1. CASE 1 65-year-old man No other diseases or previous surgeries July 2005: PSA 11.5 ng/ml; F/T: 9% After prostate biopsy revealing adenocarcinoma: RETROPUBIC NERVE-SPARING RADICAL PROSTATECTOMY HISTOLOGY: Adenocarcinoma pT2b, Gleason 3+3, pN0 (13/13) M0; positive unifocal margin PSA after surgery: 0.1 ng/ml No adjuvant radiotherapy

2.  October 2005: PSA 0.2 ng/ml  January 2006: PSA 0.5 ng/ml  May 2006: PSA 1.5 ng/ml  Asymptomatic patient  TRUS: negative  Negative bone scan CASE 1

3. What is the best predictive parameter of clinical progression? a) high Gleason score and positive margins b) b) PSA > 0,4 ng/ml followed by another higher value c)PSA > 0.4 ng/ml CASE 1 – First Question CASE 1

4. What is the best predictive parameter of clinical progression? a) high Gleason score and positive margins b) b) PSA > 0,4 ng/ml followed by another higher value c)PSA > 0.4 ng/ml CASE 1 – First Question CASE 1

5. What parameters, in biochemical recurrence, are highly associated with metastatic disease ? a) State of desease and Gleason Score b) PSA and PSA-DT c) c) PSA-DT, Gleason Score, Time from RP to BCR CASE 1 – Second Question CASE 1

6. What parameters, in biochemical recurrence, are highly associated with metastatic disease ? a) State of desease and Gleason Score b) Psa and Psa-DT c) c) PSA-DT, Gleason Score, Time from RP to BCR CASE 1 – Second Question CASE 1

7. What treatment do you suggest in this patient, taken into consideration the risk- benefit analysis ? a) Orchiectomy b) Monotherapy with non-steroidal antiandrogens c) LH-Rh agonists + antiandrogens CASE 1 – Third Question CASE 1

8. What treatment do you suggest in this patient, taken into consideration the risk- benefit analysis ? a) Orchiectomy b) Monotherapy with non-steroidal antiandrogens c) LH-Rh agonists + antiandrogens CASE 1 – Third Question CASE 1

9. CASE 2 70-year-old man BPCO, high blood pressure May 2000: PSA 9.1 ng/ml Prostate biopsy reveles adenocarcinoma, Gleason 7 (3+4), cT2aNxM0 Patient refuses radical prostatectomy and undergoes radiation therapy (DT 70 Gy) For 3 years PSA levels remain in the range of 0.5-0.8 ng/ml; Periodical clinical and instrumental evaluations are performed

10. July 2003: PSA 2.2 ng/ml October 2003: PSA 4.1 ng/ml January 2004: PSA 7.2 ng/ml Patient refuses surgical treatment. The patient receives LHRH in combination with Casodex, achieving a PSA decline to 0.5 ng/ml. Periodical follow-up are performed. March 2005: PSA increases to 13.5 ng/ml; no metastases. The antiandrogen therapy is stopped, resulting after 2 months in a withdrawal effect on his PSA level (2.5 ng/ml) CASE 2

11. July 2005: PSA increase (32.6 ng/ml) Staging of disease: CT: lung metastatic lesions CT: lung metastatic lesions Bone scan: L3 osteoblastic lesion Bone scan: L3 osteoblastic lesion PET: evidence of the previous described lesions plus a pelvic captation PET: evidence of the previous described lesions plus a pelvic captation CASE 2

12. What treatment do you suggest in this patient ? a) a new hormonal line b) cortisonics + biphosphonate c) chemotherapy + cortisonics +biphosphonate CASE 2 CASE 2 – First Question

13. What treatment do you suggest in this patient? a) a new hormonal line b) cortisonics + biphosphonate c) chemotherapy + cortisonics + biphosphonate CASE 2 CASE 2 – Question

14. The patient starts chemotherapy with Docetaxel 75 mg/mq (q21) + prednisone 10 mg/die and Zometa 4 mg (q21), obtaining a SD after the III cycles (PSA 28) and a lung PR after the VI cycle (PSA 15). Stop chemiotherapy after the VI cycle for the appearance of metabolic alterations and diagnosis of diabetes mellitus. (February 2006) CASE 2- evolution

15. Periodical follow-up are performed showing clinical and biochemical stability November 2007: evidence of lung PD PSA: 82 ng/ml PSA: 82 ng/ml PS:1, good metabolic status PS:1, good metabolic status CASE 2- evolution

16. What is the further therapeutic option for this patient ? a) Start again hormone therapy b) Start again chemotherapy with Docetaxel and Prednisone c) Metronomic chemotherapy d) Second line chemotherapy with Navelbine CASE 2 –Evolution: Question

17. What is the further therapeutic option for this patient ? a) Start again hormone therapy b) Start again chemotherapy with Docetaxel and Prednisone Prednisone c) Metronomic chemotherapy d) Second line chemotherapy with Navelbine CASE 2 –Evolution: First Question

18. What are the new sperimental drugs giving the most encouraging results in the treatment of hormone-rafractory prostate cancer ? a) satraplatin b) bevacizumab, talidomide, gefitinib, inhibitors endothelin-A c)ixabepilone, trastuzumab d) calcitriol e)vaccine therapy Final Question

19. What are the new sperimental drugs giving the most encouraging results in the treatment of hormone-rafractory prostate cancer ? a) satraplatin b) bevacizumab, talidomide, gefitinib, inhibitors endothelin-A c)ixabepilone, trastuzumab d) calcitriol e)vaccine therapy Final Question

20. CASE 3 77-year-old man. PS: 1 Arterial hypertension. Hearth attack in 1995 August 2003: dysuria and urethral bleeding Serum PSA 23 ng/ml. Chromogranin A 20; NSE 3,4 transrectal ultrasound guided A needle biopsy was performed HISTOLOGY: Adenocarcinoma cT2b, Gleason 5+5, perineural invasion; N0 M0;

21. What kind of treatment do you suggest ? a) Surgery b) Radioteraphy c) Hormonotherapy CASE 3 CASE 3 – First Question

22. What kind of treatment do you suggest ? a) Surgery b) Radioteraphy c) Hormonotherapy CASE 3 – First Question CASE 3

23. In consideration of the age, he started androgen blockade hormonotherapy Serum PSA was undetectable for 1 years October 2004: urinary obstruction, weight loss and bone pain. PS: 2/3 CASE 3 - EVOLUTION

24. Imaging studies revealed multiple bones metastases. PSA 18,0 ng/ml; Chromogranin A 450; NSE 22 A fine-needle aspiration biopsy of the bone revealed metastases of a neuroendocrine tumor which was strongly positive for NSE and Chromogranin-A CASE 3 - EVOLUTION

25. What is the most important neuroendocrine prostate cells marker ? a) PSA, PSA Free b) CEA, NSE c) Chromogranin A CASE 3 – Second Question CASE 3 - EVOLUTION

26. What is the most important neuroendocrine prostate cells marker ? a) PSA, PSA Free b) CEA, NSE c) Chromogranin A CASE 3 – Second Question CASE 3 - EVOLUTION

27. A transurethral prostatectomy (TUR-P) was performed in order to relieve the obstructive symptoms pathological examination of the resected specimen showed a small cell carcinoma of the prostate. CASE 3 – EVOLUTION again

28. What treatment do you suggest in this patient, taken into consideration the clinical condition and the comorbidities ? a) II-line Hormotherapy b) Chemotherapy c) Treatment with Somatostatin analogs and dexamethasone CASE 3 – Third Question CASE 3 – EVOLUTION again

29. What treatment do you suggest in this patient, taken into consideration the clinical condition and the comorbidities ? a) II-line Hormotherapy b) Chemotherapy c) Treatment with Somatostatin analogs and dexamethasone CASE 3 – Third Question CASE 3 – EVOLUTION again