I am T2N1, Gl9, Post-op RP (10/2019), Recurrence, and now on ADT (Firmagon) awaiting Salvage RT. Met with RO via telemed and reviewed my following questions and responses:
1) Since I am now at >.01 PSA on ADT for 2 months, could I gain anything from a PSMA scan to ID possible hot spots and prioritize these versus General RT of Pelvic bed?
Response: PSMA will not likely show much if anything at that PSA Level.
2) Should we use Hypofractionation to reduce the number of treatments during Covid for the RT?
Response: The studies done have been primarily for intact prostate RT...not post RP patients. He is concerned with possible strictures of the urethra and small bowel injury and would prefer to use the standard SRT protocol (38 sessions). Since I am on ADT...he is ok with waiting up to 6 months to begin the RT due to the present Covid/vaccine situation (that would be mid-April).
3) My URO agreed to 18 months of ADT based on articles I had gleaned from here mentioning that studies showed that result of 18-month treatment had very little difference from 24 and 36-month treatment in life extension.
Response: RO felt again that due to my high-risk situation (positive node in pathology) he would recommend 36 month ADT at a minimum.
I welcome any feedback/observations on the questions/responses.
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JRPnSD
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He's right that salvage hypofractionated RT doesn't have the same level of evidence to recommend it that primary hypofractionated RT does, but during the pandemic, a blue-ribbon panel of experts are recommending it:
3) You and your Uro are mistaken. 18 months is NOT equivalent to 3 yrs of adjuvant ADT for men with positive LNs. There are NO studies that say that.
3 years of adjuvant ADT with a positive LN is ideal. If insurance will approve Zytiga and your RO is willing, I think that is something worth considering.
Re PSMA, I have posted a while back the link to a paper from Italy that assesses the value of a negative such pet scan. In a nutshell, they claim that finding nothing at this stage is an increase in confidence that a blind SRT won't be a waste.
No, that is totally wrong. You are at the begining of the ADT and in cases with other drugs (lutamides) there is an increase of PSMA expression. This is documented. With Firmagon I have not seen anything on either side of increas-decrease. One has to understand probabilities and mainstream doctors either do not or pretend they don't because they don't want to get off the beaten track. You have to find someone that can use this tool,
No intention of offending you or your country, but Germany is 3-5 years ahead of the USA in this field. Consequently, I place more faith in them.
Excerpt from:
"PSMA PET/CT based Lymph Node Atlas for Prostate Cancer Patients Recurring After Primary Treatment: Clinical Implications for Salvage Radiation Therapy".
... Radical prostatectomy (RP) is a successful initial treatment option for patients diagnosed with PC with different prognostic factors (eg, tumor stage [T] and patient’s age). However, approximately 20–40% of patients with clinically localized PC will experience biochemical recurrence (BCR) after RP [2, 3, 4].
In this setting, salvage radiation therapy (SRT) can be a curative approach. The extent of the radiation target volume in SRT is of utmost importance, especially when suspecting nodal involvement.
When the site of recurrence is not known, the Radiation Therapy Oncology Group (RTOG) guidelines [5] for delineation of lymph node (LN) clinical target volume (CTV) is typically used.
In this case, it remains questionable whether all affected LNs are fully covered by the radiation volume. Conventional imaging technologies (computed tomography [CT] and magnetic resonance imaging) have limited potential to detect potential LN involvement reliably [6].
Over the past years, prostate-specific membrane antigen positron emission tomography (PSMA-PET) imaging has emerged as a highly useful tool to localize disease manifestations in PC with a substantial effect on clinical management, especially in cases of low prostate-specific antigen (PSA) values in BCR [7, 8, 9, 10].
A recent meta-analysis showed sensitivity to be 42%, 58%, 76%, and 95% at PSA levels of 0–0.2, 0.2–1, 1–2, and >2 ng/mL, respectively [11].
In a previous study, we investigated typical patterns of PC recurrence after RP for patients with BCR in a smaller cohort and found that almost 40% of patients had positive LNs outside the recommended RTOG target volume [12]. In this study, our aim was to validate these results in a large patient cohort and demonstrate typical patterns of recurrence in a color-coded heat map..."
This means, that if one gets irradiated blindly, there is ~ 40% probability that the only thing he will get out from this, is late RT toxicity. If trying to avoid this is not deemed useful in your logic, I can only rest my case.
Radioisotope-labeled prostate-specific membrane antigen PET/CT is increasingly used for detection of prostate cancer most often in the setting of biochemical recurrence or in primary staging. This report shows increased PSMA expression in lymph node metastases 3 months after initiation of enzalutamide for castration-resistant prostate cancer, whereas lymph node volume and serum prostate-specific antigen decreases over time. This case demonstrates that increasing F-DCFPyL uptake after initiation of androgen deprivation therapy should not be confused with disease progression."
I will take the best scenario in support of your logic, although we all know that this is too good to be true.
a) According to the Italian study, a negative PSMA supports the suspicion that the cancer is still limited to the prostate bed and sRT will have high odds of being successful.
Hence, 25.0 +17.8 = 42.8% will possibly gain from prostate bed irradiation.
b) If all the LN metastases of 2.2. are irradiated, (more optimistic-you die) then
42.8 +22.6 = 65.4% will possibly gain from prostate bed + extended Lymph Node irradiation.
c) The remaining 34.5% of 2.3. have lost the game even before entering the game field. They will only be burdened with late toxicity.
With your medical logic, provided the 42% PSMA detection rate at PSA levels of 0-0.2 is (and I quote you) "very low", the 34.5% of the unfortunate peoplr of the c) group, is even lower and further insignificant.
Just be frank and admit it openly, so readers can assess your point of view.
Sorry- I don't understand your point. Most men with a recurrence after RP should be treated before PSA reaches 0.1. At that point, PSMA PET rarely detects any cancer. You have to treat what you can't see.
No- I am asking you to tell me your understanding of what the status quo is - not what the term "status quo" means. And to tell me how YOU would like to change what you perceive to be the status quo.
It helps, when discussing things, to have a shared understanding.
The status quo has to do with the inertial behaviour of the average person. New tools require acquiring new/further competences, additional or upstart training and possibly contain hidden pitfalls that drive the average person out of his/hers comfort zone. Such persons are the rule and will not surrender easily their ruling to a handful of perfectionists wanting to do something better, easier, faster, more accessible, you name it. They have their routine jobs/practices and are very happy with them.
Personally, I am totally indifferent to changing anything! I want to offer myself the best sRT treatment available, for when I will be needing it. And I will be the sole judge of the content of this best treatment.
I believe this subject has been exhausted, so this a wrap.
You said I was defending the "status quo" about lymph node treatment. I was asking what your understanding is that that is. Your avoiding answering the question leads me to believe you don't have a clear understanding. I think you are posing strawman arguments - a waste of all our time.
You are missing the point that I am not writing to or for you. I already knew that we are totally incompatible and any attempt to converse is indeed a waste of time. But there are third readers of these posts and as the younger around here is in his late forties they can form an opinion of their own. I am posting for them. My arguments and whatever understanding I may have is already laid down. I leave any evaluation to them. Final post, write whatever you like underneath, there will be no responce from my part.
You replied to me specifically, which is why I thought you are writing to me. I hold no such feelings about you. I don't consider any civil discussion to be a "waste of time." I know that patients, perhaps yourself, are confused and distressed. I know I've seen your name before, but I don't recollect anything you've said. If you are as uncommunicative as you've been here, that would explain why I've forgotten.
BTW-You said that before about it being your "final post," yet you keep replying to me. Perhaps you are less sure about whatever opinions you hold than you think you are? Please feel free to question yourself or me - if you are civil.
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