When we talk about SBRT for oligo mets - does it mean radiating the met ? or does it mean radiating the met as well as the entire prostate area? Also, how many radiation sessions are done? Asking for my dad who has a single pubic bone met along with multiple lymph node met. He was diagnosed stage 4 with mets so has his prostate intact. Also what are the side effects one experiences with the SBRT? He is currently on Zytiga and prednisone and for a 76 year old man the fatigue and loss of sleep are the major side effects he finds bothersome, along with hot flushes. He is the kind who has avoided taking medicines his entire life, until now. The MO suggested some medicine for sleeping-aid and to lower hot flushes, but he refused. The MO said radiation is pretty well tolerated - with few prostate/urine related side effects for some. So if getting the bone met zapped - the side effects are going to be paramount for him, with no scientific evidence or studies showing it prolongs life/disease progression - should he go for radiation weighing the pros against the cons of quality of life/side effects?
SBRT for oligo mets ?: When we talk... - Advanced Prostate...
SBRT for oligo mets ?
"SBRT for oligo mets" means radiating just the mets you have detected with imaging. This is done in one or up to five radiation sessions. However, doctors will usually refuse to radiate more than three or five mets. They expect invisible mets then which will become visible shortly after the radiation. They will also refuse if the prostate is not treated with surgery or radiation already.
Ok... i am a little confused now - my dad 76 years was dx july 2019 gleason 4+4=8, PSA 114 mets to pubic bone and lymph nodes detected via PSMA pet scan, the prostate was hard and the doc said surgery is not recommended. He has since been on biclautimide and zytiga and pred. last psa was 0.103. When i read studies about treating oligo mets with radiation i discussed the same with his MO since he has only one pubic bone met (lymph node mets are not counted while considering oligo mets is what i learned on this forum and on googling), the MO said radiation to the prostate and the pubic bone met can be considered. Now, in his case his prostate has not been treated with surgery or radiation - so will they refuse to radiate his met? i believe for people dx at a metastatic stage like him the SOC is ADT+hormone therapy and not surgery - so will SBRT for oligo-mets not be applicable to them?
The lymph node mets do count if you want to determine if you are oligometastatic. However, they do not count if you want to decide whether you should radiate the prostate. (Simply put)
I would suggest to start with radiating the prostate. I think your MO did mean standard IMRT radiation for that and not SBRT. SBRT to the prostate is usually not done when there are mets and a Gleason 8. After the prostate is radiated, maybe also the lymph nodes in the pelvis together with that, you can proceed and radiate the bone met. This can be done with SBRT although the IMRT RO will offer to do that too.
The prostate contains the majority of the cancer cells so you should start with radiating that and not with the mets.
Thanks... do read my reply to Tall Allen as some confusion still persists for me. You are right as to the MO suggesting IMRT as he mentioned daily treatments for maybe a month or slightly longer. Have a meeting scheduled with the MO first week of Feb to discuss it and take a referral to an RO. Do the side effect profile vary with SBRT and IMRT? Should we push the RO for one over the other?
It can mean either. Sometimes, we use the term "debulking" to denote that the prostate is being treated. In your father's case, treating the prostate may slow progression and add to his survival:
pcnrv.blogspot.com/2018/09/...
SBRT to the prostate is usually done in 5 sessions.
Getting his bone metastases zapped is sometimes called "metastasis directed therapy" (MDT). There is no proven survival benefit for that, but most bone metastases are in places that can be safely zapped, so why not try it? They can be zapped during the same sessions that the prostate is done, although his RO will probably want to do it separately because he gets reimbursed per session.
The side effects of debulking are the same as the side effects of primary radiation treatment:
pcnrv.blogspot.com/2016/08/...
The side effects of MDT will depend on where the bone metastases are. They may want to do bone metastases in the spine over 3 sessions to reduce the risk of spinal compression. A bone met on a pubic bone can be done in a single large zap. Rib metastases may sometimes be untreatable due to proximity to vital organs.
With a single pubic bone met and other lymph node mets (more than 5) - will my dad be considered oligometastatic? The above post by GP24 says lymph node mets do count in determining if oligometastatic, though i have read contradictory thoughts on this.
The reason i ask is the post shared by you states a survival benefit is there if the men were oligometastatic, but there was no survival in polymetastatic men...so is it prudent to expose him to added side effects of radiation therapy? If there is a survival benefit it makes sense to do it, else it could add to his woes.
However it made a big difference in survival if the men were oligometastatic (1-3 distant metastases). After 37 months median follow-up:
Survival increased by 32% (hazard ratio = 0.68) in 819 oligometastatic men
3 yr survival was 81% with debulking vs 73% without debulking
No survival increase among the 1,120 polymetastatic men (defined as visceral metastases or 4 or more bone metastases with at least 1 outside the axial skeleton)
GP24 is incorrect. STAMPEDE used the CHAARTED definition of oligometastatic - high metastatic burden was defined as four or more bone metastases with one or more outside the vertebral bodies or pelvis, or visceral metastases - all other situations, like your father's, were designated as "low metastatic burden." If his lymph nodes were all pelvic, then all his metastases are locoregional and he would qualify as "low metastatic burden" according to STAMPEDE.
I wrote „However, they [the lymph node mets] do not count if you want to decide whether you should radiate the prostate. (Simply put)“. I was thinking of the STAMPEDE „low burden“ results when I wrote this.
I do not think the CHAARTED and STAMPEDE „low burden“ definition is a definition for an oligometastatic state. Almost all studies I read define oligometastatic counting all mets including lymph nodes. See e.g. these studies:
ascopubs.org/doi/full/10.12...
biblio.ugent.be/publication...
sciencedirect.com/science/a...
There is no standard definition. It is defined by each particular trial. STAMPEDE used the CHAARTED definition. It doesn’t matter what definition other studies use.
Dad's lymph node mets are not locoregional - He is metastatic with mets to 5 distant lymph nodes (enlarged bilateral external iliac, internal iliac, common iliac, paraaortic and interaortocaval lymph nodes) and only 1 bone met on pubic bone.
Everything up through the common iliacs are locoregional. Some ROs would go higher and tresat the other two.
I finished 44 sessions of SBRT in October for one pubis met (turned out to be two) and some funky lymph nodes, all near the prostate itself which also got some photon love.
The MO had noted the STAMPEDE results which said oligo-met cases could expect "significant benefit" from IMRT, though didn't quantify it.
The RO was beaming (no pun intended) at the end of the sessions and pointed to the pictures and used the term "gone." The MO walked into the exam room in our first meeting after the radiation and greeted me with, "You should be celebrating."
I'll celebrate, I guess, when I hit the two-year mark next June and again at three years, if appropriate. This malady is too devious to take lightly and I'm sure there are countless CA outposts in dark places eager for me to let up on the ADT.
Still, it's better than the initial diagnosis of Gleason 8 and maybe 18 months (Zytiga popped up two weeks later, offering maybe another 18).
And as for the IMRT itself, prepping every day for the session by filling my bladder to the bursting point (gives a better shot at the prostate) was a high-wire act. By the end, I felt sunburned in places where the sun never shines. But it's also true that I'm peeing a much straighter stream and getting up only twice at night.
And it gave me a dose of hope, which is, after all, a reason to celebrate.
I think given you had 44 sessions, you had IMRT not SBRT which is usually done in many fewer sessions.
I'm oligo also, 76 yo Gleason 4+4, psa at start 34. Spent a year on double ADT, then IMRT to the prostate and prostate bed, then SBRT to bone met. Scan is clean. Now undetectable. Nutrition, exercise a must. Had difficulty with insurance but that is behind me. Write if you have any questions. Best to you and your father. Follow Tall Allen advice. Bob
Pain post SBRT
SBRT , successes , side effects 
Divergent second opinion
