Multimodal Treatment of Prostate Cancer in a Patient with Exceptionally Long Overall Survival − Case Report

Introduction

Approximately 17% of prostate cancer cases develop metastases, most commonly in the skeleton, lymph nodes, liver, and lungs. Metastatic brain involvement is relatively rare (about 2% of cases) and dangerous due to the initial absence of symptoms. Treatment options for brain metastases are also limited. Docetaxel does not sufficiently cross the blood-brain barrier, cabazitaxel has not proven effective in this case, the effects of abiraterone are similarly uncertain, and second-generation antiandrogens are associated with a higher risk of seizures. Currently, there is no recommended guideline for the management and treatment of these patients. Analyzing individual case reports can thus catalyze clinical research in this area and help set optimal treatment strategies.

Case Description

A 64-year-old man was diagnosed in March 2008. Histological examination revealed a carcinoma with a Gleason score of 6 (3 + 3), placing the patient in the low-risk group, and bicalutamide hormone therapy was initiated. From November 2011, he was newly treated at the authors' institution, where a locally advanced carcinoma with pelvic lymphadenopathy was diagnosed. Imaging showed structural changes in the enlarged prostate, expansion at the level of the seminal vesicles, and isolated lymph node metastases (stage IVa − T3b, N1, M0). Prostate-specific antigen (PSA) levels were 3.4 ng/ml.

In November 2011, total androgen blockade with bicalutamide and gonadoliberin (LH-RH) analogs was initiated, lasting a total of 8 years. During this period, several depot LH-RH analogs were administered in different doses and intervals (triptorelin once monthly, triptorelin or goserelin every 3 months, leuprorelin once every six months). During treatment, the disease remained mostly stationary and PSA levels were normal. CT scans in June 2013 detected proliferation in the prostate with slight infiltration of the seminal vesicles and bladder wall, subdiaphragmatic lymphadenopathy, liver hemangiomas, slight adrenal hyperplasia, a right kidney cyst, and a small hiatal hernia.

Suspect bone lesions appeared on CT in September 2019. Bone scans revealed metabolically active foci in the rib area. PSA levels had increased to 30 ng/ml at that time. Chemotherapy with docetaxel and osteoclast inhibitor administration was then initiated. However, after 7 cycles of chemotherapy, neoplasia in the prostate and ribs progressed.

The patient subsequently underwent treatment with a combination of abiraterone, prednisone, and LH-RH analogs. In April 2021 (after 9 months), further prostate enlargement, a new liver lesion, and retroperitoneal lymphadenopathy were detected. Bone involvement had also progressed in many locations. For the next 9 months, the patient was treated with enzalutamide (a second-generation antiandrogen) and zoledronate. He used NSAIDs and mild opioids as analgesics. CT in September 2021 showed no disease progression. Progression occurred again only in January 2022. Subsequently, cabazitaxel treatment was initiated, lasting 6 months. PSA levels during this period rose to 1000 ng/ml, and imaging revealed further bone and liver lesions.

After discontinuing cabazitaxel, only antiandrogen therapy continued. In October 2022, lung metastases were detected, and the patient's clinical and neurological condition significantly worsened. CT showed multiple brain involvements. After palliative radiotherapy, the patient's condition improved, and hormonal treatment along with further palliative care continued for another 2 months until January 2023, when the patient died.

Discussion and Conclusion

The case report presented a patient with prostate cancer and a very long survival period. According to literature data, the survival period for metastatic prostate cancer is approximately 21 months. This case is one of the few published cases utilizing all therapeutic sequences − specifically total androgen blockade, docetaxel, abiraterone, enzalutamide, and cabazitaxel.

The patient was managed by a broad multidisciplinary team that utilized all available options and eventually addressed the transition to palliative therapy. This occurred with the development of severe neurological symptoms that significantly affected the quality of life. This patient's case can be used to study the effectiveness of various treatment modalities and confirmed the importance of palliative care for cancer patients.

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Source: Rahnea-Nita R. A., Rebegea L. F., Nechifor A. et al. The complexity of treatments and the multidisciplinary team − a rare case of long-term progression-free survival in prostate cancer until development of liver and brain metastases. J Clin Med 2023 Aug 27; 12 (17): 5579, 10.3390/jcm12175579.