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Advanced Prostate Cancer
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ADT Holiday to Locate and Zap Metastases?

My RO has suggested I might wish to consider an ADT holiday and then, when PSA reaches a sufficient level (1.7?), doing an axumin scan. If there are no bone or non-lymph visceral mets, then radiate the pelvic lymph nodes. This was in response to my question about maybe just radiating them now.

I will be talking with other ROS, and I have read the post by Tall Allen stating “the benefit of salvage whole pelvic treatment and ADT was not maintained in men with very low PSA” and the related study.

History: PSA 5.3, RP 2009 Gleason 3+4, Biochemical failure PSA 0.66 and SRT 2012–no benefit, Radboud nano-iron MRI July 2014 nine lymph nodes 4-9 mm in left para-aortic and common iliac, PSA 2.77, Feb/Mar 2015 IMRT and 4 months degarelix–PSA reached undetectable, degarelix wore off in Oct. 2015, PSA 3.64 and resumed degarelix Dec 2016, PSA 0.02 June 2017 and every time thereafter, switched to lupron Aug 2018.

What do you all think about this plan?

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In your case, you already know for certain that you have cancerous lymph nodes all the way up to the para-aortics. RTOG 0534 (which you quote) did not include men in this situation. (They also did not treat the common iliacs or the para-aortics). I think it may be curative to treat the entire pelvic field, including the common iliacs and the para-aortics, with perhaps a boost dose to those known ones.

I think the USPIO MRI you already had is far better at detecting cancerous lymph nodes than the Axumin/CT you are considering. I think that coming off ADT when you know you have cancerous LNs is risky, and may enable spread, and I see no advantage over treating them now.

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My MO thinks any treatments besides Lupron before PSA reaches 2 is of no value.

What type of Radiation therapy would be used on pelvic lymph nodes, IMRT.

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You would have to talk to a Radiation oncologist to get a more informed opinion. Yes, IMRT would be used on the pelvic LNs.

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Appreciate the info

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Many thanks, your wisdom is greatly appreciated. Now for some consultations.

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My MO, a very well respected doctor from what I hear don’t think treating oligometastatic is of benefit and suggested start of ADT

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This is about oligo-metastatic cancers not only prostate cancer. It shows a survival advantage when metastasis are treated with SBRT.

ascopost.com/News/59410

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Here is the conclusion from the article:

“But overall, for patients whose cancers have spread, and who are not expected to survive otherwise, the overall survival benefit of SABR appear to outweigh these risks,” said Dr. Palma.”

The question is: is it worth it?

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IMO it is worth it, because one can delay the use of other proven therapies. For people with MCRPC once chemo, and the new anti androges and lutetium 177 PSMA fail, there are not other treatments. If SBRT can delay using those therapies it could prolong life.

I am on Lupron and my PSA is increasing. The plan is to get a Ga 68 PSMA when the PSA is around 0.5 to 1 and if there are metastasis to treat them with SBRT or with Lu 177 PSMA. I consulted about this at the MSKCC and Dr. Morris agrees with this approach.

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There is a stereotactic radiation trial at NCI...I had one lytic bone lesion and got treated--f/u next month...a recent study--Phase2-- by Dr. Heron at UPMC showed benefit from tx of oligometastatic disease...

sciencedaily.com/releases/2...

Fish

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Hi tall Allen

I have six Mets that are clearly defined on my scans.

One on each hip bone two on my spine and one each on a rib. I too am very interested in radiation treatments to see if we can get rid of these mets. I am currently only on casodex not any form of ADT

what does everybody think should I have these done before going on ADT or go on ADT first. My PSA has been very steady at 1.5 the last 6 months. never any higher than that since on casodex for 6 years.

Thanks so much for your thoughts

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There is probably no point in irradiating all those bone mets. Your cancer is systemic and there is no data showing that such treatment accomplishes much. I'm not saying that it is completely futile, just that you should have reasonable expectations. There may be some benefit in preventing spinal compression and future fractures. Talk to a radiation oncologist to see what is safe.

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your numbers aren't even high enough to treat. so take a 6 month relaxation and then see what they are

charlie

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I interpreted that you already had IMRT to all pelvic lymph nodes in 2015, no? If not what did you have done then?

Read my profile. I had 75 grays of low dose IMRT to all pelvic lymph nodes plus 13 months of ADT3 in 15. No recurrence .

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Sorry, I was not clear. The SRT was only the prostate bed.

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You said you had SRT in 12 and IMRT in 15 . What was zapped in 15?

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Para-aortic and common iliac lymph nodes

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It’s hard to understand why all pelvic lymph nodes weren’t done. Why not?

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Don't know, and now the horse is out of the barn.

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The horse would probably be out of the barn anyway but not in your lymph nodes.

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Break60,

I read you profile -- If I understand -- you are saying that you had no recurrence in the prostate bed and lymph nodes area.

It looks like you have had several SBRT treatments since the initial salvage RT to prostate bed shortly after RP in 2015 and later to the pelvic lymph nodes in 2017.

This is my dilemma -- several MO have said it is likely "the horse is out of the barn" -(post pathology micro mets in 4 of 10 lymph nodes) - They said just wait till PET/CT scan show mets which could be 7 or 8 years and then SBRT to areas. The study evidence shows that IMRT to to lymph nodes after early BCF with low PSA didn't improve outcomes. (I would guess low PSA was something below .5 -- the study range was 0.1 to 2.0) That does seem counter intuitive. They let it grow a while and then it helps?

It looks like fairly shortly after your salvage RT and later lymph node RT it came back anyway?

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George71

My profile shows precisely my BCRs and tx. You’re right I did have BCR every time I went on ADT holiday and my PSA doubling time was 2-3 months. I never let PSA get too high before having a scan. The highest was 2.2. So my PCa is aggressive which is not surprising given my pathology post RP. At least it’s low volume: Never more than two visible mets were visible . And I’ve never had recurrence in any area treated.

I must admit that IMRT to all pelvic lymph nodes in 2015 was very tedious. 50 days and living in a rented condo. SBRT is a heck of a lot better if it can be done safely and pelvic lymph nodes are not an area that can be radiated with high dose SBRT. Too many adjacent organs in a large area.

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Thanks for the feed back.. Did you have any side effects from the pelvic lymp node and prostate bed radiation? --- thanks and good luck ..

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I had rectal bleeding after SRT to prostate bed but no SEs from lymph nodes. I used a very experienced RO for the nodes but the RO used for SRT was not so much. No SEs from SBRT.

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thanks -- It looks like you are whipping it down ! i'm pulling for you. I just read the post on BAT -- it is an encouraging option --if ADT begins to fail ... the goal is to slow it down to a crawl, that is the same as not having it.

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I switched to estradiol patches from Lupron . Sick of Lupron .

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George 71: Do you have a reference for the study (not doubting you, just want to get all the details as I consult with ROs). "The study evidence shows that IMRT to to lymph nodes after early BCF with low PSA didn't improve outcomes."

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cigafred,

I don't have the study we were discussing at the time -- it was a small study that divided the patients into 4 groups as I recall. group one was people with PSA of 0.1 to 0.5 group two included patients with PSA >0.5 to 1.0 group three was >1.0 to 1.5 and group four was PSA >1.5 to 2.0 --- the study stated that all groups benefited except the people with the lowest PSA's. It did not specify exactly --- so I would surmise that it had to be .1 and .2 but not much more. I commented that is seems counter intuitive -- how could waiting till it goes to 0.4 or 0.5 and then it will benefit? It doesn't make sense but apparently that is what the results showed and they reported. .

With that said, the problem with jumping straight to SRT at 0.1 is there is a 45% chance ones PSA may go up to as high as 0.4 and stop with no treatment. Also the chance of late, permanent GU/GI side effects are higher with SRT post surgery (less body tissue between colon and bladder -- they are more exposed.

Each of us must decide for our self when or if we should go for the SRT

"The definition of BcF after RP has been a matter of debate. The American Urological Association and the European Association of Urology designate it as a PSA level of 0.2 ng/ml or higher, with a second confirmatory value of >0.2 ng/ml (27–29). The use of a too low PSA threshold for SRT involves the risk of over-treating patients. Some investigators have described that ≤50% of patients with a single PSA elevation <0.4 ng/ml after RP may be regarded as having stable non-progressive disease. This is based on the assumption that residual benign prostatic tissue might be responsible for the rise in PSA (16,30). However, recent data suggest that residual benign prostatic elements after RP are an unlikely source of elevated PSA (31), a finding which has led to a decision to administer early SRT at our institute."

spandidos-publications.com/...

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