Case presentation
Patients’ clinicopathological data are summarized in Table 1. At the
time of BAT initiation, all patients had castrate T levels.
Case 1. A 60-year-old man with end-stage renal disease on hemodialysis
three times a week with iPSA 40.5ng/ml and prostate biopsy GS 5+5 was
found to have prostate cancer bone metastasis and bladder invasion
(cT4N0M1b). He was initially treated with MAB (LHRH analog plus
Bicalutamide 80mg qd) since June 2014. Two years later he was diagnosed
with CRPC (PSA 4ng/ml) and Enzalutamide 80mg was added to LHRH analog in
July 2016. Diabetic nephropathy progressed to end-stage renal disease
and hemodialysis was started in October 2017. In August 2018
testosterone enanthate 250mg IM was started and repeated every 4 weeks
because high Pro-GRP(160pg/ml) suggested neuro-endocrine prostate
cancer. Then the patient was re-challenged with bicalutamide which
resulted in a drastic PSA decrease to 1.5 ng/ml. PSA continues to stay
at low levels for 20 months. LHRH injections and bicalutamide are being
continued as well as testosterone enanthate 125mg IM 4 weeks (Fig 1A).
Case 2. A 59-year-old man with iPSA 9.7ng/ml and prostate biopsy GS 4+3
was diagnosed with locally invasive PCa (cT3aN0M0). He underwent radical
retropubic prostatectomy (RRP) and then salvage EBRT. As he progressed
to CRPC (PSA 8.4 ng/ml) chemical castration was started and then
enzalutamide was added to the treatment. Bone metastasis appeared and
Radium chloride (223Ra) 6 injections were done followed by EBRT to the
left femur (30Gy). Then, resection of the left femur with femoral head
prosthesis implantation was performed because of the left leg pain. AS
PSA increased (50.2 ng/ml) docetaxel was started and then switched to
cabazitaxel. Testosterone enanthate 250mg IM was started in may 2021
resulting in a more than a fourfold decrease in PSA (Fig. 1B).
Case 3.
A 65-year-old man with iPSA 15.7ng/ml and prostate biopsy GS 4+5 without
distant metastasis underwent RRP. The pathological diagnosis was pT3bN1
(a single positive right obturator LN). MAB was started right after the
operation. Bicalutamide was switched to flutamide and then to
estramustine phosphate followed by enzalutamide. PSA increased steadily
reaching 0.84ng/ml and pararectal LN metastasis was diagnosed by PET-CT.
The metastasis was surgically resected. PSA decreased to 0.03ng/ml. The
patient was sequentially treated with enzalutamide, abiraterone,
apalutamide, darolutamide, estramustine phosphate, docetaxel, and
cabazitaxel. PSA gradually increased to 8.26ng/ml. Testosterone
enanthate 250mg IM was started in May 2021 with initial PSA flare to
80.87ng/ml because of liver, retroperitoneal and pelvic lymph node
metastasis then drop to17.56ng/ml. The patient is now being treated with
monthly T with triweekly injections of gemcitabine and carboplatin (Fig.
1C). CT revealed PR in the liver and LN metastasis (Figure 2).
Case 4.
A 71-year-old man with iPSA 350ng/ml and prostate biopsy GS 4+4.
Prostate MRI revealed extracapsular invasion. CT scan revealed enlarged
left internal iliac LN, but no distant metastasis. Chemical castration
with degarelix injection was performed and MAB was started by adding
bicalutamide which was sequentially switched to flutamide, enzalutamide,
and abiraterone. Five years since the beginning of the therapy the
patient opted for surgical treatment and underwent RRP. The pathological
diagnosis was T3bN1 with 5 out of 21 LN had metastasis. Following the
operation, ADT was continued using enzalutamide. PSA increased and
salvage EBRT (70Gy) was done. A whole-body MRI revealed multiple spine
bone metastasis and multiple LN metastasis. BMA denosumab was started.
Enzalutamide was switched to estramustine followed by darolutamide. PSA
increased to 66 ng/ml. Testosterone enanthate 250mg IM was started in
may 2021 followed by a drastic decrease in PSA (Fig. 1D).