Chasing mets with SBRT?

[myamic]

Thoughts on treating with sbrt, oligometastic lesions with sbrt seen by PSMA. Currently on ADT . Delayed by 6 months ( PSA dropped but not to zero) doing second line blockade using zytiga or xtadi when one lesion was treated. PSA went down but began to rise. Now 5 lesions have been detected. Will start second line ADT regardless.

[NPfisherman]

Welcome to posting on the forum...

Before offering advice, it is important to know more of your history like Gleason score, was it ductal or intraductal, did you have a prostatectomy or radiation, did you have chemo, ADT or both in the beginning, and are you now considered castrate resistant and considering Zytiga or Xtandi or were you on one of these and had one lesion treated... a rough timeline helps also...Feel free to look at my profile by clicking on my name...

By clicking on the green "H" for Home in the left hand corner of your screen, and editing your profile and including information on your prostate cancer history and location, then we can render informed advice on your questions.

We look forward to your updated info and providing a response...

Don Pescado

[myamic in reply to NPfisherman]

updated profile NP

[NPfisherman in reply to myamic]

Thanks for updating....this will help others help you...

Since you had a PSA drop post SBRT, then it is unlikely that SBRT made the cancer more aggressive. What should happen when people are diagnosed and have metastasis is they should be put on chemo if highly metastatic or Zytiga based on the STAMPEDE trial. Some choose to do both--chemo and then start Zytiga or Xtandi. This didn't happen for you.

I am not sure if you have adenocarcinoma acinar or a ductal or intraductal form of cancer. This is based on your biopsy pathology report and may effect the success of radiation in treatment. You may have to find that report.

At this point, I would get on Zytiga or Xtandi ASAP with your ADT.

The only trials that I am aware of for SBRT with 5 mets is the SABR COMET 10 trial with locations in Canada, Amsterdam, Scotland and London-see below:

clinicaltrials.gov/ct2/show...

An RO can look at where your mets are and determine if SBRT is right for you... The same could refer you for the trial. Cryotherapy is also used to eliminate mets and there has been some success using cryotherapy with immunotherapy and sangrostim--one of my posts below:

healthunlocked.com/fight-pr......

I would also advise you to be seen at a Center of Excellence for Prostate Cancer since I am not sure why you were not put on Zytiga right away as per the STAMPEDE trial. The Prostate Cancer Foundation can help you find a center depending on your location.

Another option if you have bone mets is to get on a medication and consider Xofigo.

Lots to think about and I hope this helps...

Don Pescado

[myamic in reply to NPfisherman]

first diagnosed as prosatatic adenocarcinoma

[NPfisherman in reply to myamic]

Usually, they will tell you if it is ductal or intraductal, but if you have Adenocarcinoma (most common form) then radiation should be fine. Not sure if you are seeing your local urologist or an MO or where you are located, but if I had stayed with my urologist, then I would be in much worse shape than I am today... A really good MO is critical for best treatment and survival.

Fish

[myamic in reply to NPfisherman]

Have a MO who is not really in favor of treating the new mets. Have a radioogist who feels that I would benefit from a combination of SBRT and zytiga or xtandi.

[NPfisherman in reply to myamic]

Not trying to be nosy, but again... where are you located and is your MO a PCa specialist? It does make a difference. I go to Cleveland Clinic for my MO, but my RO was Dr Steven Burton at UPMC that did some of the SABR trials in Phase 2 with Dr Herron--see below:

redjournal.org/article/S036...

He told me that he could eliminate the one met that I had and as far as I can tell, he was successful. I do believe that being on ADT with Zytiga also played a role in my current status and helps when getting radiation in killing PCa cells....

Going to a Center of Excellence for a 2nd opinion may be the guidance you need to make a decision.. It is your journey, so you must choose, but I endorse hitting it hard early, and a 2nd opinion never hurts....

Fish

[myamic in reply to NPfisherman]

Mo is a PCa specialist....Center isin the top 10 medical center in the U.S. The one met that i had radiated has definitely got smaller .

[NPfisherman in reply to myamic]

Sounds like you are in a good place... Here is a clinical trial that includes 4 lesions, so if you had 2 lesions that were really close, they may consider that as one treatment area.

clinicaltrials.gov/ct2/show...

Another thing to consider might be Lu-177 clinical trial like SPLASH which will give you a second generation anti androgen like Xtandi or Zytiga with the possibility to cross over and get Lu-177 if you have progress-see below:

clinicaltrials.gov/ct2/show...

Not sure if you have had genetic testing which might be a good next step. Some find that they can use targeted therapy for specific genetic mutations and do well...

Take a look at your options, talk with your MO, and best of luck on your journey....

Fish

[marnieg46 in reply to NPfisherman]

Dave, a very basic question prompted by myamic's enquiry...

I've often wondered why Ron isn't offered radiation for his bone metastases...I know why he isn't on 2nd line ADT (QOL and specialists choice) but not why no radiation. Is it because he had adjunct radiation after his PR or some other reason? I don't think you can have it for the lymph nodes can you?

Thank you for all your informative posts and for being so very generous with you time and knowledge...2000 members on FPC...quite an achievement and tribute to you and others who post regularly here with information that is current, topical and sensitive and gives hope for what lies ahead....🎉

[NPfisherman in reply to marnieg46]

Hi Marnie,

They do irradiate lymph nodes and bones, but some of it may have been related to the number involved or the location. Para aortic lymph nodes and some others are considered too dangerous based on location and closeness to vital structures--heart, lungs, etc... You would have to ask his MO or his RO to be certain. Right now, the focus seems to be on radiating oligometastatic patients with SBRT--primarily 1-3 mets in an effort to slow disease progression or possibly arrive at a point where they can achieve a cure... Here is some info on radiation therapy for prostate cancer from Johns Hopkins:

hopkinsmedicine.org/health/...

Thanks for the compliments as well. As a fellow sufferer, I feel like it is in essence, a mission, to keep others informed on developments in prostate cancer research and treatments. Sorry that I did not respond faster, but the Lady M took over the office early on to type her notes, so I have to wait...

Dave

[6357axbz in reply to NPfisherman]

Dave, FYI I had my entire para-aortic lymph node string zapped at MD Anderson using 28 sessions of IMRT. No significant SEs.

[NPfisherman in reply to 6357axbz]

I guess it depends on how comfortable the RO feels and the type of radiation used. I had one guy tell me they would not do his para aortic lymph nodes due to location. I guess it is up to the provider and the type of radiation used at that location...

[NPfisherman in reply to 6357axbz]

Now Marnie and I exchange messages regularly and that's why she calls me Dave and not Fish... Are you trying to buddy me up?? ... ROFL...

[marnieg46 in reply to NPfisherman]

No apologies required...I was asleep anyway. Compliments well deserved. Your continuing to post has been a labour of love and care for the wellbeing of others I well know.

Guess it's basically because he's not oligometastatic. My contacts here with PC bit limited but most don't seem to have radiation of mets but rather Lu 177. Might get the courage to ask, as you suggest, at next meeting...I think the specialist already secretly thinks I've got Munchausen by Proxy so haven't got much to lose. Have a nice evening...👋

[NPfisherman in reply to marnieg46]

Hi Marnie,

I never saw a Munchausen Syndrome by Proxy, but I did see a suspected Munchausen Syndrome once... interesting case... I do not think you qualify for the new diagnosis.... ROFL... Ron has had some issues, but on the mend and may it continue... I would wait and see his next PSA and if up, talk with them about Lu-177 and adding on a second generation drug like apalutamide or darolutamide..... side effects seem not as bad and tolerated better... I took apalutamide in a trial before surgery and did not have any issues at all... Talk with the specialist and see... Best of luck with the specialist... A bit cloudy this am in Oz... take your umbrella if going out... chance of more rain...

Nice day here....60's and some overcast... trimming the carpet in the greenhouse and finishing grow light installation... my buddy Chris says it looks like the DIY network....LOL... such a good friend...

Dave

[marnieg46 in reply to NPfisherman]

Everyone needs a friend like Chris who calls it like it ‘looks’ but I’m sure it looks perfect to Lady M and that’s all that matters...talk soon

[cesces]

The general rule is that once it goes metastatic, spot treatment just is never going to be good enough. It is just in too many places where you don't see it.

Once it has gotten loose, the only way to reach it in all it's locations is with global systemic treatments.

The one exception is if you have a tumor that is threatening something important like a spinal vertibra or an important artery.

That being said, if you have 5 or less tumors, it seems to be an area where many docs will spot treat the tumors.

[myamic in reply to cesces]

There is also the unproven theory of the abscopal effect .

[cesanon in reply to myamic]

Just stating what I understand to be the conventional evidence-based thinking on the topic.

I believe that, at any well-regarded center of medical excellence, they will never use radiation to treat more than 5 tumors.

[myamic in reply to cesanon]

thanks