Stereotactic ablative radiotherapy for new recurrent prostate cancer nodule.

[LowT]

Is it reasonable to use Stereotactic ablative radiotherapy for small local recurrent prostate cancer nodule? And if not successful still use SR at a later date?

[tango65]

Yes, it is use all over, if there are 5 or less mets which could be irradiated. There is not evidence that prolongs life but it can prolong the time to radiographic progression.

If the nodes are in the pelvis and there are not distant mets, the direct treatment of the nodes plus ADT and abiraterone for 2 years may be the way to go.

[LowT in reply to tango65]

would cryo ablation be a consideration? It is only one area (described as small nodule in prostate bed) ( six years post RARP).. Could it be local extension as opposed to lymph node? Would that made a difference regarding treatment?

[tango65 in reply to LowT]

If there is not evidence of distant mets, discuss about radiation of the prostate fossa plus whole pelvis radiation and ADT with or without abiraterone.

I had this treatment in 2005 for BCR and I am still around trying to control the beast.

[LowT in reply to tango65]

For me at 81 YO, that would be a response I could live with!!

[EdBar in reply to tango65]

During a recent conversation with Dr. Sartor I mentioned this about it not prolonging life and his response was “where’s the data?” that there is no phase 3 trial showing that, only phase 1 and 2 that suggested it. He is going to be heading up a trial using SBRT that he is pretty excited about that is going to see if it could be a long term strategy. Just passing along…

Ed

[tango65 in reply to EdBar]

Thanks.

[Schwah]

yes good to use but not in lieu of systemic treatment but rather in conjunction with (Lupron Zytega etc)

Schwah

[Tall_Allen]

I'm not sure what you hope to achieve, but there is no evidence that playing whack-a-mole accomplishes anything. In your case, because you've already had ePLND, I'm not sure it is safe - that has to be determined with great care. ADT treatment with a second generation hormonal agent will shrink the cancer in your pelvic lymph nodes.

[pilot52 in reply to Tall_Allen]

I had SBRT after PSMA showed new activity in an old lesion on my scapula. We did decide to hit it. 12 months later I had 6 very small ones which were all meeting the SUV bar for Lu-177. We decided too much micro disease. Off to India. Will know more after PSA testing however we did have good uptake...Considering 2 years ago heavy tumor load , 23 plus advanced lesions. Fortis India has upgraded their Nuclear Medicine Department. New scanners which are impressive. Blue Skies

[GP24]

If you prefer to have no visible met and a lower PSA value, I would get it radiated. This is the usual treatment for this if you want to get it done. See this article: ascopubs.org/doi/full/10.12...

Cryotherapy could work as well but is rather experimental.

[LowT]

Would you push for Bx to assess genomics/biomarkers to help direct therapy decisions? Nodule measures 0.4 x 0.9 cm.

[GP24 in reply to LowT]

I would simply use the prostate tissue gained at RARP. After six years, you can still use them. Biomarkers cannot help with the decision whether to radiate the met though.

[LowT]

what about the mutating ability over time of PCa cells??

[LowT in reply to LowT]

could the GS score of the nodule be different from the initial GS? For example if primary tumor was 3+4, now be 4+4, etc. And would that info be helpful?

[GP24 in reply to LowT]

Every met could mutate differently. However, this applies mainly to genomic markers and not the gleason score. I saw a presentation and that showed that the biopsy probes and the mets did not have different genomic markers in most cases.

[LowT]

Additional information that needs to be taken into consideration in treatment approach:

I was on high dose statin (Pravastatin- lipophilic) for many years, even before PCa Dx. Marked symptoms consistent with low testosterone with T at times as low as 250 and free T running 3 (low normal range of 6.6). Slow rise in PSA over many years prior to PCa Dx.

Short term TRT stopped six years ago due to marked increase in PSA and PCa discovered.

Statin stopped three years ago as symptoms were intolerable and T levels were normal. Symptoms slowly improved. I think the symptoms may have been due to the statin all along.

Stopping the statin resulted rise in cholesterol (150 to 200) and rise in T to 500-700 range. There seemed to be correlation with rising cholesterol level and rising T level after stopping statin.

Rate of rise in uPSA increased last three months which prompted prostate MRI revealing new enhancing prostate bed nodule with uPSA in 0.1 range.

Subsequent PSMA PET/CT did not show the nodule to be PSMA avid which is not surprising given low level of PSA. However, it did reveal incidental finding of opacification of left sphenoid sinus which seemed to be affecting left eye vision. This was recently addressed with surgery for fungus ball. I am mindful of proximity of the spheroid sinus to the pituitary in looking for any type of explanation.

For the past many years FSH and LH have been markedly elevated and even though Testosterone reached 700 they did not decline. I have consulted with several endocrinologists. This remains unexplained.

Also, PRL has been elevated into the mid-twenties with upper end of normal range around 16.

It is my understanding elevation of any of these hormones may be detrimental in clinical setting of many types of cancer, including PCa.

FSH consistently runs 3 x high end of normal range and LH two to two and a half times high end of normal range (even with testosterone of 700).

Short term use of Cabergoline dropped PRL from mid 20s to <1.0. This had to be stopped do to apparent visual effects.

Ironically the lipophilic statin I had taken for so many years may have been slowing growth of the PCa. Its discontinuation may have resulted in removing suppressing effects it may have had. (Maybe by lowering cholesterol)

Prostate Cancer Treatment Centers do not follow these hormones in the treatment of PCa so little to no information in the literature.

I appreciate ANY thoughts on this unusual presentation.

[Healthynurse]

Not sure but I hope it's an option.

[MateoBeach]

This came out just this morning, LowT. Supports repeat use of SBRT for oligo metastatic PC sites identified on PSMA or Flucyclovine PET. Perhaps helpful in charting your path forward to the degree it is applicable. It certainly is encouraging. Paul

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