What is the optimal treatment plan for a patient with stage 2 prostate cancer, previously treated with Triptorelin (Gonadotropin-releasing hormone agonist), now experiencing disease progression with metastases (mts) in bones and lymph node enlargement?

From the Guidelines

For a patient with stage 2 prostate cancer progressing on triptorelin with bone metastases and lymph node involvement, I recommend continuing androgen deprivation therapy (ADT) with triptorelin while adding a second-generation anti-androgen such as enzalutamide (160mg daily), apalutamide (240mg daily), or darolutamide (600mg twice daily), as supported by the most recent guidelines 1. This combination therapy approach, known as combined androgen blockade, is appropriate as the disease has progressed to metastatic castration-resistant prostate cancer (mCRPC). The treatment plan should prioritize reducing morbidity, mortality, and improving quality of life, considering the patient's disease progression and symptoms.

Key Considerations

• Continuing ADT with triptorelin is crucial to maintain hormonal control over the disease.
• Adding a second-generation anti-androgen like enzalutamide, apalutamide, or darolutamide can help overcome resistance to initial ADT by targeting alternative pathways of androgen signaling.
• Docetaxel chemotherapy (75mg/m² IV every 3 weeks for 6 cycles) may be considered if the patient has a high tumor burden or rapidly progressing disease, based on evidence from previous studies 1.
• Bone-targeted therapy with zoledronic acid (4mg IV every 3-4 weeks) or denosumab (120mg subcutaneous monthly) should be initiated to prevent skeletal-related events, with denosumab showing superiority over zoledronic acid in preventing such events 1.
• Pain management should be optimized, and radiation therapy may be beneficial for painful bone metastases.
• Regular monitoring with PSA testing every 3 months, imaging studies every 3-6 months, and assessment of treatment-related side effects is essential to adjust the treatment plan as needed.

Treatment Priorities

• Reducing disease progression and morbidity
• Improving quality of life
• Managing symptoms and side effects
• Regular monitoring and adjustment of the treatment plan based on patient response and disease progression.

From the FDA Drug Label

Zoledronic acid injection is indicated for the treatment of patients with multiple myeloma and patients with documented bone metastases from solid tumors, in conjunction with standard antineoplastic therapy. Prostate cancer should have progressed after treatment with at least one hormonal therapy The patient has stage 2 prostate cancer that has progressed with bone metastases and lymph node involvement, and was previously receiving triptorelin, a type of hormonal therapy. Given this information, zoledronic acid may be considered as part of the treatment plan, in conjunction with standard antineoplastic therapy, to manage the bone metastases 2, 2.

• The recommended dose of zoledronic acid is 4 mg infused over no less than 15 minutes every 3 to 4 weeks for patients with creatinine clearance (CrCl) greater than 60 mL/min.
• It is essential to monitor renal function carefully and assess serum creatinine prior to each treatment.

From the Research

Treatment Plan for Stage 2 Prostate Cancer with Metastasis

The patient's disease is progressing with metastases in bones and enlarged lymph nodes, indicating a need for a revised treatment plan.

• The current treatment with triptorelin, a luteinizing hormone-releasing hormone (LHRH) agonist, may not be sufficient to control the disease progression 3.
• Abiraterone acetate, an orally administered potent inhibitor of cytochrome P450, family 17, subfamily A, polypeptide 1 (CYP17), has shown efficacy in treating metastatic castration-resistant prostate cancer (mCRPC) 4, 5, 6, 7.
• Studies have demonstrated that abiraterone acetate can inhibit androgen synthesis in the adrenal glands and potentially within the tumor itself, leading to a decline in prostate-specific antigen (PSA) levels and radiologic responses 6, 7.
• The addition of prednisone to abiraterone acetate has been shown to be effective and safe in chemotherapy-naïve mCRPC patients, with a significant proportion of patients experiencing a ≥50% PSA decline and improved overall survival 4.

Considerations for Treatment

• The patient's disease progression and metastasis in bones and lymph nodes suggest a need for a more aggressive treatment approach.
• Abiraterone acetate plus prednisone may be a suitable treatment option for this patient, considering its efficacy and safety profile in mCRPC patients 4, 5, 6, 7.
• Regular monitoring of PSA levels, radiologic evaluations, and assessment of symptoms and quality of life are essential to evaluate the treatment response and adjust the treatment plan as needed.