Radiotherapy for Oligometastatic Pros... - Advanced Prostate...

Advanced Prostate Cancer
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Radiotherapy for Oligometastatic Prostate Cancer

Interesting discussion for those with few mets.

From: European Society of Medical Oncology (ESMO) 2018 Annual Meeting, Munich, Germany; 19-23 October.

{Noel Clarke has been a consultant urologist at Salford Royal Hospital and The Christie, Manchester, since 1993 and was made honorary professor of urological oncology by Manchester University in 1997. His specialist expertise is in prostate, bladder, renal and testis cancer and complex pelvic and retroperitoneal malignancy. Professor Clarke is a former director of urology at both Salford and The Christie, and Chair of the Manchester and Cheshire clinical study group (CSG) and National Cancer Research Institute prostate CSG. He is currently director of Manchester University’s Genitourinary Cancer Research Group, a member of the Department of Health and National Cancer Research Network prostate cancer advisory boards, chair of the European Organisation for Research and Treatment of Cancer prostate disease group and author of over 150 publications, including eight book chapters on urological cancer. Professor Clarke has planned and managed multiple trials in the UK and Europe and given various national and international guest lectures on urological cancer.}

-Patrick

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Burnett1948.I have just finished 25 shots of spot radiation for a lymph node 13x9 picked up by a PSMA Pet scan. I watched this presentation and I believe I heard that the Pet scan would not pick up bone mets and the second Englishman said: I think, I need to have a bone scan. Did I hear correctly?

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According to the data, men with oligometastatic disease, as determined using "classic imaging", benefited from treatment. There is no advantage in using more advanced imaging when counting mets, since that merely serves to exclude men from useful treatment.

To be accepted for oligometastatic radiation, doctors should use the criteria of the trial, which is based on classic imaging, & ignore PSMA results.

(That's what I got from it.)

-Patrick

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Patrick

Seems odd that classic imaging is all that’s required to define oligomets. I’ve had oligomets three times on bcr : 2 iliac nodes imaged by MRI in 2015; one femur met imaged by axumin in 2017; and two bone mets , one in rib and one in scapula just last month imaged by PSMA scan. The last two mets weren’t seen by standard bone scan so under that criteria I had no mets! Meanwhile I’ve had (will have) all successfully treated with radiation .

Bob

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Bob,

While it seems prudent to zap all oligo mets, the implication is that the ones you can see via classic imaging have the greatest near-term lethal potential.

The message to the group, though, is to not over-detect mets if you hope to receive oligometastatic therapy.

-Patrick

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Patrick:

That’s an interesting way to look at it. I must say that it was not fun (a) flying across country incurring hotel, airfare and local transportation expenses, b) paying $875 for the PSMA tracer and (c) going through the tedious scan process.

If in fact nothing is gained by locating mets sooner , these new scans are not worth the trouble.

I was under the impression that finding and killing mets ASAP was important and extended life particularly for guys with fast Psa doubling time like me (two months).

What’s your take on the issue of locating mets ASAP for high risk guys?

Bob

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Bob,

Your question brings to mind the issue of PCa screening in the U.S., where countless men have been overtreated during the PSA era. Ideally, imaging for mets should report only those where there is some benefit from immediate treatment.

Not sure how I would handle the information if I suddenly learned of the presence & location of even the smallest met. Could drive one crazy - just like the Gleason 3+3 guys who demand treatment.

Instinctively, one expects survival benefit from having oligo mets treated. That was my belief almost 5 years ago when I found someone to radiate a lesion at L5. The radiologist pointed out that there were no studies to prove a survival advantage. I'm still here, although that's not proof.

As with my attitude towards supplements, when it looks as though one is at the wrong end of the mortality bellcurve, that's not the time to wait patiently for scientific proof.

-Patrick

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Some oncologists who treat Oligometastatic disease are using whack-a-mole, errr zap-a-met, as the first line of attack. They will hold back on standard-of-care (systemic / adt) and wait a bit for the mets to grow before SBRTing them...for a lot of oligo recurrent guys post RP, “controlling” the disease by way of today’s advanced radiation, some oncs believe, is a better way to go than intermittent ADT or systemic treatment. All of this, of course, depends on the size of the met, how many there are, psa level - my anecdotal understanding is limited to very low psa post rp guys who generally have been off adt and have one or two mets that pop on imaging after being undetectable for a few years.

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My MO at Dana Farber SBRTed the one hip met detected by the PSMA pet scan (Johns Hopkins) AND started me on ADT. He said not to ignore the systemic. We know that works... for a while.

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Patrick

I get what you think they’re saying and it’s admirable that the criteria used (classic scanning) is affordable by the majority.

But new scanning technologies can’t be ignored if it’s possible they confer more of a benefit .

Trials are needed to determine if it’s the case .

Bob

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This is another recent rticle about about RT treatment of oligometastastic hormone sensitive PC. It seems it works for a while. Oligomets were 3 or less identified by PSMA PET/CT.

Practically all patients had a decrease of the PSA and about 50% maintained a PFS by 90 weeks.(more than 1 and half year) if I understood the graph correctly.

urotoday.com/conference-hig...

This is the results of the STOMP trial:

ascopubs.org/doi/10.1200/JC...

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Thanks Tango but neither link worked. Please double check and re post Links. Thx

Schwah

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I edit the post with the correct links. Thanks for letting me know.

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"Oligomets were 3 or less identified by PSMA PET/CT."

Sorry, I have to say this in not correct. The STOMP trial used Cholin PET/CT to determine the number of mets. The ORIOLE trial used CT/Bone Scan plus the PSMA/CT to "to assess the utility of this imaging test in identifying oligometastases"

ncbi.nlm.nih.gov/pmc/articl...

So it is mainly based on CT/Bone Scan.

3 mets on a Cholin PET or even bone scan will usually result in five or more on a PSMA PET/CT scan.

The results of these trials are based on classifying the patients with less sensitive imaging. You exclude too many patients from metastasis directed therapy if you use a PSMA PET/CT.

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Professor Clarke was my urologist and did my biopsy etc. Not watched the video but on the advice of my oncologist I have just had 20 rounds of radiotherapy to my prostate as I have oligometastatic prostate cancer.

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If you had RT to the prostate it’s not considered metastatic. Only cancer outside the original tumor is considered metastatic and even mets in the pelvis are considered local advanced. Twenty sessions is a lot if sbrt was used implying more than seven lesions which is more than oligometastatic.

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I have a lesion on my L3 vertebrae and was diagnosed as T3 N1 M1. Are you saying this is not metastatic?

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Yes that would be considered metastatic but you didn’t mention that you had mets in lymph nodes and spine. Sorry to hear that. But I had mets in two pelvic nodes back in ‘15 which were eradicated but with 50 sessions of IMRT to ALL pelvic lymph nodes. Did you have SBRT to all pelvic nodes and the vertebra?

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I just watched it twice. Can you please give us dummies a down an dirty summary of what they are saying in a language the rest of us can easily follow ? Greatly appreciated!!

Schwah

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Thank you

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See my response to Burnett1948. -Patrick

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See my response to Burnett1948. -Patrick

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I am having five stereotactic radiation fractions on a pelvic lymph node seen on a PSMA PET scan but not on CT.

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Thank you!

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Burnett1948. Thanks pjoshea13. I have a question or 2. What defines “Oligometasis”. My Radiation Oncologist told me my one lymph node constitute “Oligometasis”. I am yet to have hormone or .

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If you look up the definition of oligometastasis you will see that it is evolving but Uses the number of Mets and their locations outside of the prostate area.

Because the advanced scans are exposing so many more Mets the technology is upsetting previous standard of care which cannot keep up with available scan technology.

Also exposing too many Mets may cause one to be excluded from various trials that require three or fewer Mets.

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Burnett1948.Thanks mjbach. I think I’m asking to many questions. But at the same time I understand I think.

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There is a 2 year old chart in a journal article that summarized each major hospital’s definition of oligometastatic - some use 3 or less mets including nodes, some 4, some 5, some up to 6 or 7. That was then, this is now, definition keeps moving.

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Clarke and James say that the CHAARTED trial results as well as the results of the other trials mentioned indicate a threshold of four bone mets based on CT/bone scan. If there are four bone mets or more, early chemo with docetaxel, or adding Abiraterone to ADT, or radiating the prostate in addition to ADT, provides a clear benefit. But these trial results are based on bone scan. If you determine four or more bone mets with a PSMA PET/CT this has to be ignored. You have to use a bone scan instead or you are not applying the results of these trials correctly.

I have to say you will not find a doctor who will apply this logic to his practice. If you tell him there are four bone mets on a PSMA PET/CT he will recommend chemo etc and not tell you to ignore the PSMA PET/CT and get a bone scan instead to decide - as Clarke and James recommend.

If you get a PSMA PET/CT before surgery, it will often show a few lymph node mets that would go undetected with CT/bone scan. If the surgeon knows there are lymph node mets he may refuse surgery and recommend ADT instead. Otherwise you would get your operation, a rising PSA value after that, then salvage radiation and, if this RT did not include the pelvic lymph nodes, a rising PSA value after RT that will be treated with ADT.

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