After posting questions on ADT options for BCR oligometastasis, we have new development/input from RO and MO which makes us delay starting hormone therapy now. We would really appreciate members' input and advice so that we can make informed decision.
Brief background, my husband was diagnosed in Dec 2019, Gleason 7 (3+4), PSA 4.5, CT scan: Clear, Bone scan: Clear. MRI with coil showed ECE. Had 6-week proton therapy in June/July 2020. No hormone therapy. PSA went up in March 2022. Did 3T MRI in April and nothing showed up. Did Auxmin and PSMA scans and found one uptake in prostate, two lymph nodes in pelvic, a cluster of 3 slightly above pelvic and one suspicious uptake on 6th rib.
(The below questions are focusing on local recurrence in prostate only).
Had several discussions with ROs and MOs. The suggested treatment options for local recurrence in prostate are Cryotherapy or HIFU or Tulsa Pro or Brachytherapy. However, nobody referred us to any of the specialists or mentioned what additional diagnostic things we need to do before starting hormone therapy. We had hoped that starting hormone therapy now will slow down disease progress and buy us time to investigate those options.
However, the third RO just told us that we need to do coil MRI and biopsy of that uptake in prostate. Due to scheduling issue, it will take at least 2-3 months to get coil MRI and biopsy done and we can't start hormone therapy until these are done. Meanwhile PSA is rising and we are concerned of delaying hormone therapy.
So the questions are:
1. Do Cryotherapy or HIFU or Tulsa Pro or Brachytherapy really need biopsy result to plan for treatment? Is coil MRI enough to plan/map for these treatments?
2. If coil MRI shows nothing like the 3T MRI we did in April, can these treatments be planned and mapped based on Auxmin and PSMA results only?
3. Can biopsy be done after proton radiation? What are the risks?
4. If we don't do any of the above-mentioned treatments this time and hope the 18-month hormone therapy will be effective, and if the cancer recurs in the future, can we do coil MRI then? Will having hormone therapy affect the accuracy of MRI? Can we still do the above-mentioned treatments?
5. Do we have time to wait and start hormone therapy later until coil MRI and biopsy are done in 2-3 months? Will waiting cause the current PSMA inaccurate for radiation planning/mapping, i.e. will there be more uptakes in 2-3 months if we don't start hormone therapy now? His recent PSA are:
16 Oct 2021 2.04
3 Mar 2022 3.8
16 May 2022 5.26
6. Any recommendations of specialists of cryotherapy, HIFU, Tulsa Pro or brachytherapy? We live in Oregon and will consider travelling to other states if necessary.
Thank you all so much.
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TCMG
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I agree with the doctor who advises a prostate biopsy. The radiotracers of the PET scans are excreted urinarily, making a strong possibility for false positives - a biopsy is the only way to know for sure. It is important that the radiologist reading the biopsy has experience with previously irradiated tissue. As always, Epstein's opinion is best.
Of the salvage focal therapies you mentioned, brachytherapy, and particularly high dose rate brachytherapy, would be my first choice. You can see why in the table at the end of this article:
After reviewing a lot of studies on focal thermal ablation (like HIFU, Tulsa-Pro and Cryo) I don't believe they do a good job at eradicating cancer in the ablation zone.
But the prostate itself is a relatively minor issue compared to the lymph node metastases. That, not salvage of the prostate, should be your first priority. Cure will require whole pelvic external beam radiation to the recently expanded dimensions of the entire pelvic lymph node area. This would be accompanied by 2 years of ADT. Some are experimenting with adding a second line hormonal (like Zytiga) too. They can also add a boost dose of radiation to those sites identified as cancer on the PET scan. It is possible to also boost the dose to the suspicious areas of the prostate, especially if they are found to be positive on a biopsy.
Not only PSMA PET scan shows uptake but earlier Auxmin scan shows uptake too. Are you saying both scans can be false positive?
Do you have any recommendation of doctors who specialise in brachytherapy? Can you please provide a few names?
Why do you say prostate is a minor issue? Is prostate not a rootcause of this disease? If you don't treat the rootcause, what's the point of treating other mets?
Since LN are oligo, why radiate the whole pelvic area? Why not spot radiate the LN only? Do you have any links to studies that show it's more effective to treat the whole pelvic area?
Are you saying both scans can be false positive? How high was the SUV max each time?
Do you have any recommendation of doctors who specialise in brachytherapy? Can you please provide a few names?
Joe Hsu at UCSF or Mitch Kamrava at UCLA
Why do you say prostate is a minor issue? Is prostate not a rootcause of this disease? If you don't treat the rootcause, what's the point of treating other mets?
Because they are metastases and the prostate isn't. Metastases are metastases because they travel and spread easily. You didn't say how much uptake was in the prostate. If low, they may be false positives because the radiotracers are urinarily excreted. A biopsy will tell you for sure. If positive, treat both but the lymph nodes are more dangerous.
Since LN are oligo, why radiate the whole pelvic area? Why not spot radiate the LN only? Do you have any links to studies that show it's more effective to treat the whole pelvic area?
You are making the common mistake of believing that what you can see on a PET scan is all there is. PET scans can only see reliably see metastases larger than about 5 mm, which represents tens of millions of metastatic cells. There are many more where that came from. NRG Oncology recently expanded the treatment zone:
There is a clinical trial with Ga 68 PSMA 1007 PET/CT which can identify the lesions in the prostate and in the lymph nodes. This ligand is not excreted in the urine like the PSMA 11 or the Pylarify and it can visualize the cancer in the prostate.
Thanks for your advice. Can you provide any names of RO who have successfully and skillfully done the SBRT to the radiated prostate? All ROs we have spoken to won't do it and/or think it's impossible to re-radiate it.
You cannot reasonably craft a strategy for prostate only BCR when you already know he has lymph node metastasis I’m the pelvis and a cluster beyond. The rib lesion notwithstanding. You are going down a rabbit hole that does not in any way apply to him it seems to me. See my precious posts to you. No head on the sand approach. Sorry if I sound harsh I don’t trust those other heavily marketed technologies either. Including proton beam when applied to prostate cancer (the z Bragg peak is not reliable within the pelvis.)
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