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DR ZELEFSKY: For a patient with a particularly bulky and large gland with possible rectal wall involvement, like this 50-year-old man, I would favor a nonsurgical approach with neoadjuvant androgen ablative therapy up front to achieve volume reduction followed by radiation therapy. With a very large prostate, you would probably need to administer at least four or six months of hormonal therapy.

In our institution, we would then obtain additional images for a better idea of what was accomplished during that neoadjuvant phase of therapy. Based on the data from randomized trials, a patient with bulky disease may require long-term hormonal therapy — up to two or three years, as long as the patient is able to tolerate it. We don’t have a finite period, but we follow these patients, observing their quality of life.

DR LOVE: Tom, what would be your approach?

DR KEANE: If all of a patient’s staging studies were negative, and the potential existed for rectal wall involvement, it would be reasonable to use hormonal therapy to shrink the prostate. Then, I feel the patient would be better off — and I don’t have any basis for saying this — if we could remove his prostate.

He will end up receiving radiation therapy, and probably chemotherapy and hormonal therapy also. However, we know that at 50 years of age, even if we use radiation therapy and hormones, the patient will likely experience a relapse.

DR ZELEFSKY: I believe this is an emerging notion being vocalized by a number of urologists, that if you irradiate bulky disease in their prostate, patients have a high likelihood of symptomatic local recurrences down the road.

When we examine our own data and data from others, we see that when you deliver a high dose of radiation, as opposed to the lower conventional doses, and add in the hormonal therapy, symptomatic local recurrences are rare.

DR LOVE: How about local recurrences in general?

DR ZELEFSKY: I believe it depends on the extent of disease, but probably 30 to 40 percent of patients with bulky tumors will experience biopsy-proven local recurrences after doses of 75 Gray. With higher doses, I believe the percentage will be lower than that (Zietman 2005; [1.3]).

DR LOVE: Len, how was a decision made regarding his initial treatment?

DR GOMELLA: This patient sought opinions from at least four different major centers and came back totally confused because every time he went to a different center, he was offered a different approach.

When he returned to us for treatment, we explained that he was in uncharted territory. We sat down with a multidisciplinary team, including the colorectal surgeons and the medical oncologists, and everyone agreed on total androgen blockade.

In addition, he received six cycles of docetaxel, administered every three weeks, and when we repeated imaging, we noted good involution of the prostate, down to approximately 60 or 70 grams. At that point, we restaged the cancer and everything seemed good. Even the surgeons thought he might have less involvement of the rectal wall.

DR LOVE: How did he tolerate the docetaxel?

DR GOMELLA: He experienced hair loss and other constitutional symptoms, but he was able to keep working as an insurance salesman, taking some light days and other measures like that.

After approximately 12 months of hormone therapy, he underwent a radical prostatectomy, and surprisingly, the prostate came out very easily. Of course, nerve sparing was not an option. The nodes were negative, but pathology revealed a few foci of tumor left on his rectal wall.

He received radiation therapy postoperatively, around 68 Gray, and then finished a total of three years of hormone therapy. He’s now out a year and a half, and he has no evidence of disease.

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