HDR Brachytherapy after the 20 fractions?

[Brysonal]

Hi all

I have recently finished 3 x Lu-177 and 3 x Docetaxel infusions whilst hormone sensitive. I have been on Degarelix since November so no idea what's doing what but but my PSA has fallen from 17.6 to 0.19.

STAMPEDE type scans showed I would benefit from radiotherapy to the prostate which I can have in the UK or Finland.

20 fractions of VMAT rapid arc being suggested by both BUR

Finland suggesting HDR Brachytherapy after the 20 fractions and my London MO has strongly advised against this saying this could do more harm than good.

I can't find any evidence of this 'brachy boost' in APC cases.

Does anyone have anything they can point me to here. I had full scans this week which are going to the MDT in London on 5th May but the email from my MO here think the Finland 'brachy boost' is going too far.

Any thoughts would be welcomed. I have had no radiotherapy to the prostate as my primary treatment was HIFU (well Lu-177 x 3 but all agree thats very low radiotherapy). I did have SBRT to T1 and third rib but nothing in the pelvic area.

Regards

[Tall_Allen]

I've never heard of brachy boost therapy as a salvage therapy after HIFU failure. I agree that it is a lot of radiation over hifu-damaged tissues and may cause more harm than good.

[Brysonal in reply to Tall_Allen]

Thank you TA. I have arranged for a call to discuss the plan plus the London MDT have my scans from last week so all on hold atm!

[MateoBeach]

Since you are already metastatic outside the pelvis I don’t see how it could be of benefit to you. Very high risk of severe and irreversible urinary / bladder neck damage with nothing to be gained from brachytherapy-boost in your situation. Just my view for further discussion with your team.

[Brysonal in reply to MateoBeach]

Thank you. Really appreciate the input as bladder damage is so not appealing!

Scans from last week apparently say remaining activity is all pelvic area ( I had PSMA PET and F18.) Multiple mets to the skeleton in Nov of course treated with Degarelix, Lu-177 x 3 and Docetaxel x 3.

I am adding advanced hormone this week as PSA latest is 0.19 ( from 17.6 in November). No idea of course how much of the drop would have occurred on Degarelix alone.

Further discussion with both teams booked in!

[timotur]

I don't see why not since you've not had pelvic radiation, and only done peripheral spot radiation SBRT. HIFU does not preclude followup radiation. If I remember, Stampede suggests primary treatment of the prostate is beneficial even with Stg 4-- confirm that with your RO.

[Brysonal in reply to timotur]

Thank you. I have asked for clarification that it is the ‘brachytherapy boost’ part of the plan he is concerned about as STAMPEDE style radiation to prostate has been in the plan since last November for when I was established on systemic therapy. Stampede style scans were taken that showed I would be in the sun group type who benefitted.

The brachytherapy boost ‘add on’ seems to be Finland/ consultant specific though.

Hoping to get clarification that all agree the stampede style radiation is not the issue.

Appreciate the reply

[CurrentSEO]

Hi,

My RO in Austria where I just finished receiving three Lu-177 infusions said that from observation of his patients who did any type of EBRT to prostate or prostate bed not long before or after Lu-177 had much higher level of side effects in the next two years, especially with kidneys function. My guess that was patients that did EBRT 2-4 months prior or after Lu.

I personally would have waited six months (as you are anyhow on ADT in the meantime) after last Lu-177 infusion till EBRT, I would not do Brachy also.

Good luck with whatever treatment you choose!

[Brysonal in reply to CurrentSEO]

Thank you. Definitely icing this plan until further opinions/ discussions are had.

I am two weeks after last chemo ( 3x Lu-177 and 3x Docetaxel) and 5 months on from multiple skeletal mets and rapidly rising PSA reaching 17.6 before Degarelix pulled it down.

But activity remains though much reduced and PSA of 0.19 is very much detectable as we all know.

Tapering off steriods atm and looking forward to those being done with. I did keep my hair and no impact on nails so can’t complain re chemo impact tbh.

Hate the uncertainty though!

Hope your Lu-177 is being tolerated as well I did.. not even a dry mouth for me.

Good Luck

[Brysonal]

Thank you. Yes another opinion is indeed needed, good to know this appears pretty non standard and aggressive. All on ice whilst MDT in London review scans. They already have my stampede type originals as they were done by my London RO.

Appreciate the teply

[CurrentSEO]

My Lu-177 tolerated good also, thank you! No dry mouth (maybe a bit after 1st infusion) and now back to normal. I did 3-months leuprolide shot 9 days prior third infusion, will do my next PSA test on 11th of May, that will be 1 month after leuprolide shot (testosterone should drop by then to castrate level ) and it will be 3 weeks after 3rd Lu-177 infusion, looking forward for good results🤞

Middle of June will do another FDG and PSMA PET/CT scans plus pelvic MRI and will have consultation in Austria with MO and RO on their views on best way forward. May go for some additional consults with MOs in Florida after that. Still planning to avoid continues ADT for longer than 3 months at a time and do not consider for myself radiation of prostate either. Now a lot will depends on scans and their readers.

I'm glad that you tolerated well Lu and Chemo, now In my opinion you should concentrate on recovering and restoring your body and blood values. Your PSA will continue to go down and 6 months after your last Lu infusion (it is around 3.5 months from now) you can go ahead with EBRT to the prostate if you so inclined. As you are planing to continue staying on ADT, your prostate should shrink further in the next 3.5 months and that may help to reduce side effects of EBRT. You may consider adding Avodart to shrink prostate even more and some say may help to control cancer also (read recent discussions on Avodart on this forum).

If you consider adding second line of hormonal and if you have choice, I would look for either Abirateron or if antiandrogen... then I would only go for darolutamide (do not cross blood-brain barrier, superior on side effects profile and some called third generation antiandrogen).

As you tolerated Lu-177 well, keep on your radar new development of Lu-177 targeting Fibroblast Activation Protein (FAP), it is very promising and in Austria they planning to offer it from August.

I understand about hating the uncertainty, but we need to be able to adjust our treatment plans on the go... based on recent scans and test results, then we avoid disappointment and can act based on recent development. I think bringing PSA to undetectable no matter what should not be your goal, have a long and good quality life should be.

Good luck with your choices and success with your chosen goals!