the hong kong geriatrics society - bone lesions: malignant or … lesions malignant or benign...
TRANSCRIPT
![Page 1: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/1.jpg)
A N G E L A L A U ( P M H )
I H G M 2 2 / 2 / 2 0 1 4
Bone lesions: Malignant or Benign or Both?
![Page 2: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/2.jpg)
Case Profile
M/71 (PK Ho) Good past health
Retired E&M supervisor
Father of 3 sons
Lives with elder son, GS & wife (recent #Patella with OT done) at public housing
Premorbid: main carer at home, ADL/iADL-I
Hospitalized PMH twice for 2 falls: 14/9/2012
4/11/2012
![Page 3: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/3.jpg)
History
One minor fall in 7/2012 fell on bottom while attempting to sit on sofa, could get up by
himself, no severe pain, no medical consultation
1st presented to AED on 14/9/2012 12/9/12: fell from sofa backwards onto ground while standing
on sofa to clean a fan; severe pain and could not get up
R hip and L chest wall contusion
XR (CXR, L lower ribs, Pelvis & R hip) taken
Rx Voltaren & Triact prn
![Page 4: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/4.jpg)
XRays
![Page 5: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/5.jpg)
Called back AED
Called back & admitted EM ward 18/9/2012 Persistent R hip pain
XR R hip (14/9, 18/9): no fracture
Noted high BP 245/107
Cr 98, LFT normal, Hb 13.0; ECG normal
Rx Norvasc 7.5mg, Ibuprofen, Panadol, Pepcidine, Analgesic ointment
Refer GOPC
![Page 6: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/6.jpg)
GOPD FU
FU GOPD for hypertension Persistent BP upon FU (21/9/12) Norvasc (28/9/12) Moduretic (3/10/12) Atenolol
Persistent mechanical R hip pain, able to walk unaided (3/10/12) Panadol (16/10/12) Voltaren SR
GOPC visit on 29/10/2012 not taking atenolol because feel dizziness with it still pain over R hip radiate to R LL, worst when weight bearing impression: HT , at least partially due to hip pain refer physiotherapy, NSAID, off atenolol , repeat other anti-HT
![Page 7: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/7.jpg)
Admission
Admitted PMH on 4/11/12 Sliding down from sofa to floor due to L LL weakness
L sided weakness since last episode of fall 14/9/12
Leaned on L side while walking; with unsteadiness & recurrent falls (e.g. fell while attempting to hang up clothes)
Persistent R hip pain
Power
L side muscle tone
5 4
5 3
![Page 8: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/8.jpg)
Investigations
CXR (4/11/12): RUZ fibrocaclifications show no interval change
XR pelvis (4/11/12): no fracture
CT brain (6/11/12): R frontal lobe infarct, Lacunar infarcts in genu of L internal capsule & R BG
TCD: Normal screening on IC & EC neck arteries
Dx: Stroke, delayed presentation
![Page 9: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/9.jpg)
Progress during Rehabilitation
R hip pain and LBP XR LS spine (11/12/12)
Mild diffuse osteopenia
Degenerative changes with marginal
osteophytes noted in lumbar spine
Disc spaces and pedicles intact
XR R Hip & Pelvis
Normal alignment. No fracture seen
Phleboliths noted over both sides
![Page 10: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/10.jpg)
XR Pelvis
![Page 11: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/11.jpg)
Progress during Rehabilitation
R hip pain and LBP Failed to tolerate Tramadol due to GI upset
Analgesics
Voltaren SR (100mg) with PPI cover + Gabapentin (100mg bd & 300mg nocte) + Analgesic balm
Stroke prophylaxis
Aspirin (160mg) + Zocor (20mg) + Enalapril (5mg) + Norvasc (10mg)
![Page 12: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/12.jpg)
Complication
Progressive Anaemia Hb 13 (18/9/12) 13.2(4/11/12) 10.1 (22/2/13) 8.4
(8/3/13)
OGD with Bx: mild chronic gastritis at antrum, HP –ve
FE/TIBC 8.6/48.8; FeSat 18%; Ferritin 843
FOB –ve X 3
VitB12 203 (28/11/12) ; 166 (13/3/13) pmol/L
RBC Folate 438 ; Serum Folate 6.8 (28/11/12) nmol/L
TSH 1.0 (normal)
Aspirin/Voltaren SR taken off
Rx: DF118
Colonoscopy booked
![Page 13: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/13.jpg)
Progress during Rehabilitation
Team round (19/2/13): Patient is not participating in rehabilitation due to pain Pain score 5/10 (despite given analgesics)
PE showed marked tenderness over Rt pelvis and sacrum
Previous X-rays of Ribs, Hips, LS spine & pelvis revealed osteopenia and #Rib
?Sacral insufficiency fracture complicating fall & osteoporosis
Check VitD level
Rx Calcitonin & anti-osteoporosis Rx
Book CT sacrum
![Page 14: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/14.jpg)
Vitamin D Deficient
Serum vitamin D level (20/2/13) 25OH D2 <10 nmol/L
25OH D3 18 nmol/L
Total 25OH VitD 18 nmol/L
<12.5 nmol/l Severe deficiency
12.5-29 nmol/l Moderate deficiency
30-49 nmol/l Mild deficiency
Ca/PO4: 2.31/1.25, iCa 1.19
Albumin: 36 (4/11/12)
ALP: 105 (4/11/12) 898 (15/5/13)
![Page 15: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/15.jpg)
CT sacrum (11/3/2013)
Mixed sclerotic & lytic areas in L5, S2 to S4 sacrum and L iliac bone; small lytic area in R iliac bone.
Findings are suggestive of multiple bone metastasis, with pathological fractures in L5 vertebra and R iliac bone.
Prostate enlarged
Prominent right groin lymph node (1.5cm)
![Page 16: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/16.jpg)
Approach to CT bone lesion
Morphology & Age Well-defined osteolytic
<40 years old Giant cell tumor / Osteblastoma / Enchondroma
Chondrosarcoma / HyperPTH with Brown tumor >40 years old
Metastases / Myeloma
Ill-defined osteolytic <40 years old
Giant cell tumor >40 years old
Metastases / Myeloma / Chondrosarcoma
Sclerotic <40 years old
Bone island / Healed lesions / Enchondroma / Osteoma >40 years old
Metastases Bone island
Infection
Images from www.radiologyassistant.nl
![Page 17: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/17.jpg)
What is in our mind?
![Page 18: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/18.jpg)
Differential Diagnoses
Malignant: Metastases
Prostate / Breast / Lung / Lymphoma / Carcinoid
Benign: Severe Vitamin D deficiency
Paget’s disease
ALP with normal Ca & PO4
Tuberculosis infection
Sacral insufficiency fractures
Post-traumatic osteomyelitis of Rt iliac bone & L5 vertebra
Bone island
![Page 19: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/19.jpg)
Sacral Insufficiency Fracture
Stress fracture: normal stress applied to abnormal bone that lost elastic resistance
Causes: Osteoporosis / metabolic bone disease
Imaging CT / MRI
Therapy Conservative – strict bed rest & pain control
Rehabilitation – after 6-15months
Sacroplasty
Complications Immobilization
![Page 20: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/20.jpg)
Work Up
PE DRE – Anal tone intact, Hard Prostate 3FB
Shotty R groin LN ~0.5cm
Inflammatory markers CRP 7.7 (3/4/13) / ESR 41 (22/2/13)
Spt AFB smear C/ST –ve
EMU AFB C/ST -ve
Tumor markers (13/3/13) PSA: 355
CEA: 2.2 / AFP: 8.2 / CA 19.9: 13
IgA 2.29 / IgG 13.1 / IgM 1.08 / SPE – no abnormal band
Spt Cytology -ve
![Page 21: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/21.jpg)
XRays
![Page 22: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/22.jpg)
Private CT thorax & Abdomen (13/3/2013)
Primary site at R prostate gland Evidence of R extra-capsular spread and neurovascular bundle
encasement.
Multiple bone metastases Sclerotic metastases with compression # over C7, T4, T9 and L5 Sclerotic-lytic metastases of L 1st 3rd & 7th ribs Mixed sclerotic-lytic metastases at sacrum and bilateral ilium
Lymphadenopathy: Extensive pelvic & intra-abdominal nodal metastases Thorax: pre-vascular and right axillary region
Lungs: A large area of fibrocalcific scarring with concave borders seen at R lung
apex, measuring 2 X 5.8cm Cluster of small centrilobular nodules over RLL, more likely infection
than malignancy
![Page 23: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/23.jpg)
Bone scan (20/3/2013)
![Page 24: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/24.jpg)
US Urinary
Prominent irregular prostatic mass protruding into bladder
R kidney 8.2cm & L kidney 9.6cm, no focal lesion or hydronephrosis
![Page 25: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/25.jpg)
Disease Progress
Disseminated Ca prostate Oncology (5/4/2013)
Metastatic CA prostate for androgen ablation with medical or surgical castration
Refer Urology x TRUS Bx Orchidectomy
Urology (22/4/2013)
Patient opted for bil Orchidectomy without TRUS Bx
Bil Orchidectomy done 24/4/13
Patho: No evidence of malignancy
PSA 355 10.7 (9/13) 28 (12/13)
ALP 898 (15/5/13) 590 (17/6/13) 108 (31/12/13)
![Page 26: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/26.jpg)
Problem lists
Pathological # L5 vertebra and R iliac bone Morphine SR 90mg bd & Panadol 500mg q4h prn
Attempted palliative RT to L spine but patient cannot tolerate set up position, RT cancelled
Moderate VitD deficiency CaCO3 & Alfacalcidol (switched to cholecalciferol later)
Total 25OH VitD 90 (7/8/2013)
NcNc anaemia On B12 & Folate & Fe supplement
Hb 8.4 (8/3/13) 10.2 (15/5/13) 11 (31/12/13)
![Page 27: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/27.jpg)
Problem lists
HT BP 88/45 – 115/65 mmHg
Atenolol, Enalapril, Norvasc taken off
Hyperlipidaemia TC 5.8/LDL 3.9 (6/11/2012), Rx: Zocor
Taken off with CK 488
Recheck TC 2.7/LDL 1.3 (8/3/2013)
Constipation Senokot 15mg bd & Fleet enema alternate daily
Depression GDS (18/7/13) 10/15 (very depressed), Rx Zoloft
![Page 28: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/28.jpg)
Rehabilitation Progress
Upon discharge to OAH (31/7/2013) Tolerate 10 min of sit out
BI 56/100
ADL-I up to feeding and grooming, dressing with assistance, transfer with 2 assistance
![Page 29: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/29.jpg)
Discussion
![Page 30: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/30.jpg)
Prostate cancer
Incidence 3rd most common cancer in men
10.7% of new cancer cases in male in 2010
45.3 per 100,000 male
~1000 newly dx case/year
Mortality 5th leading cause of male cancer deaths in HK
3.8% of male cancer deaths
~300 deaths/year
![Page 31: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/31.jpg)
Risk factors
Age, Median age of dx 72
Family hx BRCA2 & BRCA1 mutations
Ethnic African-Americans
Smoking
Obesity
Others Prostatitis (RR=1.6)
Hx of Syphilis / gonorrhea (RR=1.4)
![Page 32: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/32.jpg)
Decision for PSA screening
Information
Support for decision-making
![Page 33: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/33.jpg)
Decision for Prostate Bx
PSA level
DRE findings
Risk factors
Risk & benefit of Bx Having to live with the dx of clinically insignificant prostate
cancer
When clinical suspicion of prostate cancer is high (high PSA /evidence of bone met identified by positive isotope bone scan or sclerotic metastases on plain radiographs) No prostate bx for histological confirmation needed
![Page 34: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/34.jpg)
TNM Staging
Extend of tumor
Evaluation of LN
Distant metastasis
![Page 35: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/35.jpg)
Risk Stratification
National Comprehensive Cancer Network (NCCN)
Low-risk
Localized to 1 lobe of prostate, PSA <10 ng/ml, GS 6
Intermediate-risk
Intracapsular extension, PSA 10-20 ng/ml, GS 7
High-risk
Extracapsular extension, PSA >20 ng/ml, GS 8-10
Prostatectomy / ADT / RT
Watchful wait / Active surveillance
![Page 36: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/36.jpg)
Low-risk
1st visit Multiparametric MRI
Year 1-4 PSA every 3-4 months
DRE every 6-12 months
Prostate Re-Bx
Year 5 onwards PSA every 6 months
DRE every 12months
Radical Tx for disease progression
*NICE guideline 2014
![Page 37: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/37.jpg)
Intermediate/High-risk
Radical Prostatectomy Intermediate / high-risk patient * High-risk : Post-op RT
ADT plus RT (2-3 years) High-risk patient ADT & RT 10-year overall survival then ADT alone ** ADT & RT 15-year cancer specific mortality rate #
Androgen Deprivation Therapy (ADT) Bilateral Orchiectomy Gonadotropin releasing hormone (GnRH) agonist Antiandrogen
Radiation Therapy (RT) External beam RT External beam & brachytherapy
*PIVOT trial. N Engl J Med.2012;367(3):203 **NCIC Intergroup phase III trial. Lancet.2011;378(9809):2104 #Scandinavian Prostate Cancer Gp Study, open randomised phase III trial.2014 ASCO
![Page 38: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/38.jpg)
Disseminated Tx
Medical (ADT) / Surgical Orchiectomy
Chemotherapy
Table from 2014UpToDate
![Page 39: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/39.jpg)
Monitor Adverse effects
Radical Prostatectomy Sexual dysfunction Urinary incontinence
ADT Hot flushes Sexual dysfunction Osteoporosis
Zoledronic acid/Denosumab* (for castration-resistant CA prostate with bone met, failed analgesics & palliative RT)
Gynaecomastia Fatigue Anaemia
RT Radiation-induced enteropathy
* Efficacy and safety of zoledronic acid in men with castration-sensitive prostate cancer and bone metastases: Results of CALGB 90202 (Alliance). J Clin Oncol 2013; 31
![Page 40: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/40.jpg)
Same in Elderly?
![Page 41: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/41.jpg)
Prostate Cancer in Elderly
Effect of Age, Tumor Risk, and Comorbidity on Competing Risks for Survival in a U.S Population-Based Cohort of Men with Prostate Cancer Annals of Internal Medicine Sept2013 Population-based cohort 3183 men with non-metastatic prostate cancer at diagnosis Baseline comorbidity
DM / HT CHF / IHD / MI / Angina / CVA GIB / Cirrhosis or liver disease / IBD Chronic lung disease Arthritis Depression
Tumor characteristics Initial treatment Overall & Disease-specific mortality through 14years FU
![Page 42: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/42.jpg)
Mortality Curve
![Page 43: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/43.jpg)
Assess Comorbidities
Cumulative Illness Score Rating-Geriatrics (CISR-G) Grade 0: no problem
Grade 1: current mild problem or past significant problem
Grade 2: moderate disability or morbidity, requires first-line therapy
Grade 3: severe/constant significant disability/uncontrollable chronic problem
Grade 4: extremely severe/immediate treatment required/end-organ failure/severe Impairment in function
ADL & iADL
Nutritional status
![Page 44: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/44.jpg)
Health Status of Elderly
Society of Geriatric Oncology (SIOG) Healthy
No serious comorbidities, ADL/iADL-I, no malnutrition Same as young
Vulnerable with reversible problem 1 uncontrolled comorbidity, iADL-d but functionally-I, at risk of
malnutrition Same as young exclude radical prostatectomy
Frail with non-reversible problem ADL-pd, malnutrition Symptomatic mx without definitive Tx (e.g androgen deprivation)
Terminal Bedridden, major comorbidities, cognitive impairment Palliative
![Page 45: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/45.jpg)
Discussion
2008 US Preventive Services Task Force >75 cessation of screening and treatment *
Life expectancy <10 years
50% other-cause mortality
Against PSA screening in healthy men
Effect of Age, Tumor Risk, and Comorbidity on Competing Risks for Survival in a U.S Population-Based Cohort of Men with Prostate Cancer Age 60 with 3 comorbidities
10 years mortality ~50%
All cause mortality >potential survival benefit from aggressive therapy
*Screening for prostate cancer: U.S.Preventive Services Task Force recommendation statement. Ann Intern Med.2008;149:185-91. [PMID: 18678845]
![Page 46: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/46.jpg)
Progress of Mr Ho
![Page 47: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/47.jpg)
Progress of Mr Ho
Upon FU (18/12/2013) Kyphotic
Bedchair bound
Complicated with UTI with AROU (31/12/2013) with foley inserted, Rx Augmentin
Foley weaned 15/1/2014
![Page 48: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/48.jpg)
Xrays (22/7 & 21/8/13)
![Page 49: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/49.jpg)
Take Home Message
Sacral / Pelvic fractures may be subtle on XR
Sclerotic bone lesions take time to develop on XR
Devastating pain warrant further imaging
Screening & Mx of prostate cancer is subjected to individual’s health & risk of disease progression Healthy / Vulnerable elderly with 1 comorbidity &
functionally-I
Radical prostatectomy / ADT / RT / Watchful wait / Active surviellance
Frail elderly ADL-pd, malnutritioned / Bedridden
Symptomatic Tx / Palliative
![Page 50: The Hong Kong Geriatrics Society - Bone lesions: Malignant or … lesions Malignant or Benign or... · 2015-04-17 · CT sacrum (11/3/2013) Mixed sclerotic & lytic areas in L5, S2](https://reader034.vdocuments.us/reader034/viewer/2022050516/5f9fdaf1a7205c40b22aaf86/html5/thumbnails/50.jpg)
~Thank you~