Background: We investigated therapeutic outcomes of Radium-223 (Ra-223) treatment in patients with metastatic castration-resistant prostate cancer (mCRPC) and bone metastases. Materials and Methods: Outcomes were retrospectively examined in 20 patients starting Ra-223 treatment at a single university hospital from January 2017 to January 2020. Results: Median patient age was 70 years. Median values included prostate specific antigen (PSA) 10. 73 ng/ml, PSA doubling time (PSADT) 3. 7 months, alkaline phosphatase (ALP) 315 IU/L, lactate dehydrogenase (LDH) 186 IU/L, neutrophil-to-lymphocyte ratio (NLR) 2. 22, and Gleason score 9. Extent of disease (EOD) was 3 or more in 55%, and Eastern Cooperative Oncology Group performance status was 0 in 80%. 16 patients (80%) completed Ra-223 treatment. Ra-223 was administered in 11 (55%) with ≤,3 lines of treatment and 9 (45%) with ≥,4. Concomitant drug was enzalutamide and abiraterone in 6 and 7 patients, respectively. Bone modifier agents (BMA) were used in 11 patients. Symptomatic skeletal events (SSE) occurred in 5 patients and were associated with abiraterone combination. BMA during Ra-223 treatment did not affect SSE. Median overall survival from initiation of Ra-223 treatment was 32. 7 months. Prognosis was significantly better with PSADT ≤,3 months, EOD ≤,2, no SSE, no opioid use, and completion of Ra-223 treatment. PSA, LDH, NLR, PSADT, and Ra-223 treatment line after mCRPC were associated with Ra-223 completion. Anemia of Grade 3 occurred in 1 patient. Conclusion: Ra-223 treatment is safe, with good prognosis if completed. Combination treatment with abiraterone during Ra-223 treatment may cause SSE.

Introduction: Orbital metastasis of prostate cancer (PC) is very rare and even more unique in castration-resistant PC (CRPC). In this scenario, choline positron emission tomography/computed tomography (choline PET/CT) is the gold-standard restaging method of choice available in our setting, and new anti-androgens treatments show improvement in overall survival. Case presentation: We report the case of a 69-year-old male patient diagnosed with PC, treated with radical prostatectomy, and salvage radiotherapy after biochemical recurrence. After new prostate-specific antigen (PSA) progression, androgen deprivation therapy (ADT) was started. Four and a half years later, and already labeled as non-metastatic CRPC with a negative extension study, including choline PET/CT, he developed an accidental left frontal head trauma, presenting with proptosis, palpebral oedema, and oculomotor disorder. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a destructive bone lesion in the left orbit, associated with a soft tissue mass. These findings, suggestive of a neoplastic lesion, were histologically confirmed PC metastasis. Treatment was initiated with abiraterone, with a rapid improvement of symptoms, a progressive decrease of PSA, and a significant radiological response. Conclusion: Orbital metastases may present with proptosis and should be considered in patients with a history of cancer. If the ocular-orbital disease is suspected, the nuclear medicine physician should be aware that the choline PET/CT imaging includes the orbits. Tolerability and response to treatment with abiraterone were excellent.

Cancer constitutes a huge burden on societies in countries with any level of economic development. Prostate cancer is the first most diagnosed cancer of men in developed countries and the forth one in developing countries in terms of incidence rate. It is also the third incident cancer of men in Iran along with a prevalence of about 10, 000 cases. Castration-resistant prostate cancer (CRPC) is a severe stage of the disease with a number of newly discovered treatment options. These therapeutic alternatives including abiraterone acetate, enzalutamide, cabazitaxel, immunotherapy with sipuleucel-T, radiopharmaceuticals and bone-targeted therapies (zoledronic acid, denosumab) along with docetaxel have made the decision making process complex and challenging for clinicians. In addition to the challenges of selecting the best-fit treatment, high costs of new pharmaceuticals and technologies necessitates the health policy-makers to develop practice guidelines in adaptation with local resources and limitations. The aim of this paper is to review the clinical guidelines for the management of CRPC. For better comprehension of guideline recommendations, the main clinical trials on new treatments were also identified. The efficacy and safety outcomes including but not limited to overall survival, progression free survival, quality of life and adverse effects were summarized. The guidelines of American Urological Association (AUA), National Comprehensive Cancer Network (NCCN), European Association of Urology (EUA), Spanish Oncology Genitourinary Group (SOGG), Asian Oncology Summit, Saudi Oncology Society-Saudi Urology Association combined guideline, National Institute for Health and Care Excellence (NICE) and Canadian Urological Association-Canadian Urologic Oncology Group (CUA-CUOG) were covered in this paper.