Elderly patients: kidney failure prostate cancer recurrence how to treat?| cases share

2022-05-04 0 By

This article shares the diagnosis and treatment process of an 82-year-old man with renal failure and recurrent prostate cancer, hoping to provide useful information for clinicians and patients!Case Description An 82-year-old man presented with elevated PSA (21 ng/ml) in July 2015.In 2008, he underwent androgen deprivation therapy (ADT) and prostate radiation therapy (74Gy).The patient presented with grade III renal failure, a glomerular filtration rate (eGFR) of 30 to 40 mL /min, a previous laminectomy, and a history of osteoarthritis and lumbar spinal stenosis.In August 2015, the patient underwent a bone scan and only degenerative changes were detected.CT scans showed no evidence of metastasis.However, in September 2015, further evaluation of a 68Ga PMA-11 PET scan revealed slightly prominent pelvic lymph nodes of unknown significance.At the time of THE PSMA PET scan, the patient’s PSA had risen to 29 ng/ml and 40 ng/ml the following month.At this point, eGFR was 35 mL /min.Imaging findings of 68Ga SMA-11 PET scan suggest recurrence of prostate cancer with lymph nodes involved in the left supraclavicular, mediastinum, posterior foot, para-aortic and aortic lumen, pelvic and groin regions (Figure 1).FIG. 1 Coronal images of PSMA PET and fused PSMA PET/CT images showing marked uptake of active PSMA lymph nodes in the left clavicle, mediastinum, and retroperitoneal region, as well as intraperitoneal mass (arrow).Based on a signed informed consent form, the patient received peptide receptor radionuclide therapy (PRRT) consisting of three cycles of 177LU-PSMA imaging and treatment (I&T) : 6.77GBq, 6.5GBq, and 4.9GBq, in view of his prior treatment history and comorbiditions.The dose was reduced in consideration of impaired renal function.After treatment with LU-177 PSMA, the patient’s PSA dropped to a minimum of 1.2 ng/ml and the pmA-Avid lesions in the pelvis were significantly reduced (Figures 2 and 3).Adverse effects after treatment include mild (grade 1) dry mouth and short-term drowsiness.Complete blood count (CBC) or liver function test (LFT) showed no significant change, and eGFR increased to 41 mL /min. The change in eGFR may be due to the reduction of obstructive urinary tract lesions and recurrence of prostate lesions caused by previous adenosis.Figure 2 pre-treatment image (top row) showing PSMA occupying lymph nodes.Images after treatment are shown in the lower row of arrows.FIG. 3 Pre-treatment images (upper row) showing PSMA occupying lymph nodes in the aortic lumen, left para-aorta, and left inguinal region.There is also a localized strong uptake of the prostate.Images after treatment are shown in the lower row of arrows.In addition, prostate PSMA uptake levels also improved.By the end of 2017, PSA increased to 6.5 ng/ml, and prostate cancer recurred for the second time.At this point, the patient was still in renal failure (eGFR: 30 to 40ml/min).In early February 2018, the patient received an additional 177LU-PSMA I&T (5.98GbQ).Although the patient’s PSA decreased for 7 months, it began to rise again, reaching 7.5 ng/ mL in February 2019.At this point, the patient was initiated on well-tolerated interphase, low-dose enzaluamide therapy (80 mg per day).EGFR remained between 25 and 30 mL /min, and CBC, LFT, electrolyte levels, and lactate dehydrogenase levels were normal except for mild anemia (hemoglobin 11.7 g/ dL).By November 2019, PSA decreased to the lowest point of 0.39 ng/ mL, and the biochemical characteristics remained stable.PSMA PET scan (FIG. 4) prior to enzalumide treatment revealed several small bone metastases in the prostate that persisted.Figure 4. PSMA PET.On the left, PSMA PET scan results in 2019 suggest multiple small volume lesions.Repeated PSMA PET with enzalumide at low dose in 2020 (with PSA re-elevated) shows persistent lesions in the prostate and improvement of nearly all previously observed PSMA bone metastases except behind the right iliac crest.In early 2020, the patient’s PSA began to rise (1.6ng/ml), and repeated PSMA PET scans (FIG. 4) showed that most PSMA bone metastases subsided, but the prostate lesions persisted and the right posterior iliac lesions persisted.It has been controlled with an increased dose of enzalumide (120 mg per day).The latest status, May 2021, was asymptomatic prostate cancer with stable biochemical characteristics and a PSA of 3.5ng/ mL (PSA doubling time > 12 months).Discussion As shown in this case and described in the literature, patients with lymph node lesions respond well to 177 LU-PSMA.Elderly patients treated with 177LU-PSMA are well tolerated and have no specific renal toxicity, so it may be judiciously administered in patients with renal insufficiency.And the scheme can be safely and effectively repeated.Equally important, novel antiandrogen therapy as a follow-up to radionuclide therapy may provide additional options for elderly patients and patients with impaired kidney function who cannot tolerate chemotherapy.PSMA PET may also help describe diseases that do not respond to treatment.Conclusion As demonstrated in this case, PSMA PET can monitor disease progression and guide treatment.Treatment with 177LU-PSMA and enzalumide improves efficacy and survival in patients with renal insufficiency.Nat Lenzo, MMed MSc(Oncol) EMBA FRACP FAANMS;Jaideep S. Sohi, MD DISCLOSURES Appl Radiol. 2021;40-50 (5) : 43.