Dr. Lily (1/16)
There is much debate on how to approach prostate cancer and many of the guidelines are interpreted broadly.
Lily spoke with the gastroenterologist; still needs input from Patel. Some of the enlarged lymph nodes may be related to prostate metastasis, but most likely they’re all lymphoma, particularly since there are no lymph nodes around the prostate.
90% of pattern in prostate biopsy was Gleason 4, which is aggressive
Perineural invasion (PNI) means there are cancel cells around nerves which confers a higher risk of metastasis. Intraductal cancer is also sign of aggressiveness. Finally the report said that they can’t exclude that some of the cells are Gleason 5. Short answer: Dave’s prostate cancer is aggressive.
PNI is not the same as CNS invasion, so intrathecal chemotherapy is not needed for the prostate cancer. There are no known prostate metastases, but we’re not great at detecting these sorts of things, so we can’t be sure.
Bone scan shows no hot spots, but again, scans aren’t perfect. We could miss something.
They use different agents to scan for prostate metastases than they do when evaluating lymphoma, so Dave might need to do two distinct PET scans to know the states of each disease.
If Dave didn’t have lymphoma, we would definitely at least do radiation and androgen deprivation therapy (ADT) right away.
Lily implied that anything from prostate resection to radical prostatectomy might be warranted, but prefaced with “if you choose to” which is either synonymous with “if you want to live” or “if you want the best outcome.” It wasn’t clear which.
The surgery is robotic and laparoscopic. Side effects include urinary control issues.
Small possibility you could cure the cancer with just surgery, but hard to say. Could do surgery first, watch for a while, then explore other options later if PSA comes back up.
Side effects of ADT: hot flashes, decrease in energy, no sex drive, bone density loss, mood changes.
All treatment options have the side effect of impotence.
Probably makes sense to start on ADT while treating lymphoma, then treat the prostate cancer definitively after lymphoma is in remission, but need input from Patel on that.
Dave says he has some burning during urination but no other signs of infection. This symptom was present before the biopsy, went away for a while after the biopsy, then returned. It is associated with PVCs on his EKG.
Dave says he has no pain; neither in the lower belly nor back nor anywhere else.
Lily says if there’s still a stone, event though CT seems to indicate there isn’t, chemotherapy-induced neutropenia could complicate things, i.e. make an infection more likely.
Consensus is the stone has probably passed; burning sensation is idiopathic. Though the stone could be sitting in ureter, just not blocking (less likely).
Patel may reimage with CT prior to chemo. Can check for stone then.
We can track the prostate cancer during the lymphoma treatment with PSA and DRE to make sure it’s not getting worse.
Surgery is not secondary to radiation and hormone therapy. Better outcomes if you do it first.
Lily has no idea if R-CHOP (lymphoma treatment protocol) will shrink the prostate. Need to ask Patel.
There are options for restoring erectile function, including reconstruction. Can talk about those later if needed. Lack of erectile function does not prohibit orgasm.
Dr. Patel (1/20)
Dave is currently taking Lisinopril and chlorothiodine for hypertension.
The polyp discovered his Dave’s GI tract contained a lymph node positive for diffuse large B-cell lymphoma (DLBCL) which is an aggressive non-Hodgkin’s lymphoma (NHL).
Dr. Patel is going to start Dave with a PET scan. This PET scan includes a low res CT scan (with contrast) that may or may not detect if there is still a kidney stone in his ureter, however the primary reason for the PET scan is to get a closer look at the lymph nodes in his abdomen to see if they are connected to the lymphoma detected in his GI tract or if they are instead idiopathic or arthritis-associated. It’s important to make that determination because it impacts staging and stage impacts the length of the treatment protocol, which can either be four sessions of R-CHOP (which means half the lifetime dose allowed of doxorubicin) or six sessions (3/4 the lifetime dose of doxorubicin).
If the PET scan is indeterminate, Dave will need to undergo a laparoscopic biopsy where they remove a whole lymph node and assay it, looking for evidence of abnormalities. This would be a much more comprehensive biopsy than the needle biopsies he underwent previously. Meanwhile, pathologists are revisiting his past biopsies to see if they can see evidence of abnormal cells that are similar to those found in the polyp removed by the gastroenterologist, but which evaded previous analysis.
The strange thing is that aggressive lymphomas tend to be associated with fevers, night sweats, and pain. Dave is suffering from none of those, which suggests the lymph node discovered in his gut might be unrelated to the systemic lymphadenopathy, i.e. the cancer may be early stage.
The inside of the gut does not highlight well on PET, so we won’t get much more information about what’s going on in there, if anything.
R-CHOP is a combination of Rituxan, a chimeric monoclonal antibody that targets CD20 on the B-cells and marks them for scavenging by the immune system, and four traditional antineoplastic drugs: doxorubicin, vincristine, cyclophosphamide, and prednisone/prednisolone.
It is unknown whether the prostate cancer is sensitive to these drugs, but consensus seems to be that it might be partially sensitive to them, which suggests that the prostate cancer could potentially regress somewhat before treating it definitively, perhaps minimizing side effects and improving outcome.
Commercial CAR T-cell therapy is an option if first and second line treatments fail. Second line seems like it would likely be an autologous stem cell transplant (SCT).
Dave has an appointment to get a “muga,” which will ensure his heart is strong enough to handle doxorubicin, another one to have a single lumen port and catheter installed in his neck, through which they will infuse his chemotherapy over the next 12 to 18 weeks, an appointment for a PET scan, bloodwork, and PET follow up, and finally one for his first R-CHOP infusion. We’re not just in a hurry because the lymphoma is aggressive. We’re also in a hurry because there is a pending labor strike that has the potential to affect coverage.
Dr. Patel agrees with Dr. Lily that starting on ADT immediately to retard progression of the prostate cancer should be just fine.
Dr. Patel says CNS involvement in DBLCL is unlikely. PET scans don’t image the CNS very well, so there’s no way to be sure if the CNS is involved, however given the low probability, we’ll just proceed forward without doing intrathecal chemotherapy.
The PET will show whether or not the lymphoma has spread to the bone marrow, and if it has, may require changing the qualitative elements of the treatment protocol (i.e. adding other drugs).
Rituxan infusions are slow. Because of this R-CHOP will be 5 to 7 hours the first day, and 3.5 hours for each outpatient session thereafter. Those numbers don’t include ADT infusions. The time those take is unknown.
If Dave continues to have pain when urinating, Dr. Lily may order another high res CT with contrast later to evaluate.