Whats is the best treatment for locally advance prostate cancer (adenopaty of 2cm near the iliac extern) with neuroendocrine differentiation? Low PSA(1) and no evidence of metastasis in cintilogram (with octreotideo); no acess to PET
So, we're talking about a locally advanced PC, adenopathy of 2cm near the external illiac lymph node (T4), but not involving it (N0), with NED. (-)mets in somatostatin receptor scintigraphy (M0). By the NCCN guidelines, that would still mean Stage IV prostatic adenocarcinoma, which are "very high risk" patients. For these patients, the following options are:
1. EBRT (external beam radiation therapy) and long-term ADT
2. EBRT + brachytherapy +/- long-term ADT
3. Radical prostatectomy + PLND in Pts w/ no fixation to adjacent organs
4. ADT for patients ineligible for definitive therapy
I believe that long-term androgen deprivation therapy refers to adding an additional ~2-years (though another study used 2.5). I've included a news article, summarizing the results of a trial using long-term ADT for locally advance PC.
I hope that helps!
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Note that the above information is not intended for use as medical advice, nor is it intended to substitute for professional advice, and is provided for purely informational purposes only.
http://www.medscape.com/viewarticle/853089
Thank you for your help, but that is for prostate adenocarcinoma (the most frequent) and not for neuroendocrine differentiation. Besides the adenopaty is near the iliac extern vein (sorry I was not clear in the original question; so it is a N+ case)
I would suggest the best initial treatment would be cisplatin based chemotherapy, followed by surgery or radiotherapy depending on response to chemotherapy, patient age and fitness.
Some questions:
How old is the patient?
What comorbidity?
What is the stage ? ( local advanced ? extraprostatic extension ? T3a / b , T4 ?) Had he already been subjected to hormone therapy?
Neuroendocrine prostate cancer does not express the androgen receptor (and low psa could confirm it ) .
Which kind of carcinoid tumor? A small cell, large cell or carcinoid? The prognosis of prostatic small cell carcinoma is poor, with a median survival of less than 1 year. ( is frequently significant intratumoral heterogeneity that is evident at the histologic level, with pathologic specimens often showing adenocarcinoma admixed with small-cell/neuroendocrine differentiated tumors )
It may be sensitive to a chemotherapy with platinum-based chemotherapy ( and paclitaxel or etoposide) and somatostain (a limited durations of response often observed with traditional platinum-based chemotherapy)
If it is possible a radical prostatectomy + extent of pelvic lymph node dissection and chemotherapy, may be ,in my opinion , the best solution.
I don't know if a Neoadjuvant chemotherapy plus radiotherapy is the bet solution.
An alternative could be intra-arterial infusion chemotherapy using a reservoir system and external-beam radiotherapy (EBRT) to the whole pelvis and local tumor.
Also Serotonin antagonists and Bombesin antagonists and a Phase II trial evaluating MLN8237 (alisertib) have been used.
Just adding that I am working as an oncology nurse with several patients with Stage IV neuroendocrine (denovo) prostate and cervical cancer and they are seeing profound regression of tumors while self-treating with high doses of THC-rich cannabis oral medicines over several months, with and without chemotherapy. Of course, I encourage conventional therapies but also listen to the patients who have been trying to self-treat with cannabis integratively, to help educate and to reduce harm.
One prostate cancer patient with denovo Stage IV NET prostate cancer and now is NED after only 4 months, was choosing to self-treat with large doses of hundreds of milligrams of THC and CBD as well and after 4 months now has some increased PSA (was normal PSA 4 months ago) which appears to respond to androgen-deprivation therapy. Because there is some very limited evidence that THC can decrease neuroendocrine characteristics in at least some PC cell lines, and that CBD may be able to possibly "normalize" the NET transition back towards more normal status, this is complex but intriguing. I can't help but wonder that the initial THC use may have some link to anticancer effects of THC on the NET aspect and there *may* be some influence of the cannabinoids to "normalize" them to more of a standard form of pc. I think we also need to further research in the area of what may be "next" if cannabinoids *do* turn out to have some "normalization" effects on at least some forms of cancers, which could potentially require different treatment considerations as this develops.
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