar Phad Ke comes to mind.
Anyway need the opinion of the house, as to mentioned earlier " HAS THE LAST NAIL BEEN HIT OR NOT "
Hi all after further reading I think we can open the nails from the coffin again. I was going through the European association of Urology guidelines during lunch. http://www.uroweb.org/gls/pdf/Prostate%20Cancer%202010%20June%2017th.pdf
Page 30 table at the bottom of the page row 2nd I paraphrase here:
The diagnosis of PCa depends on histopathological (or cytological) confirmation.
Biopsy and further staging investigations are only indicated if they affect the management of the patient
The level of recommendation is C (so well … )
I think for your patient Chendil the key thing is are you going to be able to do anything for a 85 year old man with KPS of 30 -40?? This is I presume a Indian 85?
do the bone marrow first. When it shows PRCA cells, you won't need to do any other biopsy! Make sure you ask them to do PSA-IHC.
I am comfortable without a positive biopsy in this case. Label him as a "C80; neoplasm, malignant" treat his L1 lesion and put him on hormone therapy.
Few articles which might throw some light, positively?
I couldn't get the full text . If Possible anyone can share the same
Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults
Jean-Pierre Drozab, Lodovico Balduccic, Michel Bollad, Mark Embertone, John M. Fitzpatrickf, Steven Joniaug, Michael W. Kattanh, Silvio Monfardinii, Judd W. Moulj, Arash Naeimk, Hendrik van Poppelg, Fred Saadl, Cora N. Sternbergm
Critical Reviews in Oncology/Hematology, Volume 73, Issue 1, Pages 68-91 (January 2010)
Management of prostate cancer in older men: recommendations of a working group of the International Society of Geriatric Oncology. Droz JP, Balducci L, Bolla M, et al.
BJU Int. 2010;106:462-9
Are prostatic biopsies necessary in men aged ≥80 years?
Simon R.J. Bott, Charlotte L. Foley, Matthew D. Bull, C.C. Jeevan Reddy, Alex Freeman,
Bruce S.I. Montgomery, Stephen E.M. Langley
BJU International
Volume 99, Issue 2, pages 335–338, February 2007
I chanced upon VIADUR when going through the literature regarding Hormonal therapy options suitable for treating my patient.
VIADUR (Bayer Corporation,West Haven, CT) is a subcutaneous implant that releases leuprolide acetate at a constant rate for 1 year. Seems reasonable for an elderly patient with multiple co-morbidities considering THE once yearly change of implant.
Does anyone have experience related to using this product. ( I'am not sure if it is available in INDIA)
Few related papers on VIADUR
Evaluation of an implant that delivers leuprolide for 1 year for the palliative treatment of prostate cancer
Urology, Volume 55, Issue 5, May 2000, Pages 639-642
Jackson E. Fowler Jr, Michael Flanagan, Donald M. Gleason, Ira W. Klimberg, James E. Gottesman, Roohollah Sharifi and for the VIADUR STUDY GROUP
JACKSON E. FOWLER JR., JAMES E. GOTTESMAN, C. FREDRIC REID, GERALD L. ANDRIOLE JR., MARK S. SOLOWAY
SAFETY AND EFFICACY OF AN IMPLANTABLE LEUPROLIDE DELIVERY SYSTEM IN PATIENTS WITH ADVANCED PROSTATE CANCER
The Journal of Urology, Volume 164, Issue 3, Part 1, September 2000, Pages 730-734
No I have not used this product yet. Infact I attended a Urology seminar where the urologists were aggressively discussing Bilateral Orchiectomy which is quite common in India since majority cannot afford expensive injections.
