SBRT to Prostate and Lymph node ?

[dudubaya]

Hi All,

My Father was diagnosed as stage 4 PCa with widespread bone mets in Nov 2021. Since then he has been on ADT + Enza + Denosumab regimen (details on my profile)

His PSA had increased slightly in the last few readings but he has largely been asymptomatic

12/22 - 0.81

03/23 - 0.83

06/23 - 1.21

Based on the above our Oncologist suggested a PSMA scan and a repeat of PSA test which we did yesterday . The latest PSA score was 1.18 (07/23)

The scan did not find any new mets and found significant reduction in the old lesions, I have attached the results of the Scan below.

While we are happy to see the latest reports there are few queries I hope someone can answer

1. There is apparently an increase in PSA as seen with the repeat test but the PSMA scan has only detected reduced mets and no new mets. Only the prostate and a lymph node close to it show active uptake , if so what is behind the rise in PSA ?

2. As per our Medical Oncologist this could be due to either micro metastatic activity increase or because of the active lesions becoming resistant. For the former we have to wait and watch, If we assume the latter then he has offered us SBRT radiation to the prostate and lymph node lesion after consulting with RO, he believes this will improve overall survival. The problem here is that they are not definite about it and suggestion was based on "if then .. it may" scenario

Given this can folks here recommend how to go about it :-

a. Wait and watch with more frequent PSA readings

b. Go for the SBRT suggestion

c. Any other suggestions here ?

[dudubaya]

Uploading other parts of the report

scan report 1

[dudubaya]

part 2 of report

scan report 2

[Benkaymel]

I guess I'm the reverse of you - PSA has been dropping pretty consistently since I started on ADT+Xtandi a year ago but scans have shown no reduction in size or number of mets. It's a strange disease and we're all different!

[Helllfire]

where are u taking your treatment in India ? Which doctor ?

[EdBar]

I had the same dx and had my prostate and several nodes radiated over 9 years ago. I believe this had a very positive impact on the treatment of my disease. Not all of my docs agreed with it at the time but to me it made sense to debulk the cancer source. During one of my visits with my medical oncologist - Snuffy Myers, he commented that it was the most important thing that I could have done, eliminate the mothership.

Ed

[dudubaya in reply to EdBar]

Thanks for sharing this EdBar ... was looking for such a response, feel a lot more positive about it now

[dudubaya in reply to EdBar]

One more Qn: was it short term SBRT or the full course IMRT where all the nodes in the chain and prostate are irradiated? the RO also suggested that as a better option if we could afford it

[EdBar in reply to dudubaya]

It was full course IMRT, entire prostate and as many nodes as could be done safely were radiated. Just be sure you choose a top notch RO if you go that route. Mine did an excellent job, very few SE’s, just some fatigue and some minor burning during urination that was short lived.

[dudubaya in reply to EdBar]

noted 👍

[Magnus1964]

At your father's age, I might try switching from xtandi to zytiga. Save the radiation as I backup.

[dudubaya in reply to Magnus1964]

Yes that was one of the option indicated early on in the consultation ...but somehow towards the end of the discussion the MO drifted towards the SBRT option.. Thanks for the suggestion Magnus1964 , I will bring it up again in our next discussion

[Magnus1964 in reply to dudubaya]

The long term side effects of radiation are not pleasant. That is why younger patients should postpone radiation as long as possible.

If possible, keep switching ADT drugs to keep the cancer in remission.

[dudubaya in reply to Magnus1964]

Could you please elaborate a little here on the concerns regarding radiation first ?

a. Is it about enduring the side effects when alternate approach is available ?

b. Or is it about wasting an option that is not absolutely necessary at this juncture ?

c. Any other concerns?

I have been trying to process all the inputs from this thread but still not able to get a clear understanding of the odds that we are dealing with , your answer may help me understand it better.

[Seasid]

I was diagnosed as polimetastatic.

My first oncologist professor Richard Epstein said to me to avoid local treatment and always treat the cancer with global therapies.

I did a PSMA pet scan at PSA 1.25 and it did not find visible mets only SUV Max 14 in my Prostate and 95% of my Prostate was full of cancer.

My RO and me decided to irradiate my prostate with high precision MRI guided Linear accelerator made by a Swedish company Elekta Unity. I received 38 Gy SBRT radiation in 5 fraction. Now 8 months later my last PSA was 0.25 down from PSA 1.4 before the SBRT. I am still only on Firmagon injections 5 years after the initial diagnosis as polimetastatic. I had early chemotherapy and I believe that that was the best for me rather than to have Abiraterone plus Prednisone instead.

The cancer in the prostate usually stops responding to the global treatments. Therefore I believe that I made a proper decision to irradiate the prostate despite the advice of my first oncologist. The radiation of the prostate is delaying more advanced global treatments. My mets are all in my bones.

[Seasid in reply to Seasid]

Even if the irradiation of my Prostate will not extend my life it will still potentially save me from lots of trouble caused by local spread of the cancer to the rectum and bladder etc.

[dudubaya in reply to Seasid]

Thanks Seasid , one more 👍 . From all the responses so far seems we should take this up without much hesitation

[Seasid in reply to dudubaya]

What was the SUV Max of your Prostate on the PSMA PET and what was the SUV Max of the other on the PSMA PET visible mets?

Did they find some other lesions (non PSMA) on the investigational CT with contrast part of the PET-CT?

[dudubaya in reply to Seasid]

SUV Max of Prostate was 12 (vs 39 at dx)

SUV Max of Common Illiac Lymph nodes 37 (vs 22.7 at dx)

Old Mets noted on skeletal system with reduction in extent (SUV Max of 13 on right iliac bone)

None PSMA lesion was noted as possible healing

If you could have a look I have attached the detailed reports as Scan report 1 and Scan report 2 in the first 2 replies of this thread

Thanks

[Seasid in reply to dudubaya]

All of that with the Prostate and only PSA 1.21. I am wondering how much will the PSA drop after radiation? I am really not a doctor but If I were in your situation I would probably try some system treatment. His Cancer which is not eliminated is not confined to the prostate only. Could you ask for a second opinion?

I'm afraid that the radiation alone will not be able to eliminate the cancer. In my situation it is hopefully different as we hope that the CRPC is only confined in the prostate and we hope (gamble) that the rest of the cancer is still hormone sensitive. Therefore we still stay on Degarelix injection alone. If your mets are CRPC than you may need to adjust your treatment accordingly. Better ask for second opinion. Maybe you could avoid radiation if you could find a proper treatment for your CRPC. Maybe it stopped responding to Xtandi. I wish you best of luck. I will keep informing you how I am doing with my gamble. I could maybe ask for myself for apalutamide? You are already on Xtandi.

[dudubaya in reply to Seasid]

We are also going by the same assumption(gamble) i.e the prostate is only CRPC and rest are all hormone sensitive. He has not been diagnosed as CRPC yet and Enzalutamide was given as part of systemic treatment even though he was hormone sensitive because as per the latest trend it is the SOC to start Enzalutamide upfront

[Seasid in reply to dudubaya]

But this is a CRPC spot if the SUV is higher now?: (SUV Max of Common Illiac Lymph nodes 37 (vs 22.7 at dx))

I am just trying to think with my own head.

I am not a doctor but in the end I had to ultimately make a decision, although my MO and RO were in agreement to irradiate my Prostate.

I didn't have any visible mets on the scans. Therefore I agreed with the Prostate irradiation, otherwise I would probably push as you with enzalutamide.

[dudubaya in reply to Seasid]

I recall the MO specifically mentioning that he still does not consider the cancer as CRPC yet, wonder if he might have glossed over the readings or maybe he had some other criterias in mind to, will check with him on this next time

Nonetheless even if the illiac lymph nodes are assumed to be CRPC lesions wont SBRT to thse lesions help here ?

[Seasid in reply to dudubaya]

Yes it will definitely help but your RO should be able to advise you better if it is safe to radiate it. If you successfully change to Abiraterone the size of the lymph node may decrease. Again we are not doctors but ultimately we will need to approve any further procedure.

That is obvious that radiation is not something what you should endure lightly.

I for myself even wanted to have an FDG PET scan after the PSMA PET CT scan in order to see if I really don't have any mets only SUV MAX 14 in my Prostate. I Didn't want to fry myself if I have mets either PSMA positive or negative.

My MO didn't think that I need an FDG scan. I probably wouldn't irradiate myself if there is a chance that I will need a global treatment. I am not a doctor but I had to approve the treatment decision. It is not always easy. If you can get also second opinion. For me it was easy as we all, me, my RO and my MO agreed that irradiating the Prostate is a good thing to do.

I think that the logic is that the prostate is different than the mets. Thanks God I didn't have visible mets. With visible mets I don't know what would I do.

My MO thought that if only the Prostate has a CRPC than it is still possible that the mets live their own life and that all of them are still hormone sensitive therefore not visible on scans.

We have a member here who had a visible met and he successfully removed it with SBRT radiation. He was on and off on Abiraterone for years. I wish you luck and that you make a proper decision regarding further treatment. We all need luck.

[Seasid in reply to Seasid]

This member had a successful SBRT of his met:

healthunlocked.com/user/jfoesq

[Seasid in reply to Seasid]

And was on and off on Abiraterone.

[dudubaya in reply to Seasid]

Thanks for spelling out your approach in detail, helps a lot in this situation .... yes we all need luck, lets hope and pray that we all get generous portions of it 🙏

[Seasid]

Could you ask your MO what they think about switching from Xtandi to Zytiga as Magnus suggested? Maybe you can avoid radiation for a while? Or come out with some other systemic solution?

[dudubaya in reply to Seasid]

sure I will

[GP24]

I agree with Edbar. For me it makes no sense to keep the mets you see on a PSMA PET/CT. Why keep them for later? SBRT radiation of mets is usually done without side effects and will kill the resistant cancer cells which are present in the visible mets. ADT will shrink them but radiation will remove them.

I have done SBRT radiation of lymph node mets myself twice and had no side effects from it. So no reason to keep them. While you are at it, you can radiate the prostate too.

[Seasid in reply to GP24]

But they may need a new and better system treatment as the current one is obviously not effective anymore.

If they can safely radiate the visible mets why not? But the possibility is that if you don't introduce a new and effective system treatment that the micromets will cause problems. It is only my personal idea. I just know that I would myself for my personal purpose (I can't recommend it as I am not a doctor and I have zero oncology education.) Just introduce a new system treatment and see if the cancer will shrink. If the cancer will not shrink than I would radiate the visible mets and maybe even change the system treatment again. The good thing with me that I have a MO who would advice me. But ultimately I have to be comfortable with the decision. I would not rush myself with radiation if I would have a New and effective system treatment as an option.

[GP24 in reply to Seasid]

You can usually radiate the mets safely. Then choose a systemic therapy to shrink the micromets remaining. It is not sufficient to shrink mets until they become resistant. Rather erase them with radiation. Since you cannot erase all, continue with a systemic therapy that works.

[Seasid in reply to GP24]

Good point. Thanks

[dudubaya in reply to GP24]

Curious to know if you had visible mets in bones and other locations when you had the SBRT to prostate?

Asking because as per the second opinion I got from another RO it will not be beneficial to Radiate the Lymph nodes and Prostate if we are also having visible mets elsewhere in the PSMA PET scan

[GP24 in reply to dudubaya]

I had lymph node mets only. However, you can radiate bone mets with SBRT too.

All the knowledge your RO has is based on CT/bone scan and not the more sensitive PSMA PET/CT. So you can count the mets based on CT/bone scan to determine if it is beneficial or not. My opinion is that systemic therapy works longer if there is less tumor to fight against.

Here is a study that could be relevant for you: esmo.org/newsroom/press-rel... The number of mets is based on CT/bone scan in this study.

[dudubaya in reply to GP24]

Thanks for the reference link. but almost all such studies that I have come across on the internet refer to efficacy of prostate radiation for "newly diagnosed" patients having different disease burden.

In our case Father was diagnosed in November 2021 and was diagnosed as a high burden patient from PSMA PET Scan mets (we never had a CT scan) , he was put on ADT + Enza for the systemic therapy, 20 months after initiation of ADT we are now being advised for radiation of the Prostate and Lymph Nodes so not sure if our situation fits into the "newly diagnosed" criteria mentioned in all these studies. Would you be aware of any studies in such situation or any other member in the forum who has been in this situation?