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Page 458 Julka et al. J Transl Genet Genom 2020;4:455-63 I http://dx.doi.org/10.20517/jtgg.2020.46

Figure 1. Baseline CT image (January 2018) showing slightly increased prostate-specific membrane antigen (PSMA) uptake in the base
of urinary bladder and the adjacent prostate along with a large PSMA avid hypodense liver lesion in segment VIII

recapitulates the tumor microenvironment ex vivo. The sensitivity testing was performed as per the priority
list of treatment protocols decided by the attending physician. Option with the highest assigned priority
(Tx1) is considered as physician’s preferred choice. The test uses a proprietary algorithm to generate an
[20]
M-score (0-100), with a score of ≤ 25 predicting non-responders and ≥ 26 predicting responders . Eight
treatment arms were tested including drugs commonly used for prostate/bladder cancer, immunotherapy
and hormone therapy and the M-score ranged between 3 and 71 with the highest score for Tx1 [Figure 2].
Based on the clinical judgement and the information obtained from the CANscript report, a choice of
combination therapy was made, and the patient was started on paclitaxel and carboplatin combination
chemotherapy (Tx1) along with androgen deprivation therapy (ADT), degarelix (Tx4). Paclitaxel and
carboplatin either alone or in combination with hormonal treatment have been used in the treatment of
prostate adenocarcinoma but are not well established for ACC of the prostate. As there was a diagnostic
dilemma followed by therapeutic dilemma of prostate vs. bladder, a combination of platinum (bladder
carcinomas are sensitive to platinums), paclitaxel (approved drug agent for prostate cancer) and GnRH
antagonist (approved for prostate cancer) was used. Post-3 cycles, PET-CT-PSMA demonstrated stable
disease. The size of the liver lesion decreased to 8.0 cm × 5.9 cm along with an increase in necrosis [Figure 3].
Due to poor tolerance, further treatment with chemotherapy was deferred and the patient continued with
maintenance on degarelix. PET-CT post-3 months on degarelix showed a slight increase in size of liver
lesion with an increase in necrosis [Figure 3]. At present, the patient is alive with good performance status
after 16 months (at the time of submission of this manuscript) of follow-up and is on degarelix maintenance
therapy.