Salvage Therapy after Brachytherapy or IMRT

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John T
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Date Joined Nov 2008
Total Posts : 4229
   Posted 10/25/2009 9:45 PM (GMT -6)   
There is a myth that there are no 2nd chances after radiation, IMRT or Brachytherapy. Many on this forum have stated that they chose surgery because if it faled there was always radiaton to fall back on.
This is not true! First for any salvage technique to work the reoccurrance must be local, approximately 25%-30% of all reoccurrances are local in either surgery or radiation; the rest are systemic and cannot be salvaged with any technique.
For failed radiation salvage surgery is difficult and should only be done by an expert surgeon, even then the results and side affects are not good. Cryosurgery and HIUF are also salvage therapies for radiation, these have good cure rates, but again the side affects are not good.
The best salvage therapy for failed radiation is HDR Brachytherapy. These are temporary implanted radioactive rods that can be precisely placed, even the seminal vessels and uretha can be treated.
The side affects are better than either cryo or HIUF and cure is in the 80% range at 5 years.
So if anyone says that there are no 2nd chances in radiation, they are dead wrong.
For Brachytherapy only patients a 2nd seeding with a different isotope can also be done; but it appears that HDR Brachytherapy is becoming the best therapy for failed radiation that is local.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


chris nz
Regular Member


Date Joined Sep 2007
Total Posts : 33
   Posted 10/25/2009 10:38 PM (GMT -6)   
thanks for putting the record straight and showing a light at the end of the tunnel.
chris nz

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 10/26/2009 8:16 AM (GMT -6)   
I don't recall any poster saying there is no second chance after failed radiation or seeding as a primary treatment. I have seen it said that the options are more difficult.

Surgery after radiation shouldn't even be a choice. It was would be hard to find a surgeon with a good reputation to do it. It is almost always a total failure, and I have had surgeons tell me straight up, that you can almost guaranty the man 100 incontinence for life and ED forever. My own surgeon assisted in a couple of salvage surgeries as an intern, and he said they were the most brutal operations he ever assisted. He said he would never do one for any reason, not good for the patient, and terrible liability risk.

Yes, if once's reoccurance is not local, then any of the salvage treatments are going to fail. When I was talking to the radiation oncologist I finally chose, she said it was good news that I had a positive margin. Confused me. She said that if I had psa rising after surgery with no postive margins, it usually meant that the cancer was already distant. With the positive margin, there's hope that my SRT might work. That gave me some hope.

In the more common approach of surgery first, radiation second, which many men here prescribe to, there's and added bonus in the deal, you have the extracted prostate in its entirity, lymph nodes, and other bits and pieces that have been examined and the pathology on this matter is known. It less of a guess what to do next if you know a fuller extent of the cancer .

In the radiation methods of primary treatment, you only have partial knowledge for most men of the extent of their cancer based in one or more biopsies.

Now if you have the more complex 3-D scans, more would be known, at least to the size and extent of the tumor in question

To me, my opinion, the conventional treatment method gives the removal of the prostate, where most men's cancer is contained, or at least the sheer bulk of it, you will get extensive pathology report on what you do have, and if you need salvage, you can have radiation of which most men endure well (with or without HT), and later, if needed, there is still the HT path.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 10/26/2009 10:35 AM (GMT -6)   
But isn’t risk assessment part of the equation? I don’t know nearly as much about pca as many others here, but it is my recollection from reading that surgical salvage treatment after radiation will likely have disastrous results.

An issue that I still haven’t been able to figure out is the radiation versus surgery conclusions. There are two ways to look at this. For example, if a man chooses surgery because there is always the option of radiation later in case surgery “didn’t get it all”, why not chose radiation in the first place? On the other hand if you examine the nomograms and do the numbers you’ll see that surgery with the option of salvage radiation has the best probable outcome. It just doesn’t make sense.

geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 10/26/2009 11:08 AM (GMT -6)   
This is a good thread but don't sell brachytherapy short either. It is particularly attractive for men with relatively non-aggressive localized tumors.

Some men, for reasons of health or prior operations are simply not candidates for surgery.

Another part of the equation is quality of life. Surgery has immediate impact while the effects of radiation may appear many years later. For a man with other serious health issues, putting off side effects may make sense.
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads
6 mo. PSA 0.00 -- 1 light pad/day


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4229
   Posted 10/26/2009 11:22 AM (GMT -6)   
The purpose of this post was to point out that HD Brachytherapy is a very acceptable salvage treatment for failed radiation, just as salvage IMRT is an acceptable option for failed surgery.
The fact that there is more information to be obtained from surgery is beyond question. The fact that there is no good option availabe if you fail radiation, as some patients are led to believe, is false.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4229
   Posted 10/26/2009 2:37 PM (GMT -6)   
Squirm,
Radiation failures are caused by insufficient dose that fails to kill all of the PC cells. This was common when the standard dose was 6500gy. The newer machines give about 8100gy which gives superior killing power with similar side affects. A combination of seeds and IMRT will give close to 10,000 comparable gy. This should kill any PC cells in the prostate and up to 15mm outside the prostate. It will take 10 years before any hard evidence proves the higher doses reduce reoccurrances. Nothing in PC is 100% and there could be some cells that survive and grow; just as surgery cannot get 100% of all the prostate tissue or all the PC at the margins. By far the most common cause of failure in both radiation and surgery is the fact that some of the PC cells have escaped into the blood stream or lymphatic system before radiaton or surgery. There has never been a head to head study for surgery vs radiation, but all indications are that cure rates for low grade PC are similar. There is a lot of disagreement when it comes to intermediate and high risk PC, because you can't tell whether the PC is localized or matastized when treatment is done. It is generally accepted that the side affects from radiation are less than those from surgery.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 10/26/2009 2:44 PM (GMT -6)   
John, what you said to Squirm is right in line with a conversation I had with my Radiation Oncologist recently. She said it was hard for RT to be a sucessful primary treatment before IMRT, because you couldnt safely deliver enough gys. to the area for a knock out blow. They use it for a primary all the time, with and without seeding, and have a decent success rate when compared to surgery.

When I was told that I would be getting 72 gy for SRT, I thought it was a lot. SHe said it was, but she can safely deliver it to me without killing me off, lol. And that at 72, I stand a much higher chance of it finishing off the cancer, assuming it is still all local to the prostate bed.

Good post.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


stxdave
Regular Member


Date Joined Nov 2008
Total Posts : 65
   Posted 10/26/2009 3:01 PM (GMT -6)   
Purgatory said...
Surgery after radiation shouldn't even be a choice. It was would be hard to find a surgeon with a good reputation to do it. It is almost always a total failure, and I have had surgeons tell me straight up, that you can almost guaranty the man 100 incontinence for life and ED forever. My own surgeon assisted in a couple of salvage surgeries as an intern, and he said they were the most brutal operations he ever assisted. He said he would never do one for any reason, not good for the patient, and terrible liability risk.


I had 42 EBRT treatments and six years of hormone therapy when I became refractive. A biopsy of the prostate at this point showed the right side to be filled with cancer (5+4=9) grade. I was offered a prostatectomy and took it. After the catheter was removed I had 99% continence. After radiation and six years of hormone therapy you can forget about erectile function, so that was not a consideration. I gambled on incontinence and won for a while. A stricture that showed up a year after surgery has me fighting incontinence and considering an artificial sphincter.

Some of you who like to make hard statements here should rethink before you speak. Everyone's situation is different, everyone's cancer is different, and everyone's response to treatment is different. Any time you start trying to put this stuff in a neat box it's going to come back and make you a liar.

Dave
Dx'd 1999, Age 60, PSA 43, Gleason (3+4=7), T3c
42-3d EBRT w/Lupron/Casodex for 24 months.
July 2001 - Intermittent ADT. Lupron only, MDAnderson biopsy revised Gleason (4+5=9).
March 2007 - Diminishing returns with Lupron, Prostate biopsy (5+4=9) in unradiated lobe.
August 2007 - RRP and bilateral orchiectomy. PSA <0.1
99% continent immediately
Sept 2008 - PSA 0.45, Nov 2008 - PSA 0.67,
Dec 2008 - Resume Casodex, Stricture in bladder neck requiring surgical removal. 99% incontinent immediately.


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 10/26/2009 3:22 PM (GMT -6)   
Dave, hope you aren't calling me a liar, no need for that.

I am thrilled that you are an exception to a rule that many surgeons have told me, and most books on PC advocate. It's not some pet theory of mine.

Sounds like in your situation, there was no choice but to try that approach. There is nothing about PC that fits in a standard size box, think we all know that here.

I still stand by the statement that as a general rule, salvage surgery is bad news. You are indeed a fortunate exception, and I am glad.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 10/26/2009 3:30 PM (GMT -6)   
John,
Is there any data on the survival rates for HDR Brachy as secondary treatment after failed radiation? I had no idea that HDR Brachy could be used in that respect. Interesting.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4229
   Posted 10/26/2009 5:12 PM (GMT -6)   
Because this is relatively new there are 3 studies on a small number of patients.
1. 89% biochemical free at 2 years
2. 71% disease free survival at 58 months
3. 41% biochemical free in 41 mos
I don't know what the salvage radiation after surgery rate is, but I suspect it is well under 50%.
Because of the small number of patients in the studies 1 or 2 patients either way can drastically move the percentages.

JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 10/26/2009 6:00 PM (GMT -6)   
John, due to my pre and post surgery psa velocity, my radiation oncologist gave me a 40% figure at best.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.

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