Hi there, my first post here. I’m 61, Gleason 4+3, PI-RADS 5 lesion on L side of prostate with capsular invasion, likely seminal vesicle involvement and cribriform. 15 of 17 cores positive. Findings:
—Primary tumor with SUV of 5.5
—7mm left side lymph node involvment with SUV of 3.5
—Bone lesion on right side (away from main tumor) with SUV of 4.2. Further imaging needed to confirm metastasis.
—nothing else remarkable
My treatment plan, to be finalized next week with my MO and RO was 18-24 months of ADT, followed by 5-6 weeks of whole pelvic IMRT and 5 fractions of SBRT boost to the prostate. Does anything found in the PET scan change my treatment scenario? Any other thoughts?
Seems like bad news (I’ve been getting plenty lately) but I just want to get started with treatment. I was diagnosed at Kaiser but opted out to give me access to Fred Hutch and Swedish in Seattle. Pretty sure I’m going with Swedish; I had a great rapport with their RO there. He’s young but spent a ton of time with me, going over all the scenarios and coming up with a very nuanced plan. And he works closely with Dr Meier, a very well regarded RO and CyberKnife expert.
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I think it’s an awesome treatment plan, and it appears that it is still localized. The Gleason score is not the worst, and the SUV max isn’t that high on any of the lesions. The bone finding could well be incidental. I would want to get started on the ADT as soon as possible to put the cancer to sleep and possibly kill any micromets. Then, I would ask if a second generation hormone therapy such as Abiraterone with prednisone should be added for a total androgen blockade. Next, I would ask if the lymph nodes and the bone lesion (if confirmed to be a met) would be included in the radiation plan. I think you are still in the window where you can be cured if the treatment is aggressive enough. If not, I bet you will have many, many good years to enjoy. Take care and keep us posted!
Do you feel that Orgovyx would be sufficient by itself as hormone therapy? I would appreciate any ADT advice in advance of my MO visits on Wednesday, many thanks.
Even if your Gleason score is not over the top but you seem to be diagnosed in the area of T3BN1M1 and you defenitely need to be on ADT, why not go all in and add Abiraterone to the cocktail to really have a total testosterone blockade?
I mean, your’e treatment plan sounds very innovative and is really ’kick cancer ass’ so, why not add the Abiraterone as well
That very well might be the advice from either/both MOs I visit this week.
My RO at Swedish prefers a SBRT boost rather than a brachy boost. This is a fairly new change for his practice but reflects the updated 2024 NCCN guidelines and it is something I’m comfortable with unless there was convincing evidence otherwise.
Well, yes a boost is boost I believe and if I’ve read your bio / staging with probably SV involvment (e.g T3B), probable LN involvment (e.g. N1) and perhaps (or not) a bone met (perhaps a M1) then i would prefer the ’kick cancer ass’ in the hope of long remission / curative intent.
So why not up success posibility with adding something to the cocktail Just my personal thoughts
Yes. There is no evidence that adding anything to Orgovyx will have any extra benefit. The lymph node SUVmax is marginal and its size is too small to qualify for adding abiraterone as in the STAMPEDE trial.
But, if your bone lesion is a metastasis, you should consider triplet therapy.
The recommendations of the guidelines are based on this trial pubmed.ncbi.nlm.nih.gov/209... These patients were diagnosed with a bone scan. Using a PSMA PET most of them would have had mets like you. So RT followed by ADT is according to the guidelines. I cannot understand your doctors.
Because you asked for other thoughts - if I had a do-over I would still have RP but with extended pelvic lymph node surgery using the frozen section pathology method (the latter was my third treatment after salvage RT). I appreciate some in this forum will profess how wrong I am - I see it as we each have to choose our poison. All the best with your decisions and outcomes!
those SUVmax don't sound high enough to be metastasis. They could be. They could easily not be. I wouldn't make any assumptions. They usually do a CT scan at same time and that usually confirms a lesion, like on the bone, that would be a metastasis. But apparently they did not do that with you. But sometimes they will go ahead and radiate the area with the questionable SUVmax anyway. To be honest, I would assume those are just questionable uptakes that could be inflammation or something else. But still radiate them as if they are. Better safe than sorry.
Do I understand you are going to have 18-24 months of ADT followed by radiation? As in starting it 2 years later? Or did you mean the radiation will commence sometime soon after you begin the ADT?
Great. I would really get after it now instead of ‘holding something in reserve’, an approach which is thoroughly outdated. Especially adding the abiraterone, if your overall health and fitness are good. Assess yourself honestly! None of this is easy on your body of course, but being fit and strong gives you the best possible outcome.
I was T3B also. Abiraterone was added as part of a clinical trial to the ADT, post RP. This was in 2019, before PSMA pet was widely available, or widely recognized as invaluable as it is now.
Had I the chance, I would have gotten a PSMA pet and subsequently neither the RP or the early chemo which rounded out the clinical trial, which I dubbed ‘kitchen sink’ at the time. All this began 3 months post RP with an undetectable PSA , also an unusual path. But it was recommended to me by my urologic surgeon of all people, and I took the suggestion.
I have always believed your first shot is your best one. Was I over treated? No one can know. However, I remain undetectable, in good health and not on ADT or any other treatments.
Eventually dying of something else first in this condition is my working definition of ‘cured’. Great luck to you!
Hey…since my post I’ve gone from T3B to N1 and therefore ineligible for a brachy or SBRT boost (per my insurance company). My RadOnc still feels that 28 fractions of full pelvic IMRT can encompass a boost to the prostate and impacted node. But I feel as you do that I want to go full kitchen sink with my radiation. My IMRT will be done locally but I am meeting with another Fred Hutch RO (younger guy who is more creative/aggressive than the other FH guy I consulted with) who I am hoping can convince an insurance co to reconsider a boost per the ASCENDE-RT study. I hope I have similar results to what you have experienced. Cheers…
I forgot to mention IMRT was a part of the trial also. The RP preceded all of it. I like the aggressiveness. Get the boost if you can but either way you’re set up nice. Great luck to you!
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Just my personal thoughts 
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