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As one of the most common malignant tumors in men, the incidence of prostate cancer is increasing year by year, which seriously threatens the health of middle-aged and elderly men in China
.
The treatment of prostate cancer is inseparable from androgen deprivation therapy (ADT).
While reducing PSA, reducing serum testosterone (T) and maintaining it below the castration level is the main goal of treatment
.
Differin® (triptorelin pamoate for injection), a commonly used ADT drug, can relieve PSA levels and deeply reduce testosterone levels, bringing more benefits to patients
.
In order to improve the clinical diagnosis and treatment level of doctors related to urogenital tumors, Yimaitong invited Professor Li Jun from Sichuan Provincial People's Hospital to provide prostate cancer cases, and invited Professor Wang Shaogang from Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology to comment
.
Case Provider Li Jun Li Jun, Ph.
D.
, Department of Urology, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Deputy Chief Physician Vice-chairman of the branch, Youth Vice-chairman of the Urology and Andrology Society of Sichuan Anti-Cancer Association, Secretary of the Oncology Group of the Urology Branch of the Sichuan Medical Association Vice-chairman of the Urology and Male Reproduction Society of the Cancer Society A 77-year-old male patient with a medical history of visiting scholar's case card at Dorff University; in March 2017, he was admitted to the hospital because of "pain in the left lower limb for 1+ month"
.
Past medical history: history of type 2 diabetes
.
Auxiliary examination laboratory examination: PSA=75.
64 ng/ml, T=15.
76 nmol/L
.
MRI: The size of the prostate is about 42mm×28mm×39mm.
The structures of the prostate are not clearly displayed, the diffusion of the right peripheral zone is also limited, and the prostate capsule breaks through the prostate capsule in a local nodular shape; bilateral pubis, ischium, ilium and sacrum have extensive signal abnormalities
.
Whole body bone scan: skull, multiple segments of spine, sternum, bilateral scapulae, multiple ribs on both sides, multiple pelvic bones, and multiple irregularly-shaped contrast-enhanced lesions in the upper femur of both sides, which are consistent with the signs of extensive bone metastases of the tumor
.
The diagnosis results were prostate cancer with extracapsular invasion, extensive bone metastases (T3aN0M1b); metastatic hormone-sensitive prostate cancer (mHSPC), adenocarcinoma (Gleason score 7)
.
Treatment went through the first phase of therapy—conventional combined androgen blockade (CAB): goserelin 3.
6 mg iH q28d + bicalutamide 50 mg po qd
.
PSA follow-up results: PSA decreased since March 2017, and reached the lowest value in June 2018.
Then, until September 2020, the patient's PSA continued to rise and entered the stage of castration-resistant prostate cancer (CRPC)
.
Figure 1.
Follow-up results of PSA trends in the first stage of treatment: Testosterone values decreased from March 2017, and then tended to stabilize
.
Figure 2 Phase 1 Treatment Testosterone Trends Phase 2 Treatment - Novel Endocrine Therapy (MAB): Triptorelin Pamoate 15 mg iH q3M + Abiraterone Acetate 1000 mg po qd + Prednisone from September 2020 5 mg po bid
.
The second phase of follow-up: From September 2020, testosterone decreased to 0 nmol/L, and PSA decreased to 0.
01 ng/ml
.
Figure 3 The trend of testosterone in the second stage of treatmentFigure 4 The trend of PSA in the second stage of treatment Case analysis This case received traditional endocrine therapy in the hormone-sensitive stage, the testosterone decreased rapidly and stabilized at the level of castration, and the PSA decreased rapidly in June 2018.
It began to rise from the beginning, and the patient reached the CRPC stage
.
After the patient reached the CRPC stage, goserelin was replaced with triptorelin, and new endocrine therapy was used in combination.
The follow-up results showed that the serum testosterone was deeply decreased to a lower level, and the PSA was well controlled
.
Both testosterone and PSA are important predictors of survival in prostate cancer patients
.
A retrospective analysis showed that patients with T < 20 ng/dL and T reduction ≥ 480 ng/dL had better overall survival [1]
.
As the most basic treatment method for prostate cancer, ADT includes various embodiments, among which simple castration (surgical or medical castration) is the most widely accepted core treatment method, and luteinizing hormone-releasing hormone represented by triptorelin (LHRH) agonists are the most commonly used antitumor "weapons" by clinicians
.
A study evaluating the efficacy and safety of triptorelin in patients with locally advanced or metastatic prostate cancer showed that after 8 weeks of treatment, median PSA levels remained below 4 ng/ml until the study endpoint; treatment At 26 weeks, the PSA level decreased by 96.
0%, and the proportion of patients with a T < 20 ng/dL was 90% [2], which suggests that triptorelin can sustainably reduce PSA and testosterone levels in prostate cancer patients
.
Figure 5.
Triptorelin study results.
Introduction to experts.
Professor Wang Shaogang, chief physician, doctoral supervisor, director of the Department of Urology, Tongji Hospital, Tongji Hospital, Huazhong University of Science and Technology Vice-chairman of the study group Vice-chairman of the Urology Branch of the China Medical Equipment Association Standing Committee Member of the Medical Robotic Physician Branch of the Chinese Medical Doctor Association Standing Committee Member of the Endoscopy and Robotic Surgery Branch of the China Anti-Cancer Association Deputy Head of the Minimally Invasive Group of the Society of Urology, Deputy Director of the Urology Branch of the Hubei Provincial Medical Doctor Association, Director of the Clinical Research Center for Minimally Invasive Treatment of Hubei Province Urology, Director of the Robotic and Endoscopic Surgery Branch of the Wuhan Medical Association The staging is generally late, and the incidence rate is also on the rise in recent years.
Endocrine therapy has become the basic treatment drug for prostate cancer
.
The principle of ADT is mainly through the hypothalamus-pituitary-gonadal axis to reduce testicular secretion of androgens.
Even in the case of hormone resistance in advanced prostate cancer, ADT should be used as the basis for treatment
.
Testosterone is associated with the occurrence and development of prostate cancer, risk assessment, treatment selection and efficacy evaluation, and is a key indicator for evaluating the efficacy of ADT
.
Testosterone management is an important part of prostate cancer diagnosis and treatment, which runs through multiple processes of prostate cancer diagnosis, evaluation, treatment and prognosis evaluation
.
Compared with the castration standard of T<50 ng/dL in the past, more and more studies have shown that lower serum testosterone levels are significantly associated with better prognosis [3], and the concept of "deep ketone reduction" has entered the public eye
.
EAU guidelines and Chinese expert consensus on testosterone management in prostate cancer (2021 edition) both recommend maintaining T levels below 20 ng/dL
.
In this case, the patient's T was consistently <20 ng/dL, and the patient benefited well
.
Triptorelin, leuprolide, and goserelin are the most commonly used ADT treatments.
After the patient's disease progressed, goserelin was promptly replaced with triptorelin, which further decreased the testosterone level and finally stabilized it.
Controlled at 0 ng/ml, while the PSA level was deeply relieved, the patient's condition was stabilized
.
A retrospective analysis [4] compared the changes in testosterone levels within 9 months of triptorelin, leuprolide, and goserelin treatment, and the results suggested that in 125 patients, the triptorelin treatment group (regardless of All patients (either the overall population or the monotherapy subgroup) were able to reduce testosterone levels to <20 ng/dL at 6 and 9 months
.
In addition, of the three drugs, the 3-month dose of triptorelin reduced testosterone levels to <10 ng/dL in the highest proportion of patients
.
At present, clinicians will pay attention to the changes of PSA in the process of disease change, but not enough attention to testosterone
.
Testosterone levels below castration are necessary for the diagnosis of CRPC and should be maintained during subsequent treatment
.
Without continuous monitoring of testosterone levels, it is impossible to tell whether a patient is stable at castration levels, and therefore cannot accurately judge disease control
.
Therefore, in the Chinese Expert Consensus on Testosterone Management in Prostate Cancer (2021 Edition), the whole-process management of testosterone is standardized and recommended to increase the attention of clinicians to the standardized management of testosterone
.
The consensus recommends that regular monthly testosterone testing is recommended before the initiation of ADT and within 6 months of treatment
.
As the condition becomes stable, the testosterone test interval can be extended to once every 3-6 months, or the testosterone test and PSA test can be carried out simultaneously
.
The significance of testosterone monitoring is not only to reflect the efficacy of ADT, but also to monitor whether prostate cancer has disease progression
.
For example, when PSA rises during ADT, whether it is due to the effect of ADT drugs, or whether prostate cancer develops into CRPC, it needs to be clarified through testosterone monitoring
.
Figure 6 Standardized flow chart of testosterone monitoring and management during ADT treatment
.
At present, domestic doctors and patients' awareness of testosterone management and clinical application effect need to be improved.
Through this case sharing, it is hoped to improve the standardized application of ADT and standardized monitoring of testosterone by doctors related to urogenital tumors, and to further improve the quality of prostate cancer in China.
survival of cancer patients
.
References: [1] Yamamoto S, Sakamoto S, Minhui X, et al.
Testosterone Reduction of ≥ 480 ng/dL Predicts Favorable Prognosis of Japanese Men With Advanced Prostate Cancer Treated With Androgen-Deprivation Therapy.
Clin Genitourin Cancer.
2017 Dec; 15(6):e1107-e1115.
[2] Lebret T, Rouanne M, Hublarov O, et al.
Efficacy of triptorelin pamoate 11.
25 mg administered subcutaneously for achieving medical castration levels of testosterone in patients with locally advanced or metastatic prostate cancer.
Ther Adv Urol.
2015 Jun;7(3):125-34.
[3] Urology Branch of Chinese Medical Association, Urogenital Tumor Professional Committee of China Anti-Cancer Association, Urology Branch of Chinese Medical Doctor Association.
Testosterone Management in Prostate Cancer Chinese Expert Consensus (2021 Edition)[J].
Chinese Journal of Urology,2021,42(04):241-245.
[4] Shim M, Bang WJ, Oh CY, et al.
Effectiveness of three different luteinizing hormone-releasing Hormone agonists in the chemical castration of patients with prostate cancer: Goserelin versus triptorelin versus leuprolide.
Investig Clin Urol.
2019 Jul;60(4):244-250.
Approval number: DIP-CN-008092 Valid until 20/03/2024 Review: Bingxin Typesetting: XY Execution: XY
.
The treatment of prostate cancer is inseparable from androgen deprivation therapy (ADT).
While reducing PSA, reducing serum testosterone (T) and maintaining it below the castration level is the main goal of treatment
.
Differin® (triptorelin pamoate for injection), a commonly used ADT drug, can relieve PSA levels and deeply reduce testosterone levels, bringing more benefits to patients
.
In order to improve the clinical diagnosis and treatment level of doctors related to urogenital tumors, Yimaitong invited Professor Li Jun from Sichuan Provincial People's Hospital to provide prostate cancer cases, and invited Professor Wang Shaogang from Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology to comment
.
Case Provider Li Jun Li Jun, Ph.
D.
, Department of Urology, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Deputy Chief Physician Vice-chairman of the branch, Youth Vice-chairman of the Urology and Andrology Society of Sichuan Anti-Cancer Association, Secretary of the Oncology Group of the Urology Branch of the Sichuan Medical Association Vice-chairman of the Urology and Male Reproduction Society of the Cancer Society A 77-year-old male patient with a medical history of visiting scholar's case card at Dorff University; in March 2017, he was admitted to the hospital because of "pain in the left lower limb for 1+ month"
.
Past medical history: history of type 2 diabetes
.
Auxiliary examination laboratory examination: PSA=75.
64 ng/ml, T=15.
76 nmol/L
.
MRI: The size of the prostate is about 42mm×28mm×39mm.
The structures of the prostate are not clearly displayed, the diffusion of the right peripheral zone is also limited, and the prostate capsule breaks through the prostate capsule in a local nodular shape; bilateral pubis, ischium, ilium and sacrum have extensive signal abnormalities
.
Whole body bone scan: skull, multiple segments of spine, sternum, bilateral scapulae, multiple ribs on both sides, multiple pelvic bones, and multiple irregularly-shaped contrast-enhanced lesions in the upper femur of both sides, which are consistent with the signs of extensive bone metastases of the tumor
.
The diagnosis results were prostate cancer with extracapsular invasion, extensive bone metastases (T3aN0M1b); metastatic hormone-sensitive prostate cancer (mHSPC), adenocarcinoma (Gleason score 7)
.
Treatment went through the first phase of therapy—conventional combined androgen blockade (CAB): goserelin 3.
6 mg iH q28d + bicalutamide 50 mg po qd
.
PSA follow-up results: PSA decreased since March 2017, and reached the lowest value in June 2018.
Then, until September 2020, the patient's PSA continued to rise and entered the stage of castration-resistant prostate cancer (CRPC)
.
Figure 1.
Follow-up results of PSA trends in the first stage of treatment: Testosterone values decreased from March 2017, and then tended to stabilize
.
Figure 2 Phase 1 Treatment Testosterone Trends Phase 2 Treatment - Novel Endocrine Therapy (MAB): Triptorelin Pamoate 15 mg iH q3M + Abiraterone Acetate 1000 mg po qd + Prednisone from September 2020 5 mg po bid
.
The second phase of follow-up: From September 2020, testosterone decreased to 0 nmol/L, and PSA decreased to 0.
01 ng/ml
.
Figure 3 The trend of testosterone in the second stage of treatmentFigure 4 The trend of PSA in the second stage of treatment Case analysis This case received traditional endocrine therapy in the hormone-sensitive stage, the testosterone decreased rapidly and stabilized at the level of castration, and the PSA decreased rapidly in June 2018.
It began to rise from the beginning, and the patient reached the CRPC stage
.
After the patient reached the CRPC stage, goserelin was replaced with triptorelin, and new endocrine therapy was used in combination.
The follow-up results showed that the serum testosterone was deeply decreased to a lower level, and the PSA was well controlled
.
Both testosterone and PSA are important predictors of survival in prostate cancer patients
.
A retrospective analysis showed that patients with T < 20 ng/dL and T reduction ≥ 480 ng/dL had better overall survival [1]
.
As the most basic treatment method for prostate cancer, ADT includes various embodiments, among which simple castration (surgical or medical castration) is the most widely accepted core treatment method, and luteinizing hormone-releasing hormone represented by triptorelin (LHRH) agonists are the most commonly used antitumor "weapons" by clinicians
.
A study evaluating the efficacy and safety of triptorelin in patients with locally advanced or metastatic prostate cancer showed that after 8 weeks of treatment, median PSA levels remained below 4 ng/ml until the study endpoint; treatment At 26 weeks, the PSA level decreased by 96.
0%, and the proportion of patients with a T < 20 ng/dL was 90% [2], which suggests that triptorelin can sustainably reduce PSA and testosterone levels in prostate cancer patients
.
Figure 5.
Triptorelin study results.
Introduction to experts.
Professor Wang Shaogang, chief physician, doctoral supervisor, director of the Department of Urology, Tongji Hospital, Tongji Hospital, Huazhong University of Science and Technology Vice-chairman of the study group Vice-chairman of the Urology Branch of the China Medical Equipment Association Standing Committee Member of the Medical Robotic Physician Branch of the Chinese Medical Doctor Association Standing Committee Member of the Endoscopy and Robotic Surgery Branch of the China Anti-Cancer Association Deputy Head of the Minimally Invasive Group of the Society of Urology, Deputy Director of the Urology Branch of the Hubei Provincial Medical Doctor Association, Director of the Clinical Research Center for Minimally Invasive Treatment of Hubei Province Urology, Director of the Robotic and Endoscopic Surgery Branch of the Wuhan Medical Association The staging is generally late, and the incidence rate is also on the rise in recent years.
Endocrine therapy has become the basic treatment drug for prostate cancer
.
The principle of ADT is mainly through the hypothalamus-pituitary-gonadal axis to reduce testicular secretion of androgens.
Even in the case of hormone resistance in advanced prostate cancer, ADT should be used as the basis for treatment
.
Testosterone is associated with the occurrence and development of prostate cancer, risk assessment, treatment selection and efficacy evaluation, and is a key indicator for evaluating the efficacy of ADT
.
Testosterone management is an important part of prostate cancer diagnosis and treatment, which runs through multiple processes of prostate cancer diagnosis, evaluation, treatment and prognosis evaluation
.
Compared with the castration standard of T<50 ng/dL in the past, more and more studies have shown that lower serum testosterone levels are significantly associated with better prognosis [3], and the concept of "deep ketone reduction" has entered the public eye
.
EAU guidelines and Chinese expert consensus on testosterone management in prostate cancer (2021 edition) both recommend maintaining T levels below 20 ng/dL
.
In this case, the patient's T was consistently <20 ng/dL, and the patient benefited well
.
Triptorelin, leuprolide, and goserelin are the most commonly used ADT treatments.
After the patient's disease progressed, goserelin was promptly replaced with triptorelin, which further decreased the testosterone level and finally stabilized it.
Controlled at 0 ng/ml, while the PSA level was deeply relieved, the patient's condition was stabilized
.
A retrospective analysis [4] compared the changes in testosterone levels within 9 months of triptorelin, leuprolide, and goserelin treatment, and the results suggested that in 125 patients, the triptorelin treatment group (regardless of All patients (either the overall population or the monotherapy subgroup) were able to reduce testosterone levels to <20 ng/dL at 6 and 9 months
.
In addition, of the three drugs, the 3-month dose of triptorelin reduced testosterone levels to <10 ng/dL in the highest proportion of patients
.
At present, clinicians will pay attention to the changes of PSA in the process of disease change, but not enough attention to testosterone
.
Testosterone levels below castration are necessary for the diagnosis of CRPC and should be maintained during subsequent treatment
.
Without continuous monitoring of testosterone levels, it is impossible to tell whether a patient is stable at castration levels, and therefore cannot accurately judge disease control
.
Therefore, in the Chinese Expert Consensus on Testosterone Management in Prostate Cancer (2021 Edition), the whole-process management of testosterone is standardized and recommended to increase the attention of clinicians to the standardized management of testosterone
.
The consensus recommends that regular monthly testosterone testing is recommended before the initiation of ADT and within 6 months of treatment
.
As the condition becomes stable, the testosterone test interval can be extended to once every 3-6 months, or the testosterone test and PSA test can be carried out simultaneously
.
The significance of testosterone monitoring is not only to reflect the efficacy of ADT, but also to monitor whether prostate cancer has disease progression
.
For example, when PSA rises during ADT, whether it is due to the effect of ADT drugs, or whether prostate cancer develops into CRPC, it needs to be clarified through testosterone monitoring
.
Figure 6 Standardized flow chart of testosterone monitoring and management during ADT treatment
.
At present, domestic doctors and patients' awareness of testosterone management and clinical application effect need to be improved.
Through this case sharing, it is hoped to improve the standardized application of ADT and standardized monitoring of testosterone by doctors related to urogenital tumors, and to further improve the quality of prostate cancer in China.
survival of cancer patients
.
References: [1] Yamamoto S, Sakamoto S, Minhui X, et al.
Testosterone Reduction of ≥ 480 ng/dL Predicts Favorable Prognosis of Japanese Men With Advanced Prostate Cancer Treated With Androgen-Deprivation Therapy.
Clin Genitourin Cancer.
2017 Dec; 15(6):e1107-e1115.
[2] Lebret T, Rouanne M, Hublarov O, et al.
Efficacy of triptorelin pamoate 11.
25 mg administered subcutaneously for achieving medical castration levels of testosterone in patients with locally advanced or metastatic prostate cancer.
Ther Adv Urol.
2015 Jun;7(3):125-34.
[3] Urology Branch of Chinese Medical Association, Urogenital Tumor Professional Committee of China Anti-Cancer Association, Urology Branch of Chinese Medical Doctor Association.
Testosterone Management in Prostate Cancer Chinese Expert Consensus (2021 Edition)[J].
Chinese Journal of Urology,2021,42(04):241-245.
[4] Shim M, Bang WJ, Oh CY, et al.
Effectiveness of three different luteinizing hormone-releasing Hormone agonists in the chemical castration of patients with prostate cancer: Goserelin versus triptorelin versus leuprolide.
Investig Clin Urol.
2019 Jul;60(4):244-250.
Approval number: DIP-CN-008092 Valid until 20/03/2024 Review: Bingxin Typesetting: XY Execution: XY
