PCa Recurrence Treatment Advice

[ac61418]

Diagnosed w/PCa--Gleason 4+5 in R lobe, 1st/12 cores & 3+4 in L lobe 2nd/12 cores, biopsy & pathology by Johnathan Epstein, June 2018 (age 62).

Treatment: EBRT 81 Gy over 45 fractions (completed Jan 2019) + adjuvant Firmagon for 8 mos (completed Mar 2019). PSA reached undetectable nadir in Nov 2019.

PSA begins steady rise from nadir. Sept 2021 w/PSA @ 0.29 ng/ml, 3T Dotarem MRI --Negative. July 2022 w/ PSA @ 0.95, Pylarify PSMA scan shows intense focal uptake (SUV 20.2) in L apex of prostate only. 3T Dotarem MRI shows corresponding 0.9 cm lesion suspicious for tumor and diffusely decreased T2 signal intensity in prostate likely due to post radiation TX changes. Prostate size 17 cc. Continued monitoring only, was recommended unless PSA reaches 2 pts above nadir (the Astro-Phoenix criteria for BCR), per consults with Fox Chase & Sloan Kettering (Monmouth NJ), MED ONC & URO ONCs.

Feb 2023, PSA continues to rise to 2.21 ng/mL (exceeding the Astro-Phoenix criteria for BCR, a rise of 1.26 ng/mL over 6 months, with a declining PSADT of about 4.5 months). Mar 2023, second Pylarify PSMA shows that there is progressing malignancy within L lobe (much larger uptake area than before, now 18.3 x 22.3 mm, SUV now 25.5) and new uptake area (9.6 mm) in R lobe (SUV 5.6), but there continues to be no obvious evidence of regional lymphadenopathy. April 2023, recent PSA now 2.57, & Total Testosterone continues to drop below normal to 170 ng/dL.

Fox Chase MED ONC & RAD ONC both recommend Local Treatment, RAD ONC wants salvage HDR Brachy to entire prostate (no Focal), 24 Gy over two 12 Gy sessions and no adjuvant ADT. RAD ONC also wants biopsy for pathology (but with an irradiated prostate pathology may not be possible?) and SpaceOAR hydrogel to reduce RT complications?.

Local RAD ONC, partner of the RAD ONC who did my EBRT (since retired) disagrees, and does not recommend any salvage RT because I already received full dose EBRT and any further RT dramatically increases RT Toxicity risk in my case (I did have some mild RT side effects from initial EBRT) and added RT may not cure my PCa. Moreover, it is unclear if I have micro metastases, highly likely with Gleason 9 PCa, and that would render Local Treatment moot. He recommends ADT only and my Local MED ONC agrees (Orgovyx oral over Firmagon, intermittent ADT, to reduce side effects).

I am thinking of asking for another 3T Prostate MRI, this time w/o Dotarem (avoids bioaccumulation risk, had too many w/ Dotarem already) that can be used for fusion biopsy (vs random) and may shed some more light before I decide which way to proceed and if I go w/salvage Brachy, I think I may refuse biopsy (prostate needs time to heal from needles punctures and will delay RT?) and also refuse Space OAR (reduces the risk of insertion complications).

Any feedback/advice would be helpful and much appreciated.

[Tall_Allen]

What is the argument against focal salvage HDR brachy?

[ac61418 in reply to Tall_Allen]

RAD ONC stated -"I would treat the entire prostate and not just a portion. I do not believe there is a reduction in side effects by treating less than the whole prostate , especially because of the prostate size."

[Researcher50]

Wondering what you decided as could be on same path. Brachy looked appealing with intent to cure or at least delay ADT. As to biopsy, just read a study that said biopsy could possibly be eliminated with radiorecurrent PCa if using PSMA-PET.

[ac61418 in reply to Researcher50]

Just received latest PSA, now 3.3, up from 2.4 in six weeks w/ PSADT still about 4.5 mos. Probably start Orgovyx right after other baseline labs are received.

After pushing back on biopsy/Space OAR, RAD ONC relented and said they would still salvage brachy treat if I refused, noting possible "catastrophic consequences, although unlikely" and logistically, it will take time to schedule appointments for planning (CT/MRI) and actual Brachy 2 sessions a week apart. I remain unconvinced salvage brachy would cure (when initial 81 Gy did not) and toxicity is highly likely and with PSA rising quickly any further delay may allow PCa to spread. Hope this helps.

[Researcher50 in reply to ac61418]

Thank you. Please continue to share your journey.

[RMontana]

Check this podcast out...it includes 3 case studies. Plug yourself into the flow of discussion. I learned much from the panel. There is a lot of testing, scanning and treatment discussed. See if this helps you make an informed decision. Rick

healthunlocked.com/active-s...

[ac61418 in reply to RMontana]

Thanks, I will review.

[billy1950]

ac, Have you decided what salvage treatment, if any, to go with…I have a recurrence after radiation…originally had 8 weeks of radiation in 2004-5…not sure what way to go!