Case sharing Abiraterone breaks metastatic prostate cancer, deep and lasting decrease in PSA

Prostate cancer is highly aggressive, and most patients have metastasized when they are first diagnosed
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Metastatic hormone-sensitive prostate cancer (mHSPC) is a type of metastatic prostate cancer with a better prognosis, but patients at this stage will turn into metastatic castration-resistant prostate cancer (mCRPC) after progression, with a significantly worse prognosis
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How to improve the prognosis of mHSPC patients and delay the onset of castration resistance has attracted much attention from clinicians
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At present, Zeke® (abiraterone acetate) has become the first-line treatment option for mHSPC and mCRPC recommended by domestic and foreign guidelines
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This time, I will bring you 2 cases from the real world to share with readers
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Case 1 male with medical history, 66 years old
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Main complaint: urinary frequency and urgency for 2 years, worsening for 2 days
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Digital rectal examination: the size of the prostate is about 5*4cm, the texture is hard, the left lobe can be palpable and multiple small nodules, local tenderness
.

Auxiliary examination laboratory examination: total prostate specific antigen (T-PSA): 59.
04ng/ml, free prostate specific antigen (F-PSA): 5.
08ng/ml
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 Color Doppler ultrasound of urinary system (September 1, 2010): Right kidney cyst; bladder parenchyma space; prostate enlargement with calcification; urinary retention
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Prostate-enhanced MRI (September 3, 2010): 1.
Left prostate cancer, involving seminal vesicles; 2.
Prostatic hyperplasia, the left bladder mass is considered to be part of the hyperplastic prostate; 3.
Combined with CT pelvic multiple metastasis; 4.
Both sides of the iliac Swollen perivascular lymph nodes
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Diagnosis Results The first diagnosis (September 2010): high-risk mHSPC invaded the bladder and seminal vesicle glands, accompanied by multiple bone metastases, and urinary retention
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The second diagnosis (May 2018): After mCRPC treatment in September 2010, transurethral resection of the prostate + intraoperative rapid resection + bilateral testicular medullary enucleation
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Postoperative pathology: prostate adenocarcinoma with neuroendocrine differentiation (5+4=9 points)
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After the operation, bicalutamide and goserelin were given endocrine therapy, and zoledronic acid was given to treat bone metastases
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In March 2012, re-examination of MRI: prostate hyperplasia; abnormal signals on the left pubic bone, ischia, and femoral neck, consider metastasis
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T-PSA: 0.
02ng/ml, F-PSA: 0.
004ng/ml, testosterone: 0.
61ng/ml
.

In May 2018, re-examination of MRI: tumor recurrence, converted to mCRPC; PSA progressively increased, T-PSA: 7.
997ng/ml, F-PSA: 1.
912ng/ml, testosterone: 0.
8ng/ml; switch to the original research A Bitter Dragon treatment
.

Figure 1 MRI results July 2021, re-examination MRI: 1.
After prostate cancer, the posterior wall of the bladder was thickened with mild enhancement, and the original residual prostate, seminal vesicle glands, and bladder soft tissue masses were not seen in this film
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2.
The right acetabulum has a small patch of low signal, which is similar to the previous one.
It is recommended to review it
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3.
A small amount of fluid in the pelvic cavity, which is less than before
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T-PSA: 0.
130ng/ml, F-PSA: 0.
082ng/ml, testosterone: 0.
07ng/ml
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Figure 2 MRI results in July 2021 Figure 3 PSA changes after surgery Figure 4 Testosterone changes after surgery Case thinking: This patient was diagnosed as high-risk mHSPC before surgery for the first time, and was subsequently treated with surgery, and Bikaru was used after surgery Amine + goserelin endocrine therapy and zoledronic acid for bone metastases
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However, in the second diagnosis, PSA was found to be progressively higher.
A re-examination of MRI revealed that the tumor recurred.
The patient was switched to mCRPC and switched to the original abiraterone treatment.
The lesion was relieved by imaging, PSA levels and testosterone levels were significantly reduced, and the patient's curative effect was achieved.
Improve
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The COU-AA-302 study showed that 1, compared with placebo + prednisone, mCRPC patients receiving abiraterone + prednisone significantly prolonged the median survival to 34.
7 months and reduced the risk of death by 19% (HR=0.
81, P=0.
0033)
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In addition, studies have found that 2, abiraterone + prednisone significantly delays the progression of tumor imaging metastasis, bone destruction and pain deterioration
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Therefore, it is emphasized that patients in the mCRPC stage should use abiraterone as soon as possible to prolong survival and delay progression
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Figure 5 The efficacy of abiraterone + prednisone in the treatment of mCRPC.
Although the patient switched to abiraterone treatment, the efficacy of this patient was better, but the new endocrine therapy was not used early in the initial treatment stage.
The efficacy of traditional endocrine therapy was not ideal, suggesting For patients with high-risk mHSPC, the new endocrine therapy of abiraterone should be used earlier
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Case provider: Professor Lei Zhangming, Chief Physician, Professor Lei Zhangming, Deputy Director of the Department of Urology, Quzhou People’s Hospital, Member of the Quzhou Municipal Committee, Member of the Fourth and Fifth CPPCC Committee of Quzhou City Professor) In recent years, the treatment of mCRPC has made significant progress
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Among them, abiraterone has become the preferred option recommended by NCCN guidelines in the mCRPC stage 1 category, and the benefits are confirmed by the COU-AA-302 study, and the study found that the PSA level and Gleason score of patients are low, that is, the disease is still relatively early At times, the use of Abiraterone can bring more significant OS benefits
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This patient did not use the new endocrine therapy early and was transferred to the mCRPC stage.
However, after switching to abiraterone treatment, the imaging lesions resolved and PSA decreased.
This reflects the good effect of abiraterone on patients in the mCRPC stage, and the follow-up should continue to be standardized.
Treatment and monitoring of related indicators
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Reviewer: Professor Wang Shuo, Professor Wang Shuo, Deputy Director, Department of Urology, The First Affiliated Hospital of Zhejiang University, Director, Minimally Invasive Center of Urology, The First Affiliated Hospital of Zhejiang University, Member of the Robotics Group and Deputy Secretary-General of the Chinese Medical Association Urology Branch, Zhejiang Medical Association Male Chairman of the Science Society Case 2 Male patient with medical history, 74 years old, chief complaint: dysuria for 3 months, aggravated by 10 hours
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Auxiliary examination In November 2018, a local hospital examination: T-PSA>100ng/mL, MRI of the prostate and seminal vesicles showed: prostate cancer involved the anterior and left side walls of the pelvis; involved the bottom of the bladder and seminal vesicle glands
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Multiple lymph node metastases around the iliac vessels, both anterior and bilateral groin
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There are multiple abnormal signal shadows in the pelvis (>3 locations), consider metastasis
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In November 2018, the lung CT in our hospital showed: 1.
Hilar area of ​​both lungs, considering enlarged lymph nodes, possible metastasis; 2.
Multiple small nodules in both lungs with slightly enlarged lymph nodes in the mediastinum, metastasis waiting to be rowed; 3.
Chronic inflammation of both lungs
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Skeletal ECT showed: abnormal concentration of cervical spine radioactivity, tumor bone metastasis cannot be excluded
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Figure 6 The results of the first-diagnosis imaging examination in November 2018 Figure 7 The results of the first-diagnosis imaging examination in November 2018 The diagnosis result of high-risk mHSPC (CT4N1M1)
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After treatment in December 2018, the patient was given bicalutamide + leuprolide acetate endocrine therapy, and PSA was monitored
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On May 23, 2019, PSA dropped to 4.
12 ng/ml
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Figure 8 PSA level after treatment with bicalutamide + leuprolide acetate.
In May 2019, the patient underwent laparoscopic radical prostatectomy + bladder neck plasty.
During the operation, tumors in the bladder neck and triangle area were found to be involved.
Swollen lymph nodes were seen in the lateral pelvic cavity, and there were serious adhesions around the prostate
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PSA was also detected .

Postoperative pathology: see prostate cancer invasion, Gleason score 5+5=10 points
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Metastatic cancer was seen in the lymph nodes ("left pelvic LN" 1/6, "right pelvic LN" 1/8)
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Figure 9 Preoperative MRI In July 2019, the patient was switched to abiraterone + androgen deprivation therapy (ADT)
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On March 23, 2021, PSA dropped to 0.
021 ng/ml
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Figure 10: Follow-up results of PSA level after abiraterone treatment: The current patient is generally in good condition (1.
The original bilateral lung hilar and mediastinal enlarged lymph nodes were significantly smaller than before; 2.
The original bilateral lung multiple nodules were significantly absorbed less than before.
, Reduced; 3.
Scattered chronic inflammation in both lungs)
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Figure 11 Postoperative follow-up CT case thinking.
The patient was diagnosed with high-risk mHSPC.
First, bicalutamide + leuprolide acetate was used, and the PSA decreased
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Six months later, the patient underwent laparoscopic radical prostatectomy + bladder neck plasty
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For patients with advanced prostate cancer, the pros and cons of surgery need to be analyzed
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Advantages: minimize tumor burden; obtain more accurate clinicopathological staging, guide follow-up treatment (radiotherapy, chemotherapy, endocrine therapy); avoid local symptoms caused by the primary tumor, and improve the quality of life of patients
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There are disadvantages: high risk, high complications
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During the operation, the patient found tumor involvement in the bladder neck and triangle area, swollen lymph nodes were seen on both sides of the pelvis, and severe adhesions around the prostate were found
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Subsequently, using Abiraterone + ADT, the PSA depth and lasting decrease
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The new endocrine drug treatment of abiraterone is indispensable in the treatment of advanced prostate cancer.
It helps delay the progression of the disease and prolong the survival of patients
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The LATITUDE study confirmed3 that compared with the control group, abiraterone combined with prednisone+ADT prolonged the time to PSA progression in mHSPC patients by 4.
5 times (33.
2 vs 7.
4 months, HR=0.
3, P＜0.
001), and significantly prolonged the median The imaging progression-free survival (rPFS) is up to 33 months
.

Abiraterone provides better treatment options for mHSPC patients
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Figure 12 Progression time from LATITUDE study to PSA Figure 13 LATITUDE study of rPFS results Case provider: Professor Li Mengqiang Professor Li Mengqiang Deputy Director of Urology Department of Fujian Medical University Union Medical College Hospital Comment from the Youth Committee of the Urology Branch of the Fujian Medical Association (Professor Ye Lefu) For high-risk metastatic prostate cancer patients, studies have shown that the clinical benefit of traditional endocrine therapy is limited, and some high-risk patients may rapidly progress to the mCRPC stage and shorten the hormone-sensitive time , Thereby affecting the overall prognosis
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At present, the treatment of advanced prostate cancer often adopts a "comprehensive" approach
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The results of this case show that: for patients with high-risk mHSPC, postoperative application of abiraterone can help patients with a deep and lasting decrease in PSA, delay disease progression, and prolong patient survival
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The classic research in the field of prostate cancer, LATITUDE, has confirmed3 that the new endocrine therapy of abiraterone for mHSPC and mCRPC patients can cause a rapid and deep PSA response
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The long-term stability of PSA at a low level means a better prognosis and survival benefit
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Therefore, patients with high-risk mHSPC need to start abiraterone treatment as soon as possible, so that PSA can be controlled more effectively and patients can obtain the greatest possible survival benefit
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Commenting expert: Ye Lefu Professor Ye Lefu Professor Chief Physician, Professor, Doctoral Tutor, Graduated from Shanghai Medical University with a Doctor of Clinical Medicine in 1999
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The current deputy director of the Department of Urology of Fujian Provincial Hospital (presiding work) and the deputy director of Department of Surgery of Fujian Provincial Jinshan Hospital
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 Currently serving as a national committee member of the Chinese Medical Association Urology Branch, a national committee member of the Urology Branch of the Chinese Medical Doctor Association, a vice president of the Urology Branch of the Fujian Medical Doctor Association, and a vice chairman of the urinary and male reproductive tumor professional committee of the Fujian Anticancer Association, Fujian Vice President of the Urology Branch of the Provincial Strait Medical and Health Exchange Association, Member of the Standing Committee of the Urology Branch of the Fujian Medical Association and Deputy Leader of the Transplantation Group, Member of the Organ Transplant Branch of the Fujian Medical Association, Member of the International Urolithiasis Alliance, China Healthcare International Member of the Urinary Health Promotion Branch of the Exchange Promotion Association, member of the Urology Professional Committee of the Cross-Strait Medical and Health Exchange Association, and member of the Prostate Disease Group of the Urology Professional Committee of the Chinese Integrative Medicine Association
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He also serves as a young editorial board member of the "Journal of Modern Urology" and an electronic edition member of the "Journal of Urology"
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The editor's note on prostate cancer varies greatly among individuals, and the diagnosis and treatment programs provided to patients are also different
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It is necessary to comprehensively determine the treatment plan according to the patient's life expectancy, physical condition, physical condition, and treatment willingness
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For the treatment of high-risk mHSPC and mCRPC patients, the efficacy and safety of Zeke® (abiraterone acetate) have been widely recognized in clinical practice
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The above two cases remind us that abiraterone should be used as soon as possible for the treatment of mHSPC and mCRPC patients, especially mHSPC patients, to alleviate the imaging lesions and make the PSA deep and durable
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Note: Abiraterone acetate tablet is referred to as Abiraterone in the text.
References: 1.
Ryan CJ, et al.
Lancet Oncol.
2015; 16(2): 152-160.
2.
Rizzo S, et al.
Crit Rev Oncol Hematol.
2017; 120:227-233.
3.
Fizazi K, et al.
N Engl J Med.
2017;377:352-360.