The Management of Biochemical Recurrence in Prostate Cancer - Episode 10

Molecular Recurrence in Oligometastatic Prostate Cancer

Raoul S. Concepcion, MD

Brian Helfand, MD, PhD

Munir Ghesani, MD

Judd Moul, MD

An expert panel discusses the challenges of detecting and managing biochemical recurrence in the context of oligometastatic prostate cancer. 

Raoul S. Concepcion, MD, FACS: Brian, you mentioned this earlier. Let’s take the situation where this happens, and sometimes we’re trying to find disease in the patients we’re worried about. If the bone CT is negative, but let’s say you had a molecular scan that was positive, let’s say you got a fluciclovine that’s positive, and…remember, this was a patient who got external beam [radiation and] refused androgen deprivation therapy [ADT]. Let’s say it showed a 1.5-cm node above the field of radiotherapy and was seen on molecular imaging. How do you look at that patient now? What are the options that open up to you in that setting?

Brian Helfand, MD, PhD: I think it sounds like that would be a low-burden tumor recurrence, if indeed it’s 1 node that’s positive. I think some of the data are still somewhat emerging and still somewhat controversial, but it certainly depends on what level that node is, if it’s M0 [no metastasis detected] in the pelvis, or it’s M1, above the bifurcation. If it is M1, I think you can still go after it, or even M0 in the pelvis, [you can still] go after it. I think certainly the options in the pelvis these days are somewhat controversial, with data emerging, but whether it’s stereotactic guided radiation to that area, or we do offer salvage lymph node dissection if appropriate. If it’s M1, I think we’re more hesitant to be as aggressive with surgery. I still think there may be a role, although [the patient] may not fare as well if it is M1 disease.

Raoul S. Concepcion, MD, FACS: Judd, what if it was an isolated lesion that they found on molecular imaging, say, L3 vertebral body?

Judd W. Moul, MD: That’s a good one.

Raoul S. Concepcion, MD, FACS: ADT, stereotactic radiation…I think what’s going to happen is as these scans get used more and more in this setting, these are the clinical scenarios that we’re going to start to see, which addresses the question in the queue, this concept of oligometastatic disease, and do you still put them on ADT? Regarding isolated bone lesion L3, what are your thoughts on that?

Judd W. Moul, MD: I think No. 1, we’d present it to our tumor board, because obviously it’s very controversial, and there’s no level 1 evidence on what to do. He’s like an old-fashioned biochemical recurrence, but now he’s not really a biochemical recurrence because he has a positive novel imaging. I think we’re going to have to come up with a stage, and something to call it, like biochemical recurrence-plus, or biochemical recurrence molecular imaging. What I’d probably do in practice, and I know Dr Ghesani’s going to kick me, but I’d probably still get a regular imaging to see if that L3 lit up on a bone scan because if it least lit up on a regular scan, he would become eligible for some clinical trials that we have going on. What I don’t know, and I would ask Brian this, let’s say if you believe that’s a positive bone scan, then he becomes hormone-sensitive M1 disease.

That means you open the door for enzalutamide or abiraterone or docetaxel, not docetaxel because he’d be low volume, but you’d at least open the door for those 3 oral agents. So, is the insurance company going to approve an expensive drug like ENZA [enzalutamide] or APA [apalutamide] in the setting of a negative bone scan, but a positive Axumin scan? I’m asking more questions than I’m answering, and the honest answer is, I’d probably have to individualize, and chances are our Duke [Cancer Center] tumor board, if that was an oligometastatic site, they’d probably end up doing some spot radiation to that. I don’t know if our medical oncology team would push for ABI [abiraterone], ENZA [enzalutamide], or APA [apalutamide] in that case.

Munir Ghesani, MD: This scenario is already playing out in our tumor boards. I see instances like these where, and Judd, you would not be wrong in ordering the bone scan, and I’ll tell you the reason why. When we look at these scans, and if we see that on CT there is a sufficiently large focus of sclerosis that lit up on the molecular imaging side, then it also gives you an idea that a bone scan may be positive given the size of the lesion. Then, if the patient’s going to the trial, you’re going to need that bone scan as a baseline so that you can compare it for treatment response in the future. So, it would be appropriate after the fact to consider doing a bone scan.

Raoul S. Concepcion, MD, FACS: Dr Ghesani, this is a comment from the audience. Is it helpful, and should we be better about providing—especially because these scans now are so difficult to read—are we giving you enough clinical history to assist you in adequate interpretation when you read these scans?

Munir Ghesani, MD: Yes, I can speak for my practice, and then I can relate to the other settings where there might be some difference. In our case, not only have we seen these cases being discussed at the tumor boards before the patients come in, but even if they were not presented yet and they are coming directly for imaging, we have the electronic medical record. Whenever we read the scans, we have multiple screens and I dedicate 1 screen for my Epic [medical record system] window, which is where all the records are always open.

Even nowadays, things are such that if you open up a case for dictation, not only does your dictation window open on one screen, your images open on the other, and your Epic window automatically pulls the patient’s data, so that everything is synchronized. In my practice, all the information that we need, it’s available at my fingertips. I can see that in a private practice setting, people may be wishing for more specific information that they need to make a clinical judgment about what the background of that patient is, like the 2 cases we discussed. Knowing all that information is critical when you interpret the images.

Transcript edited for clarity.