Recent Auxmin and PSMA scans show that my husband has BCR oligometastesis (MRI shows nothing). It seems there are two different treatment options/opinions:
1. Lupron OR Eligard OR Firmagon OR Orgovyx for a few months and then radiation, then continue hormone therapy for 1-1.5 years
2. Lupron OR Eligard + Zytiga for a few months and then radiation, then continue hormone therapy
There seems to be indication that Zytiga causes early hormone resistance. We are a bit concerned.
What's your experience/thoughts on what hormone therapy to take? If it's a combination of Lupron + Zytiga, do you take them simultaneously or do you take Lupron for 1 or 2 months or 3 months and then add Zytiga? What dosage each?
My husband's medical background:
Diagnosed in Dec 2019, Gleason 7 (3+4), PSA 4.5, CT scan: Clear, Bone scan: Clear. 3T MRI showed ECE. Had 6-week proton therapy in June/July 2020. No hormone therapy. PSA went up in March 2022 and did Auxmin and PSMA scans. He has a stent in his heart.
Thanks very much.
Distant Lymph node treatment options?
Radiation or operation with mets and beginning ADT only once symptoms arise?
ADT stop or not
Considering adt vacation 
Hi TCMG and spouse. Where exactly were the oligometastasis sites and how many? If they are lymph node only and located within the pelvis and none beyond, the he should definitely seek attempted curative therapy with IMRT radiation treatments (NOT protons beam) to the entire extended pelvic lymph node fields. With boost dosage targeting the identified nodes. This would be accompanied by ADT for a short term, probably 18-24 months. His choice for ADT should be Firmagon (Degarelix) or oral Orgivox, as these have less cardiovascular risk than the others.
Zytiga + p is a fine AAR drug to add if it is felt needed. It would be my first choice over Xtandi etc. but it may not be necessary for the adjuvant ADT to the pelvic RT described above. However, if there is metastasis beyond the pelvis then adding an AAR drug is important. On that case whether to target the oligomets with SBRT will need to be carefully considered with a good radiation oncologist. My own bias is to go after them if it can be done with reasonable safety.
Thanks for your reply. There are 5 areas of disease that show up in PSMA scan. See detailed findings below. One uptake in prostate, two lymph nodes in pelvic and one cluster slightly above pelvis I think (but RO seems to regard it as if it's in pelvis and is able to target it), one in 6th rib (One RO think it's mets but another RO is not sure).
FINDINGS:
PROSTATE/PROSTATE BED EVALUATION:
Focal uptake in the posterior prostate gland at the apex with max SUV 6.3 (axial 312).
LYMPH NODE EVALUATION:
Multiple prominent PSMA avid retroperitoneal/iliac chain nodes are stable to mildly increased in size compared to prior Axumin PET. For example:
-1.2 x 1.1 cm right common iliac chain node with max SUV 14.4, previously 0.9 x 0.9 cm (axial 264).
-0.9 x 0.6 cm left internal iliac chain node with max SUV 8.9, previously 0.9 x 0.5 cm (axial 268).
-5 mm right distal retroperitoneal retrocaval node with max SUV 5.9 (axial 247).
OSSEOUS STRUCTURES EVALUATION:
Redemonstrated right lateral sixth rib groundglass/sclerotic lesion with focal PSMA avidity of max SUV 4.2 (axial 150).
No additional suspicious lytic or sclerotic osseous lesions.
OTHER VISCERAL FINDINGS:
Head and neck:
Physiologic uptake in the salivary and lacrimal glands.
Thorax:
Unchanged medial left lower lobe tissue/atelectasis with background uptake.
There are no suspicious pulmonary nodules.
No foci of abnormal uptake or pathologically enlarged mediastinal, hilar, or axillary lymphadenopathy.
Gynecomastia is incidentally noted.
Abdomen and pelvis:
Physiologic uptake in the liver, spleen, and bowel.
Physiologic radiotracer clearance is seen in the urinary system, with moderate amount of radiotracer in the bladder.
The gallbladder surgically absent.
The abdominal aorta is normal in caliber.
IMPRESSION:
1. PSMA positive disease in the prostate gland consistent with local recurrence, and within bilateral iliac, and a small distal retroperitoneal lymph nodes, consistent with nodal metastases.
2. Mild focal uptake in a right sixth rib sclerotic lesion is indeterminate, may reflect a benign fibro-osseous lesion however metastasis is difficult to exclude. Prior imaging if available may be helpful for comparison to ensure stability; if no priors are available, consider follow-up.
Thanks for the detail on the report. It seems we are in alignment in suggesting not to think it futile to treat all the LN Mets, whole pelvis extended and prostate. Not diverted because of the equivocal rib finding. Certainly short term ADT will be of value to support the efficacy. And often it has been started a couple of months before the RT. But a recent trial suggests that starting it at the same time as the RT )with Lupron or similar) and NOT adding bicalutamide may provide a therapeutic extra benefit by stimulating the cancer with the androgen flare right as RT is started.
I’m traveling now but will try to find the link for you to discuss with your team.
Here you go:
pubmed.ncbi.nlm.nih.gov/354...
You may be right, but my urologist on the front end said Firmagan had more SEs than Lupron. He proposed starting on Firmagan and switching to Lupron after a month or so. I ultimately saw an MO and started on bicalutamide, then added Lupron three weeks later, then dropped bicalutamide three weeks after that.