Spinal metastases are tricky. They can cause pain and spinal compression. But radiation of them isn't without risk either. There are no clear answers. Here's what we know so far:
prostatecancer.news/2022/12...
Treatment has to be approached on an individual basis, sometimes with a neurological consult.
This would make the case to get a scan even if you have your PSA under control.
Thanks TA for all of your knowledge.
Here's another view: medpagetoday.com/meetingcov...
That's not another view. That was dealt with in the article.
The situation could be different if the mets are diagnosed earlier using PSMA PET/CTs and SBRT is performed before mets are seen in MRI studies.
No evidence for that. The retrospective evidence is against that.
I may be wrong. but none of the studies you mentioned in your blog
prostatecancer.news/2022/12...
had patients studied with PSMA PET/CTs with early diagnosis of spinal mets done with this technique. The retrospective evidence does not have patients diagnosed early with PSMA PET/CTs.
The study at Mayo covered all patients treated with MDT from 2009-2013, which was well before PSMA PET scans became available. However, all had their oligorecurrent metastases detected via C-11 Choline PET/CT, which was the most sensitive available at the time. So they were indeed all detected early.
With Choline PET/CT these mets were detected earlier if compare with bone scans , CT or MRI scans but we all know these techniques are less sensitive than PSMA PET/CTs or 18 F Fluoride PET/CTs.
Most probable , bone mets in the spine could be detected and treated earlier than in any of these studies if PSMA PET/CTs were used.
An earlier treatment may have had a completely different outcome than in these studies.
There are not data yet, but it will eventually be enough information.
The PSMA PET/CTs are readily available and people with mCRPC should request to be follow with PSMA PET/CTs to catch mets much earlier than with the "old" techniques.
Nobody knows if doing this will offer an advantage but people with mCRPC does not have the luxury of waiting for RCT in this subject.
There will always be more sensitive scans. But what evidence would you be willing to accept that MDT is worthless (if it is)? If you always put forth an argument "if only they did it earlier!" - is that falsifiable? Is it science or wishful dreaming?
I very much agree that if safe, why not? But safety is all important, and systemic therapy should never be forgone just because MDT has been used (unless there is evidence for that).
In the Prostate Cancer News study referred to by Tall Allen, all the patients were castrate resistant. In the study from MedPageToday, I did not see any indication if the patients were CR or CS. Also, neither study was clear about other treatments these patients were receiving. My case is a study of one. I am still castrate sensitive, have a T9 tumor diagnosed almost 5 years ago. It was radiated by IMRT at Mayo in 2018 (a mistake), then again this year with SBRT at my local treatment center here in Colorado. I had ADT for 2 years, then off for 2 years, and re-started in June of this year. With ADT (and the radiation), I am undetectable and I hope to defy the survival statistics that these studies report.
In my article, both are dealt with. Only 22% had prostate cancer in the Gillespie study.
Was that onmy tumor....?...no regrets on vac. ......yet?
Only one tumor
Yes, the only spot seen on PSMA scans in 2018 and 2022.
Maybe some regret about the 2 year ADT vacation, since the T9 tumor grew significantly.
what drives do mss add by of us nuts is that two respected people can look at the sane data snc gone to vastly different conclusions. The article above from Rsgdmd medpagetoday.com/meetingcov... comes to a complete different conclusion from you. TA, can you help us reconcile ?
Schwah
Read the linked article and you will not be driven crazy. What drives me crazy is when people form opinions without reading what is in front of them.
I read both your article and the linked article and my understanding was that they offered a very different take on the efficacy of of MDT. I know you read these type of articles on a daily basis. I am also guessing your IQ exceeds mine by a substantial margin. I urge you to not be driven crazy by other people’s inability to comprehend this material this type of material as well as you.
Schwah
It plainly says:
"The discrepancy with the larger Dearnaly trial may be due to the identification of high-risk spinal mets; or the lower incidence of prostate cancer, the small sample size, and limited follow-up."
I dealt with two studies in that article. I don't know how to make it plainer.
Have you had any recent conversations with Dr Kishan on this subject to get his most recent thoughts on the subject ? For those of you who do not know Dr. Keshawn, he is a very well-known radiation doctor at UCLA that treated me with SBRT to my mets and that Tall Allen knows
Schwah
Dr Kishan and I are of one mind on this.
I'm part of a MD Anderson study where oligo mets are treated initially or not after chemo. It's end goal is to see if there may be curative properties if treated initially, with the limited spread. We'll see in a few years if it was a good idea or not, since I was still castrate sensitive.
I will be meeting with a radiation onc at UTSW next week to discuss this very problem. I have developed considerable low back pain following my first dose of Lu177, and we are discussing palliative radiation to lumbar spine and sacrum mets to reduce pain. What are the risks of radiation to lumbar area ? thanks Allen
It depends how large they are and if it has penetrated into other tissue. If small and on bone only, I think it's pretty safe, but I'm no expert. There are some really good ROs there. I know they recently built a new facility.
I will be seeing Dr Daniel Yang. And yes, there new cancer center at UTSW is very nice. Hoping with bone mets there is less of a chance of damage to intestines and such, but who knows.
The dose to intestines from SBRT to lumbar and sacral metastases is pretty minimal.
i completed 3 of 4 LU177 cycles. My soft tissue mets improved but bone mets continued. Had significant increase in generalized bone pain. MO thinks that a side effect of the LU can be increasing bone pain for some patients.
I have CT and bone scans coming up in a few days, so I will find out next week if there is any improvement. So far after the first dose of Lu177, bone and lymph nodes both progressed, but given the increase in pain around lumbar mets, maybe it has at least pissed it off a little......
Joeguy
only my observation but I think the LU really pissed off my bone mets. Pain was a 10 of 10 all through ribs back hips. dr gave me a steroid pack for a week that helped a lot to calm things down. Since bone mets were still progressing, the dr cancelled my round 4 of LU. Now moved to SOC chemo.
Hope the LU works great for you and many others. Just remember that the LU is not a silver bullet for the cancer. Just like all the other treatments, successful for some and not so much for others.
Good luck and keep us updated
Thanks Fightinghard,
I always find it difficult to answer when they ask "on a scale of 1 to 10, where is your pain"....... I am telling them my lumbar bone mets are like a 6 or 7 , but I am comparing that to a compound, multiple fracture of the tibia and fibula I had years ago.
thanks T. A!
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