Lowering tumour burden in metastatic cancer

[CrocodileShoes]

I had a consultation yesterday with a cryotherapy specialist. My situation: after rising PSA (BCR), I had PSMA done 8 months ago. It showed seminal vesicle involvement but no mets, no lymph node involvement. My oncologist and I have been discussing what salvage options might be open. It seems there are few cryotherapists willing to do salvage with SVI. I'm going to Vitus in Germany soon to discuss IRE (with possible Electro chemo therapy). I'll also get an updated MRI soon.

Of course I have to face the possibility that there could well be micro mets floating around. So, my question is this: if we worked on the assumption that micro-mets have occurred, is there still a benefit to having full-gland nano-knife treatment, with electro-chemo? I read somewhere that lowering the tumour burden would lengthen the time before ADT/Chemo regime would be necessary.

My issue is that I still want to keep working for a few more years, which involves lots of travel, so I fear that if I jump straight to Lupron, etc that my working days will be over. Vitus IRE offers few side effects, and they have treated men with quite advanced cancer. But it's expensive, and I wonder if I'd simply be throwing money away. I'm not looking to be cured - just want to kick the can down the road for a few more years yet.

All thoughts gratefully received.

[GP24]

I had SVI after IRE. The doctor at Vitus was unsure if he would be able to locate the seminal vesicle with his ultrasound system to properly treat this with IRE. I guess different doctors at Vitus see no problem.

So I had this done with Cyberknife radiation. I convinced them to put fiducial markers into the seminal vesicle. This was done in a small operation at the university hospital. Then the Cyberknife machine had a good target to radiate. This worked well, the SVI no longer shows up on PSMA PET/CTs. No side effects at all.

[CrocodileShoes in reply to GP24]

Fascinating. Did you get this done in the UK? I'm struggling to find places to do cyberknife on the NHS.

[GP24 in reply to CrocodileShoes]

In the UK you can get Cyberknife radiation at:

Royal Marsden, London

Barts and The London NHS Trust, London

The London Clinic

Cyberknife Center London, Harley Street,

Mount Vernon, Northwood

Queen Elisabeth, Birmingham

I got it done in Cologne.

Placing the fiducials will be payed by NHS, this is standard for radiation. The Cyberknife radiation will cost about as much as an IRE treatment.

[CrocodileShoes in reply to GP24]

And could I ask how you found Vitus? DId Prof Stehling reject IRE for SVI?

[GP24 in reply to CrocodileShoes]

No, it was Dr. Zapf. He did not reject it, he said "I hope I will find it (the SVI)". This made me look for alternatives.

[407ca]

Croc,

I have tried a similar approach with BCR in an attempt to postpone ADT.

My mets were to 4 nodes and srernum which were found with a PSMA scan . I had SBRT to the met sites and TULSA PRO to the prostate area. At 6 month post treatment a bone scan and MRI did not detect any cancer at those sites. Granted others may be there and too small to see. Other cancer is likely drifting around as well but a cure was not expected, postponing ADT was the goal. If I get two years without ADT it will be worth it as I also believe ADT would force me out of work.

Best regards

[CrocodileShoes in reply to 407ca]

Thank you for this. It's very encouraging (though it adds yet more to my research!) As far as I understand it, the Tulsa Pro system is urethral HIFU - is that correct? I don't think it's yet available in the UK. And I was previously told I was unsuitable for HIFU as my disease in the prostate is quite extensive (I think I'd need whole gland treatment). But I'll read some more on it.

[407ca in reply to CrocodileShoes]

Croc,

Tulsa Pro is transuretheral ultrasound (HIFU).

Because it it delivered from the center towards the outside, it can reach all the prostate whereas HIFU is delivered from one side, that being the rectum,entire gland ablation is not always possible. It is done while you are in an MRI so there is real time feedback to monitor temperature. This aids in killing the cancer and also lessens the incidence of collateral damage. Also, the rectum and urethra are protected by active cooling in order to prevent damage.

I live in southeast USA but traveled to Turku, Finland for it at the University of Turku. My biopsy showed 11 of 12 cores positive

with 4+5. It is hard to get much more extensive than that. My whole gland was treated as the cancer was very extensive.

A 6 month post treatment MRI did not find any cancer in the prostate. Yes, there might still be some too tiny to see but that is the case with anything else as well. And, I might have other mets as yet unseen. The bottom line is that I feel I can postpone ADT and keep working for a while longer.

Best regards

[Tall_Allen]

Your title says "metastatic prostate cancer," but you say that scans show no evidence of metastases. SVI is not metastatic.

Why are you not looking to be cured? So, you had IMRT as your first therapy? The best salvage options seem to be HDR brachytherapy to the seminal vesicles or whole gland salvage SBRT. The table here includes IRE, which had high urinary toxicity:

pcnrv.blogspot.com/2017/09/...

I am skeptical of whether cancer ablation in the ablation zone is complete, as discussed here:

pcnrv.blogspot.com/2016/12/...

IRE with direct chemo penetrance into the open pores sounds like a better way of insuring completeness, but there is as yet very little data. It does require full anesthesia with assisted heart/lung function.

[CrocodileShoes in reply to Tall_Allen]

Hi TA,

I didn't list my previous treatments as I was trying to keep it short. I had the triple treatment: Casodex, followed by HDR Brachy, followed by EBRT (low dose) . As it happens my oncologist specialises in HDR brachy, so when I see him next week, I'll be sure to ask about having Brachy to address the SVI. I think he's reluctant, however, to re-apply the Brachy to the whole gland. I share your doubts about thermal focal ablation (especially as my tumours are bilateral and quite widely dispersed) As I understand the IREtreatment however, it's non-thermal and they can do the whole gland. Since I still have some sexual function, I'd be keen to try to preserve it if possible. Incidentally, I looked at the comments to the Brady Urological post. What do you make of the comments suggesting that Gleason 3+4 (my diagnosis) have very little risk of metastases, and therefore dying of PCa?

It's so confusing being a patient!

[Tall_Allen in reply to CrocodileShoes]

Thanks - the background helps. So, given the intensive treatment you had, and I assume the entire seminal vesicles had a full dose, it seems you have a very radioresistant type of PC in your seminal vesicles, which explains why you are looking at ablation now. I didn't suggest whole gland HDR-BT, I wrote "HDR-BT to the seminal vesicles"or whole gland SBRT, but now that you've explained your prior treatment, I doubt that either would work for you.

I think IRE was originally thought to be non-thermal, but it was later found that it is thermal, albeit less so than HIFU, FLA, or cryo:

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

I don't know if PDT is more or less sparing of neurovascular bundles. Perhaps that is an option worth discussing as well. I know that Coleman is investigating it as a primary focal treatment, so if anyone would know, he would.

I don't understand what you mean by "the comments to the Brady Urological post", but I strongly disagree that there is little risk of mets with a GS 3+4. Keep in mind that is entirely different to say that (1) men diagnosed with mets are seldom found to have GS 3+4 at the time of met diagnosis and (2) men originally diagnosed with GS 3+4 and untreated are seldom ever found to have mets. #1 is often true, while #2 isn't. Some believe too that men with GS 3+3 are always safe from mets- this is not true either, as you can read here:

pcnrv.blogspot.com/2017/11/...

[CrocodileShoes in reply to Tall_Allen]

I didn't even know that PDT was used for PCa... I will look that up!

[scarlino]

I have been in Lupron as well as various other hormonal drugs and now chemo. I run my own business so I can’t just walk away but up until chemo I did not find it particularly hard to continue working. I still do just not as much. Of course, all our responses are different, but I wouldn’t assume you have to stop working until you actually start therapy and see how you feel. You may have to adjust your schedule and limit some travel, but I would endeavor to live a normal life as much as possible. Be blessed!

[CrocodileShoes]

Thanks, Scarlino. I hope I can be as resilient as you when the time comes!

[j-o-h-n]

Caution: Don't scuff those shoes kicking the can down the road...

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 11/15/2019 11:35 PM EST