Take-home Message

Diagnostic and staging workup

(Fictional narrative by the doctor)

James Fleck, MD, PhD & João A de Andrade, MD

Anticancerweb 02 (03), 2019

Following the urologist's earlier recommendation, Theophilus agreed to perform a multiparametric magnetic resonance imaging (MMRI) of the prostate. Confirming the findings of the transrectal ultrasound (TRUS), the MMRI showed that tumor had already spread beyond the borders of the prostatic tissue. 

He was very impressed by how much technology could help Medicine. He closely followed the technicians’ work and constantly asked probing questions. He already knew that the human body is mainly formed by water. MMRI applies a strong magnetic field that aligns and flips proton spins inside the water’s hydrogen nuclei. When this field is turned off, the protons gradually return to their normal spins producing a radio signal that is received by the scanner and then translated into very accurate anatomical images.

During the diagnostic and staging workup, Theophilus constantly reminded himself of the flowchart he designed for our mutual challenge. He witnessed firsthand how the MMRI technology improved the accuracy of prostate cancer diagnosis and staging. MMRI could even quantify the risk. A standardized terminology called PI-RADS has being used to assess cancer risk based on a five-point scale. His risk was classified as PI-RADS 5, indicating a high cancer probability. MMRI also showed invasion of the seminal vesicles, but fortunately there were no regional lymph node metastases. 

The urologist suggested a Transrectal Ultrasound-guided biopsy and the material was sent for pathological examination. One week after the biopsy, he returned to the urologist's office and was informed of the diagnosis. The surgeon went straight to the point. He had a prostate adenocarcinoma, Gleason 8 (4 + 4). 

Adenocarcinoma is the most frequent type of prostate cancer and a Gleason 8 is the combination of the two most prevalent differentiation patterns (4 + 4) found at the biopsy sample. The increasing Gleason classification shows how much the tumor cells have changed from its original and normal shape. 

Theophilus listened attentively to the Urologist’s explanation. He knew the information would be used to define tumor extension (staging). The urologist translated the information using a staging system provided by the American Joint Committee on Cancer (AJCC). His primary tumor (T) showed a locally advanced disease with extension beyond the prostatic limits, invading the seminal vesicles, which was classified as “T3b”. There were no pelvic lymph nodes (N) detected on MMRI and so it was classified as “N0”. He had a high Gleason score 8 (4 + 4), and a PSA > 20. The urologist, combing all this information, decided not to recommend surgery. He sent Theophilus back to me, suggesting primary treatment with radiation therapy.

Theophilus arrived at my office within a couple of hours. He was very concerned, since he was hoping for a complete surgical removal of the tumor. He shared his disappointment and did not completely understand the reasoning behind the surgeon’s opinion. He mentioned his flow chart and felt that a complete tumor resection was absolutely necessary. Moreover, based on his own reading of the literature, none of the imaging findings would preclude resection.

I explained to him that the recommendation on whether surgery is indicated or not is based on a cost-effectiveness analysis. Sometimes, even when a radical prostatectomy is technically feasible, the risks do not justify the potential benefits. The fact that he had tumor extension beyond the limits of the prostate, already infiltrating the seminal vesicles (T3b) made him fall into the prognostic group IIIB of the AJCC. I also shared with him that, based on the National Comprehensive Cancer Network (NCCN) risk stratification for localized prostate cancer, his case had a very high-risk of relapse. 

Theophilus reacted angrily, and yelled at me saying that this disease would kill him and that we were just playing a game of numbers and probabilities. I touched his shoulder, inviting him to sit down. Having a NCCN classification in a high relapse risk group does not mean that the disease is incurable. There are other organ preserving treatments, such as radiation and hormonal therapies, that can achieve the same results as a surgical resection.

Hearing this, Theophilus calmed down!

Considering the fact that he had what is considered “advanced local disease”, combined with a Gleason 8 (4 + 4) and a PSA> 20, further imaging would be necessary to assess and guide the treatment plan. I recommended a 99-technetium bone scan. Although he had no pain, I wanted to make sure no bone metastases were present. I also ordered thoracic and abdominal CT scans to further survey for the presence of metastatic lesions. If none these tests suggested metastases, he would be treated with curative radiotherapy.

Theophilus sighed in relief!

He was in very good shape, the urinary symptoms did not limit any of his daily activities, and he was proud to be sexually active, which was clearly a very important aspect of his life.

Fortunately, all the imaging tests were negative. Despite having a locally advanced disease, there were no signs of metastases in the lymph nodes, bones, liver or lungs. His stage was confirmed as AJCC IIIB and he would be treated with a combined approach, including radiation therapy (RT) and androgen deprivation therapy (ADT). I would further explain the rationale, benefits and expected toxicity of the treatment.

However, Theophilus still felt uneasy about being diagnosed with an advanced disease and wanted to know more details about the meaning of it. 

Promptly, I explained that prostate cancer was not uncommon and even a high-risk stage III disease usually have a very good response rate to the proposed combination therapy (RT + ADT). Prostate is a type of cancer with one of the highest five-year survival rates.

Theophilus was alone and I asked him if he would like me to debrief his family.

He looked into my eyes with a protective expression and said: 

My dear doctor, I trust you. After all our meetings, I realize that there is a long way to go before recommending a treatment. It is a very hard journey and I decided to take it alone. I am gradually learning from you how to live with this disease and I would like to share all of it with my family but only when everything has been decided. I believe that my decision will protect them from unnecessary suffering. Sometimes I felt like we were moving back and forth and it was very stressful. Explaining medical strategy to them would cause additional emotional distress. I am a mature and independent man who always protected my family. I know they are worried, but life goes on. At the right time, I plan to gather my family, explain everything in detail, answer their questions, and then allow them to return to normal lives.

I was really delighted to have met Theophilus! 

He was doing it his way…

*       Attention: The story 2 will be published sequentially from the PLOT 1 to the PLOT 6, however it will appear backwards. So, you will always see the most recent publication. Just browse in numbered pages located at the bottom of the homepage and start to read the story 2 from the beginning. 

To be continued in PLOT 4 (climax): Evidence-based Medicine

© Copyright 2019 Anticancerweb

 James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2019

Joao A. de Andrade, MD: Professor of Medicine and Chief Medical Officer, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Nashville, TN – USA 2019 (Associate Editor)