My husband is 62, fit, active, but is Gleason 9 (4+5). All 12 cores were positive and he has seminal vesicle invasion and some evidence of extra capsular extension. Thankfully, Pylarify PSMA-Pet scan was clear with no lymph node or bone metastasis. So, he is cT3b N0M0. 2 urologist/surgeons thought surgery wasn't recommended because he would have needed pelvic radiation anyway. One urologist thought the RO would want to do HDR, but after meeting with 2 RO's and an MO, they are suggesting Casodex/Lupron for 2 yrs + Abiraterone + 8 weeks of EBRT. We still need to learn if they are going to radiate the lymph nodes too or just the pelvic area/tumor area. We really thought HDR would be recommended, and I see others on this forum who say they had HDR with seminal vesicle invasion, but both RO's thought it wasn't recommended (and one of them does A LOT of HDR). My husbands case went before the tumor board at UChealth Anchutz Cancer Center in Denver where a variety of docs could chime in about treatment possibilities. Question is... I don't understand why others on this site are getting HDR with seminal vesicle invasion, but these RO's are reluctant? And, does the Casodex/Lupron + Abiraterone (Zytiga) for 2 yrs + 8 weeks of EBRT sound like "enough" treatment for such an aggressive PCa?? Thanks for your help/guidance, I appreciate it.
Should our RO's be doing HDR for Glea... - Advanced Prostate...
Should our RO's be doing HDR for Gleason 9?
Casodex/Lupron + Abiraterone (Zytiga) for 2 yrs + 8 weeks of EBRT is enough. HDR is used to treat the prostate with a higher dose, not the seminal vesicle. If you have an RO with experience with HDR and he does not want to use HDR then trust him. If the PSMA-Pet scan was clear with no lymph nodes affected, you could omit radiating the lymph nodes too. This radiation can cause side effects.
In my case, I have 3/12 cores positive with G 4+5, no seminal vesicle invasion nor ECE, however, I am receiving 3 mo neo-adjuvant ADT (but 2 years total) + HDBT + EBRT. All three scans, MRI, planer bone and Parlify showed no indication of metastasis but they are still irradiating my entire pelvis as a precautionary given the high Gleason score. There are published nomagrams whereby you enter your patient specific data and it will tell you the likelihood of micrometastasis and lymph node invasion. If the values exceed 15%, they will irradiate everything.
HDR-BT is a very good option for t3b +SV. Ten year survival rates for BT are higher than EBRT alone (search NHI studies). For a similar DX, I had HDR with Dr Chang/UCLA with good results, please see profile.
My dad was diagnosed earlier this year with T3bN0M0. He started Eligard in August and was offered a choice of either EBRT or HDR-BT followed by EBRT to treat the surrounding area as a precaution. Both options include ADT for 18-24 months. Both his RO and a second opinion obtained suggested HDR-BT would give him the best results based on the vesicle involvement; however, but having said this, I know every case can be different. I wish you and your husband the best with whatever decision you make!
Whole pelvic EBRT +HDR-BT+18 months of ADT is the SOC for high risk localized PCa. It has been used since the mid-1980s for that purpose. More recently, ROs have tried whole pelvic EBRT monotherapy and boosting the hormone therapy in the hope of lessening side effects. They give some extra dose to known sites of cancer. The results have been very good, as you can see here:
prostatecancer.news/2021/06...
Consider the following clinical trial, which has sites in your area:
clinicaltrials.gov/ct2/show...
With seminal vesicle invasion and GS9, there should not be any question about whole pelvic radiation. You have to treat what you can't see.
Tall_Allen has said much better what I'd try to say - but in radiation oncology - the machines, techniques, and results are changing on what seems to be almost a monthly basis.
It's worth asking the radiation oncologist why he recommends what he's recommending and not including HDR-BT.
It could be he has more current results from current treatments that indicate the path forward for a case like your husband doesn't indicate the need to include BT. The issue with rapidly advancing treatments is it takes 10 years before results are considered for the treatment, and in 10 years lots of new and different treatments have evolved and the results on treatment from 10 years ago may be basically meaningless.
Due to a heart condition I have a slightly elevated risk to anaesthesia. My RO offered a treatment of whole pelvic PBT with an integrated boost to the prostate in place of HDR-BT to boost the prostate (as the latter would entail anaesthesia). Perhaps your RO is offering a similar integrated treatment?
Re-emphasizing: Insist on whole pelvic LN fields SRT in addition to treating the prostate, prostate bed and SVs, whether by EBRT alone or combined with HDR BT.
Has he had genetic testing? This could help find effective treatment options.
I am in my 8th year after G9 diagnosis with extra capsule extension.Had IGRT 25 sessions followed by two HDR brachy sessions. Had casodex for a month before any radiation then two yrs of Lupron. After 18 or so months psa rose to 2. Then Eligard for a bit until psa rose again. Ogolionetastic treatment of one lymph node. Since then monthly Lupron and Nubeqa. Psa <0.02. All good and soon will be 75 and get to keep my shoes on in airports .
Stay positive!
what are HRS sessions?
All good and soon will be 75 and get to keep my shoes on in airports .
just learned this on a trip to Florida, 7 months to go for TSA precheck line
Stay positive!
Typing error. Meant HDR High dose brachy. Sorry. Will fix that
I was DX'd in Sept G9 (4+5), cT1b N0M0, talked to two different urologist and two different RO's. I felt RT was the best option for me. The RT options proposed were 5 weeks of IMRT + 3 yrs of Orgovix or SBRT + 18 months of Lupron. I discussed HDR with both ROs, and neither felt it was needed and would introduce more toxicity (I currently have BPH). I'm going to start SBRT on 11/29. I trust the doctor to prescribe a curative rate of treatment.
In early 2017 had t3bn0m0 as well PSA 22.1 while on finesteride for close to twenty years, so needed to multiply PSA by 2.4 so PSA well over 50. Gleason 7.
Hade the choice of RP or Radiation. Two things tipped me to RP. One just about everything I read said RP gave 15% better chance of survival at my stage and survival was the up most concern. And the second was if you don't get to NED with radiation you might need to have the prostate removed anyway after radiation and that is difficult and only done a certain centers. And then side effects are much more likely.
The plan was to remove and then follow with radiation about six months later.
My PSA was 2.3 six weeks after RP way too high for radiation they said. And canceled radiation.
I had 4 months ADT and then long wait and a number of scans until PC showed on scans at 3.9.
I received two second opinions that said salvage radiation was still recommended. PSMA scan found pelvic spots and I had whole pelvic in 2019. With two years ADT.
PSA began rising after discontinuing ADT in July 2021 and currently waiting for PSA to hit 1.0 or higher for rescan expected in spring 2023.
Having RP gave me seven months of incontinence, and ED.
Radiation is much easier route, but my thought process was life was worth the extra effort. I wanted to know right away not two years down the road. Right or wrong don't know but I am happy knowing its removed and it's not clouding the picture.
In my case Prostate radiation would have required Whole pelvic radiation later as well.
While I was at the hospital waiting for a MRI at my first visit. There were a number of other patients there as well who already had Radiation as their first therapy and then had recurrence and they were there for MRI and planned surgery. Their faces were as concerned as mine.
Their is no choice that is 100 percent sure, it is a gamble either way.
Those are all good options. The nice thing about HDR-BT is that it can reach the seminal vesicles. An HDR-BT boost with whole pelvic IMRT is the "tried and true" method of treating cases like yours, having been used since the mid-1980s. Now, there are many ways of intensifying the dose to the prostate and of intensifying adjuvant hormone therapy. See the table in this article:
prostatecancer.news/2021/06...
But whatever method you choose to irradiate the prostate, seminal vesicles, and a margin around it, you will also need whole pelvic radiation to reach the microscopic cancer in the pelvic lymph nodes. You have to treat what you can't yet see.
prostatecancer.news/2021/08...
The following clinical trial, which is being conducted at the U of Colorado, tests patients for genomic risk using their Decipher score on biopsy tissue. If the genomic risk is high, patients are randomized to get either IMRT+2 yrs of ADT or IMRT + 2yrs of ADT+Erleada. The choice of IMRT is up to you and your doctor.
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