Prostate Cancer with Bone Metastasis: the Consideration of Radiotherapy

Transcription

1 Prostate Cancer with Bone Metastasis: the Consideration of Radiotherapy Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of prostate cancer with bone metastasis; to discuss the RT consideration for this case Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 81 year-old male patient, 林 OO, was referred to us via OPD for RT assessment of Prostate cancer with bone metastasis on 2007/08/17. S: C.C: neck pain and left knee soreness with pain for 3-4 months 1. On 2004/11/18, TURP was performed at LMC. The pathology reported adenocarcinoma of the prostate, Gleason score 4+5 = 9. After diagnosis, bilateral orchitectomy and hormone therapy were given. No RT or chemotherapy was given. 2. In 2005/10, bone mets was found. Hormone therapy was keeping to be used. 3. In 2007/05, he came to our GU section and continuously treated with leuprorelin by our GU doctor (Apply leuprorelin since July, 2007; total 3 sessions till now) O: 1. ECOG: 1, 81 y/o male, ambulatory status 2. PE: soreness over neck without noted tenderness 3. whole body bone scan: multiple bony destroyed. (2007/05), (Bone scan not seen at visiting) 4. Formal pathology report not seen at visiting (Adenocarcinoma, Gleason score 4+5=9, of the prostate found on OPD e-chart) 5. PSA data unknown at visiting 6. ABD/Pelvic CT in 2007/08: pending result.

2 Key Image(s): Fig. 1. ABD CT Prostate level Fig. 2. Panel A. ABD CT Fig. 2. Panel B. ABD CT

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis and/or other Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) Q7: Please denote the regional LN distribution for prostate cancer. Q8: Please denote the difference between T1a and T1b classification in prostate cancer. Q9: Please denote the difference between T2a and T2b and T2c classification in prostate cancer. Q10: Please denote the difference between T3a and T3b classification in prostate cancer. Q11: Please denote the difference between M1a and M1b and M1c classification in prostate cancer.

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: initial stage unknown based on current evidence Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no pathology stage can be defined. Q4: What are your Oncology Diagnosis and/or other Assessments for this case? A4: Adenocarcinoma, Gleason score 4+5=9, of the prostate, initial stage unknown, post TURP (2004/11, LMC), with irregular follow-up, with disease progression (2005/10, multiple bone mets), r-txnxm1a (bone), r-stage IV (AJCC 2006), on Leuprorelin (since 2007/07) with neck pain and left knee pain Q5: What is your Oncology Plan for this case? A5: 1. Suggest keep leuprorelin and add palliative RT to bone mets 2. Need re-view the bone scan and pathology report Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: prostate cancer with bone mets (2). Goal: palliative (3). Target & Volume: the bone mets region with adequate margin (based on bone scan) (4). Technique: 2DRT or 3DCRT (5). Dose & Fractionation: 3060 cgy in 17 fractions to the bone-scan-positive-only region; cgy in fractions to the bone-scan-positive & CT-mass-formation region.

5 Q7: Please denote the regional LN distribution for prostate cancer. A7: as the following figure [AJCC 2006]. Q8: Please denote the difference between T1a and T1b classification in prostate cancer. A8: as the following figure [AJCC 2006].

6 Q9: Please denote the difference between T2a and T2b and T2c classification in prostate cancer. A9: as the following figure [AJCC 2006].

7 Q10: Please denote the difference between T3a and T3b classification in prostate cancer. A10: as the following figure [AJCC 2006]. Q11: Please denote the difference between M1a and M1b and M1c classification in prostate cancer. A11: as the following description [AJCC 2006]. Further Readings & References: NCCN 2009 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/02/01

8 Key Image(s): (with marked) Fig. 1. ABD CT Prostate level Fig. 1. The prostate size shows insignificant enlargement with a relatively dilated urethra(as the short white arrow); the rectum behind the prostate with fecal material in the lumen (as the long white arrow). Fig. 2. Panel A. ABD CT Fig. 2. Panel A. the osteoblastic bone metastasis was found in the visible L spine (as the white arrow). Fig. 2. Panel B. ABD CT Fig. 2. Panel B. in the another L spine, more evident osteoblastic bone mets lesion was found (as the white arrow).