Finished HDR-BT and IMRT

[timotur]

It's been a long haul, started in March with neoadjunctive ADT, Lupron+Zytiga, for PCa diagnosed at t3bN1M0 +SV +/mesorectal lymph node, and PSA 33. By June, PSA had dropped to 1.0 just before going into HDR-BT with Dr Chang at UCLA. He did a great job, the procedure was smooth, drove home the next day, and had no SE's, urinary functions good after things settled down. During the procedure a SpaceOar was placed, after some discussion about whether or not it would complicate treatment of the suspect mrLN. It is usually not in the chain of metastatic progression, so it was thought it may have been a false PSMA positive near the cutoff SUV, and it could be treated later by IMRT. Anyway, as I saw later on a followup MRI, the SpaceOar was placed perfectly, with a nice smooth symmetrical shape between the rectum and prostate.

One month after HDR my PSA had dropped to <0.1. Then started IMRT at UCSD, with Dr Eintz. He planned out a 25 session, 45Gy treatment of all the lymph nodes below the aortic split, plus the mrLN. The five weeks went smoothly, albeit tedious, showing up with a full bladder each day. I learned I had to start drinking fluids about 2 hours before the appointment to allow the kidneys to filter enough fluid to fill the bladder. The only side effect was rising blood pressure during IMRT, which went from 110/70 to 165/90. I read one of TA's posts about Zytiga effectively causing water retention by causing the adrenal to release ACTH, and overhydrating every day probably caused even more water retention. Now my main goal is to try to get my BP back down. I hope this is not a permanent effect of Zytiga. Also, I noticed my total lymphocyte count had dropped from about 1324 to about 250, way below normal. So I guess IMRT killed a lot of lymphocytes over the last five weeks. At the end of IMRT, PSA is still <0.1 and no other SE's such as rectal burning, so the SpaceOar probably did its job.

I guess the ADT is masking any PSA bounce that may have occurred from radiation, so I really won't know how effective this treatment is until I have finished the full 18 months of ADT, about 12 more months to go.

If anyone has any questions about this course of treatment, let me know.

[jazzy53]

My blood pressure has risen similarly, from about 110/60 to 145/75. (I'm on two years of ADT and completed a two-month course of IMRT). I've assumed that the cause is the ADT because the problem arose after I started ADT and has persisted both during and after a two-month course of IMRT. The unnerving thing is that nobody on the treatment team seems to recognize that this is a potential side effect of one or the other, or both. Is there any science on this? And any evidence that bp will return to normal after all treatment is done?

[timotur in reply to jazzy53]

My BP was ok the first three months of ADT, but after the 3rd week of IMRT, it jumped to the 150/90 range. So perhaps it just took three months for Zytiga to affect my BP. Will discuss with Uro and MO this week.

Here's the post by TA describing how Zytiga effects BP:

"In the STAMPEDE trial of early Zytiga, patients took 5 mg prednisone once a day. For men with metastatic castration-resistant PC taking Zytiga, the suggested prednisone dose is 5 mg TWICE a day (= 10 mg/day). This is supposed to replace what is lost because Zytiga shuts down cortisol production from the adrenal glands. When cortisol production is insufficient, the pituitary responds by releasing Adrenocorticotropic Hormone (ACTH) which paradoxically causes a mineralocorticoid excess. The symptoms of such excess include hypokalemia (low potassium), fluid retention, and hypertension."

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[Dreamweaverman]

Hey Tim, I’m in month 8 of Adt. Good luck my friend!

[tsim]

It's good to finally see someone in the same relative situation and diagnosis as me. I had a small cancerous lesion in my left seminal vesicle and slight perineural involvement. My original PSA was 40,t3b N0M0, and our freakish intermediate gleason( I was 3+4, grade group 2). Have you run into any others with this set of dx criteria? I chose almost the same treatment protocol as you. My HDR brachy was performed by Dr Dan Fernandez at Moffitt Cancer Center in Tampa, FL. They parallel the UCLA dose and sessions exactly. I also had the propylene glycol spacer put in and I am 13 months out with no toxicity of any kind as yet. 25 sessions IMRT at 1.8 Gy each. Finished my last Lupron injection of the 18 month cycle in May. I cut back on this from the recommended 24 months since there was no clinical data to support that it is any better. PSA has been undetectable throughout. No Zytiga so can't comment on the hypertension issue. Were you taking Tamsulosin at all for urinary issues? That usually lowers blood pressure considerably. Hate the ADT, all of it. I'm taking D-Aspartic acid capsules which have a luteinizing hormone agonist action to try to raise my testosterone. Just waiting for it to come back, hopefully it wont take too long. Junior's getting some party invitations and it makes me sad I can't attend.

[timotur]

tsim: Nice writeup and congrats on finishing ADT...! I have 12 more months to go, but tolerating reasonably well, except for low RBC's. I think it was a good decision to stop at 18 months, because I think the real benefit occurs in the early stages of treatment. No, haven't seen any other cases in a high-PSA/low-Gleason category with SV involvement-- that puts us in a unique high-risk t3b category with low-risk GL-7 (3+4) pathology. Dr Scholz commented on this today it's very unusual. I am node-positive, N1, mesorectal node, per a PSMA scan before ADT started, and am trying to assess if it was a false positive, because the mesorectal node is not in the normal chain of lymph node progression and the SuV was right at the cutoff. I suspect if it actually is positive, it came through the SV. The reason this is important is because if there are is micro-metastasis to this node, there may be to others as well that weren't detected. To address this, Dr Sholtz is recommending adjunctive chemo of 1-4 rounds. There is a study that addresses this, RTOG 0521, that says adjunctive CT improves OS for non-metastatic hormone-sensitive PCa of about 4%-- but these were for Gleason > 8 with high met burden. But on the other hand, there is a Swedish study that that says there is no benefit of adjunctive chemo for GL-7. Further, he says an OS rate of 4% is about like a cure rate of 10%. So the question is, do I risk the SE's of chemo for up to a 10% increased chance of a cure? That's what I'm trying to figure out in the next few weeks. It's good you were N0 to avoid such an option, did you have a PSMA test before you started ADT? Anyway, sounds like you sailed through without complications, and hope your T comes back strong in the coming weeks. I have zero interest in sex right now, after things settle down, I may try the blue pill and see what happens.