Any benefit to RP given likely extracapsular extension

[mooman80]

My 70 year old father is currently on ADT since March after gleason 9 diagnosis, awaiting IMRT likely starting in June (details in profile). His MRI tests came back showing extracapsular extension and large tumor volume, with likely extension into nearby lymph nodes and seminal vesicles and abutting rectum. Given the MRI results, the surgeons he talked to (Froedtert and Mayo) lean toward just doing radiation but were willing to do the surgery if he wanted.

So I guess the main question is there any benefit in quality of life and long term prognosis in doing the RP understanding salvage radiation is probably a given down the road? Surgeons thought high likelihood of incontinence issues afterward, although he is dealing with some of that after the TURP which caught the cancer. He also was dealing with difficulty urination requiring a cath and bowel issues due to tumor pressure, but this has improved significantly with ADT. Fortunately no sides from ADT so far other than poor sleep.

Dad otherwise in good health. I think a big concern is doing radiation and potentially being struck with a cath the rest of his life. It sounds like once the radiation is done, future surgery is pretty much infeasible.

Thank you!

[Tall_Allen]

I can't imagine why he is even thinking about surgery. It's all downsides and no upsides, especially a terrible idea after a TURP.

There is only one kind of standard therapy he should be considering - brachy boost therapy. This involves whole pelvic radiation with a brachytherapy boost to the prostate and 2-3 years of ADT. He should also have an external beam boost dose to the pelvic LN that is enlarged.

Non-standard, but less risk of urethral stenosis, is SBRT monotherapy. Fairly nearby, he can talk to Arica Hirsch at Advocate Lutheran General Hospital in Chicago. Here are the details of her clinical trial:

clinicaltrials.gov/ct2/show...

I've talked to a few guys who have been treated by her and they all speak glowingly of her.

If he has a local recurrence, he can have focal brachytherapy at the site of the recurrence.

I'm sure he's had a bone scan/CT, but perhaps he should get a PSMA PET scan to rule out distant metastases first. He can get it at UCLA or UCSF. If that is cost-prohibitive (travel+$3000), he should at least have an FDG PET/CT at Froedert.

[mooman80 in reply to Tall_Allen]

Appreciate the response Tall_Allen , that is kind of how I feel. He was onboard the radiation train but I think his urologist put doubt in his mind. He did inquire about brachytherapy with his local RO but he said it was not a good option given the size of his tumor. I'll push him to ask Mayo about brachy when he is there in a couple weeks. He hasn't seemed to get much positive feedback regarding brachy when he has asked locally and at Froedtert. Is it fairly common to be done with aggressive large tumors?

He had standard CT and bone scans that came back clean. Benefit of doing PSMA/FDG PET at this point would be to avoid radiation side effects if it has already spread? Start chemo and hit mets earlier?

[Tall_Allen in reply to mooman80]

I am not talking about brachytherapy. I am talking about brachy BOOST therapy - two different things entirely.

Urologists, and radiation oncologists who don't do it, wouldn't know much about it. It is much more curative for high-risk patients than surgery or IMRT, as you can read in this article:

prostatecancer.news/2018/03...

Mayo is not a good place to go for radiation, only for surgery. There are many that are better. For brachy boost therapy ( which has been around since the 1980s) you have to see an expert. The closest expert I know of would be Brian Moran at the Chicago Prostate Cancer Center. Maybe he can arrange to meet with Arica Hirsch and Brian Moran the same day.

Yes, the purpose of the PSMA PET would be to avoid the side effects of unnecessary treatment. Although, he may want to have at least SBRT to the prostate anyway to avoid future urinary problems.

[mooman80 in reply to Tall_Allen]

Very helpful, I will pass this on to him. Is the brachy boost typically done at the same time as EBRT or is this something he could do shortly afterwards?

I believe he did ask the Froedtert RO specifically about brachy BOOST and she seemed to feel term ADT (2-3 years) with EBRT was on par with EBRT and brachy boost. I don't believe they do it at Froedtert so not too surprising.

[Tall_Allen in reply to mooman80]

They specifically did a randomized clinical trial to compare brachy boost therapy to external beam radiation (both with equal ADT). Brachy boost was far superior:

prostatecancer.news/2017/03...

It should be given with 18 months of ADT:

prostatecancer.news/2020/04...

[tsim in reply to mooman80]

Agree with TA, and run away from Froedtert, cancer treatment is not their thing.

[teacherdude70 in reply to Tall_Allen]

could you explain the difference between brachy boost and HDR brachy?

[Tall_Allen in reply to teacherdude70]

Either HDR brachy or LDR brachy can be given as part of a brachy boost therapy. Brachy boost has 3 elements:

1. EBRT to a wider area

2. Brachytherapy (HDR or LDR) to the prostate itself

3. adjuvant ADT

It should be reserved for unfavorable risk PC because of high risk of urinary side effects. LDR brachy monotherapy is reserved for favorable risk. HDR brachy monotherapy has been used experimentally for high risk because its radiation can extend beyond the prostate capsule (unlike seeds).

[Hidden]

I too was beyond surgery .. The good news for me was imrt and adt put me in a clear status five years now. Does this mean that I’ve conquered it ? . Hell no! But it’s given me a few years in appreciation of what I still have left . I’ve see many men here after an Rp

Going on to every other form of treatment post rp . What was the point of surgery ?

[Justfor_]

In Australia they have an ongoing trial where a PSMA PET/CT is used prior to any primary treatment on high risk cases for better clarity and decision making.

[nonm in reply to Justfor_]

US is falling behind...

[Gemlin_]

If he choose radical prostatectomy, of course with extended pelvic lymph node dissection, potential benefits could be:- avoiding years of ADT (the main benefit in quality of life)

- enabling full pathological staging (reality can be better than what MRI and scans indicate)

- avoiding late adverse effects from radiation therapy.

[rosatt1]

I had same Gleason score and was told to have radiation and ADT. So far so good with PSA down to 0.01. As Tall_Allen states I am told to have 2-3 years of ADT and had an external beam.

[RonnyBaby]

I'm in full agreement with T_As comments and recommendations.

Surgery is a waste of time and dealing with urologists LIMITS the proper treatments he should be planning on and seeking.

They do the TURP of course.

Urologists = surgery - typically end of discussion - damn the torpedos and the elephant in the room.

[dentaltwin in reply to RonnyBaby]

"Fish gotta swim, birds gotta fly..."

[Peppertree602]

I live in MKE and SRQ and go to Froedtert and Moffitt. My MO Kilari said Froedtert is getting their PSMA equipment this July as an FYI. I see Lawton as well just for follow ups basically as a tag team with Moffitt. She is not a boost RO from what I recall

[mooman80 in reply to Peppertree602]

That’s great news, much more convenient than flying to California! I think my dad had his consult with Dr Siker who is an RO and she also indicated boost wasn’t done at Froedtert.

[JWPMP]

HelloMy husband has GL 9. Total prostate involvement, 2 pelvic nodes, seminal Vesicle and getting close to rectal wall. Dr Peter Carrol head of the Prostate Cancer Department of UCSF said not a candidate for surgery ( he is a world renowned urological surgeon). They are doing 24 months ADT. Started January 2021. Will have seed implant at UCSF in June followed by 25 External Beam treatments. His PSA has dropped from 51.3 December 2020 to 0.8 April 2021.

Has a PSMA scan May 10th if there is still enough PSA. Bone Scan and CT scan both clear in November and December.

P.S. My husband had his heart set on surgery...Dr Carroll said absolutely not.

Don't know if this helps.

Thank you

Paula

[teacherdude70]

Look at it this way...Surgeons love surgery. At Gleason 9, psa 20.61 the surgeon said operation after radiation was not possible. I saw the Chief Rad Onco and was told nonsense I have seen him do it. Then she showed me statistics that said my situation the results for either was the same for survival. She also told me that given the extracapsular extension I would need radiation anyway. I had 25 sessions of IGRT and 2 HDR Brachytherapy. While on 24 months of adt. Side effects no bad, pills and shots for erections and a loving wife. Bow 6 yrs later back on adt and very livable. On and rad onco told me I would die with pca not of it. At 73 I feel she is spot on.