To recap my previous two posts: I was treated with seeds and external beam in 2006. Although it took several years, my PSA finally dropped to < 0.1. It stayed at 0.1 for several years. It started rising three years ago. In August it was at 3.1.
On 9/10, I had an Axumin scan. I am enrolled in a trial for rhPSMA scan to be done on 10/23. On 9/21, I had a consult with a radiation oncologist to see if I qualified for the trial. At that meeting, he gave me some great news. The Axumin shows the only cancer is in the center of the prostate. Organ confined. No nodal involvement. He said he expects the PSMA to show the same.
His first suggestion is that we do a biopsy. Although my original cancer was Gleason 3+4, he said it's possible this is 3+3. Then maybe we could do AS and postpone or never do additional treatment.
Then he reviewed some of my treatment options, barring any surprises from the PSMA. His specialty is HDR brachy and he suggested that first. This hospital offers proton beam so he mentioned that. I then asked about SBRT. He said that was an option, but not his favorite. Then he mentioned FLA or ultrasound or cryo. He said his understanding was most men who do cryo become impotent.
As he is recommending his own specialty, I fear he suffers from the hammer syndrome (when the only tool you have is a hammer, everything looks like a nail.) Since he did not inquire about the dosimetry of my radiation in 2006, it concerns me. I am fearful of any additional radiation. My RO in 2006 told me I could not have any additional radiation to the prostate bed. Does that change over 14 years?
My inclination, if its organ confined, is to go with ultrasound. One of the four Tulsa Pro treatment clinics in very near me. Another option is FLA. I have some concerns about that because I believe it is done transrectal. My original RO told me to always tell a doctor when I have a colonoscopy "Don't biopsy the anterior rectal wall." I think he mentioned fistula. I worry that anything done transrectal (including a biopsy) could become a problem. Since the Tulsa is ultrasound delivered through the urethra, it seems safer for my situation.
I would appreciate any input or suggestions on my situation.
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LeeLiam
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What he is talking about is FOCAL brachytherapy. That certainly has the best outcomes to recommend it - lowest recurrence rates and lowest rates of side effects, as you can see in the chart here:
With focal brachytherapy, the risk of cumulative radiation damage is minimized. (in fact, sometimes boost doses are given to sites on large prostate tumors even with primary therapy).
The high recurrence rates when focal thermal ablation (HIFU, TULSA) is used is a result of incomplete ablation ablation in the ablation zone. I know it seems like thermal ablation should destroy the cancer entirely, but because of various protective mechanisms, it doesn't. See the sections on the heat sink effect and biochemical effects in the article below:
With treatment of the center of your prostate, there is a risk of urethral stenosis from every salvage therapy, but particularly from the thermal ablative ones.
TA, thanks for the links. Like everyone here I really appreciate your thoughtful input. I read the posts for both links. However, I think both are treating HIFU and TULSA as being more similar than they really are. Although both use ultrasound, the delivery is entirely different. TULSA is delivered through the urethra, not the rectum. In addition, TULSA uses a cooling device in the rectum to protect the rectum and the nerve bundles from the heat. Also, the applicator inserted into the urethra has a cooling system to protect the urethra from heat. While recurrence rate might be slightly higher than HDR, unlike HDR the TULSA can be repeated. Also, TULSA does not preclude other treatment later. I also like the idea the treatment can be completed in one day as an out-patient.
Did you read those sections that I referenced? Those effects are independent of how the energy is delivered. Ultrasound (whether HIFU or TULSA) just has a lower cell kill rate.
Focal salvage HDR BT is a one day out patient treatment as well.
BTW- the differential effects of HIFU and TULSA you mention have everything to do with toxicity and nothing to do with cell kill. You seem to be parroting their promotional literature instead of thinking through how it applies to you, or doesn't. With treatment of the central zone, rectal injury and injury to neurovascular bundles are not a concern. Cooling the urethra can help, but it will not entirely prevent injury when the central zone is the target. Focal HDR brachy will not entirely prevent urethral injury either. You should expect that from any central zone treatment.
With Focal TULSA, they are relying on MRI to delineate the treatment zone. This will miss around 80% of the cancer.
Because of the heat sink effect, even if they leave a large margin, the margin will have sub-lethal damage. With HDR brachy the margin receives the full dose.
As for retreatment, I don't know how much thermal injury that part of the urethra can take. But I think it is a mistake to go into any treatment with the idea that it may be salvageable. One is always better off with less salvage.
Just so you understand just how poor TULSA is at killing cancer, here are the results from a recent study where the whole gland was ablated with TULSA. There was a 35% recurrence rate.
Keep an open mind to HDR-BT as it’s very precise in dose admin and coverage, and you could probably do mono-therapy with no ADT. Search this forum for BT and you’ll find a lot of good results. Tulsa seems to have good results for low Gleason tumors, but it probably needs more long-term studies to compare its effectiveness to BT.
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