great SRT summary

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Galileo
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Date Joined Nov 2008
Total Posts : 697
   Posted 6/18/2010 1:17 PM (GMT -6)   
For anyone who's really, really interested in salvage radiation, like me, here is a review of current practice and research.

"Salvage Radiotherapy for Patients with PSA Relapse Following Radical Prostatectomy: Issues and Challenges" Cancer Research and Treatment. 2010 March; 42(1): 1–11
Richard Choo, M.D.
Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA


The full text of the article is freely available:
www.ncbi.nlm.nih.gov/pmc/articles/PMC2848745/?tool=pubmed
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 and thereafter <0.1
pcabefore50.blogspot.com


SubicSquid
Regular Member


Date Joined Oct 2009
Total Posts : 252
   Posted 6/18/2010 1:36 PM (GMT -6)   
Very intersting article. With my positive margins and Gleason 7, makes me wonder how successful my IGRT will be. Only time will tell. Thanks. Squid.
*Age 63, PSA July 2009 5.66
*Diagnosed July 2009, Biopsy: 2 of 12 cores positive, Gleason 3 + 5 = 8
*MRI and Bone Scan Negative.
*open Surgery October 22, 2009
*Prostate, both nerve bundles, seminal vessels, and lymph nodes removed during surgery.
*Post surgery Biopsy, Gleason 4 + 3; 2 positive margins
*Still slightly incontinant after 3 months - 1 pad per day (light). Dry at night. 1-2 trips to toilet.
*ED - Yes (will start Levitra possibly in January)
*30 day PSA (ultra-sensitive) .07
*90 day PSA (standard) <0.15
*01/10 - bladder neck stricture. opened during cysto exam. Cath #2 in for 5 days.
*03/01 - bladder neck stricture. Dilated during cysto exam. Cath #3 in place.
*03/11 - Bladder neck surgery. Cath #4 in place.
*03/15 - Cath #4 out. Great urine stream. Unfortunately, incontinence back to post surgery level.
*04/14 - Six month PSA - .21.
*05/15 - Incontinence basically under control.  99% dry.  Wear pad daily at work "just in case".
*06/10 - Started IGRT.   39 treatments scheduled.
 


Piano
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Date Joined Apr 2008
Total Posts : 847
   Posted 6/18/2010 6:12 PM (GMT -6)   
Galileo: Thank you for the link to that report -- as you said it's for anyone who is really, really interested in SRT. It seems to be quite readable, but (for me!) will need several readings to understand it all.
Pre-op:
Age 63 at diagnosis, now 65.
No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4 of 12 cores.
Operation:
Non-nerve-sparing open surgery on 7 March 2008.
Two nights in hospital; catheter out after 7 days.
Post-op:
Continent; no pads needed from the get-go.
Pathology showed organ confined and negative margins. Gleason downgraded to 4+4=8.
PSAs:
6-week : <0.05
7-month: <0.05
13-month: 0.07 (start of a trend?)
19-month: 0.09 (maybe)
25-month: 0.2 (yes, bummer)
27-month: 0.2 (not up; glad about that)
ED:
After a learning curve, Bimix injections (0.2ml) worked well. From 14 months, occasional nocturnal erections. At 18 months, "graduated" to just the pump.


Ed C. (Old67)
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Date Joined Jan 2009
Total Posts : 2461
   Posted 6/18/2010 7:21 PM (GMT -6)   
Interesting article. With EPE and Gleason 8, the article does give me much of a chance to remain relapse free.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Pathology report:
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm in circumference.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 5 months
2 months PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1
8 months PSA test 10/9/09 result <0.1
11 months PSA test 1/21/10 result 0.004
14 months PSA test 4/19/10 result 0.005


English Alf
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Date Joined Oct 2009
Total Posts : 2218
   Posted 6/20/2010 2:43 AM (GMT -6)   
Thanks for the link Galileo,

It made interesting reading, even if not all of what I read gave me a good feeling about my own situation. (the discovery of SVI)

I think this paragragh from the article is worth quoting.

"The optimal management for patients with post-RP PSA relapse has remained unclear.This stems from the inability to separate patients whose recurrent disease is confined to the prostate bed from those that have already developed occult metastasis.

Furthermore, the clinical course of patients with post-RP PSA relapse is highly variable. Some experience rapid clinical progression to metastasis, while others have a very indolent natural course. As a result, management options are diverse, ranging from salvage RT, either alone or in combination of androgen ablation therapy, as a definitive therapy to expectant management or androgen ablation therapy alone as a palliative therapy.

Up to now, there have been no published outcomes from randomized clinical trials addressing the efficacy of salvage therapeutic modalities. As such, treatment strategies for patients with PSA relapse have been mostly derived from retrospective series and small prospective studies, or by extrapolating evidences from clinical trials of primary cancer setting."


As I have previously mentioned in posts, my RT doc and I discussed the fact that it was not possible to tell if the PSA was being produced in the prostate bed or elsewhere in the body and that I was thus going to have RT without HT so that if the PSA went down it would indicate that the PCa had been left in the prostate bed. (With HT to follow if this did not prove to be the case)

Alfred
Age at Dx 48 No Family history of Prostate Cancer
Married 25 years, and I cannot thank my wife enough for her support.
April 2009: PSA 8.6 DRE: negative. Tumour in 2 out of 12 cores. Gleason 3+3.
RALP (nerve-sparing) at AVL-NKI Hospital Amsterdam on 29th July 2009. Stay 1 night.
Partial erections on while catheter still in. Catheter out on 6th Aug 2009.
Dry at night after catheter came out
Post-op Gleason 3+4. Tumour mainly in left near neck of bladder.
Left Seminal Vesicle invaded, (=T3b!)
no perineraul invasion, no vascular invasion. clear margins,
Erection 100% on 15th Aug 2009, but lots of leaking of urine
Stopped wearing pads on 21st Sept 2009
Pre-op style intercourse on 24th Oct 2009 !! No use of tablets, jabs, VED etc. but...
Nov 17th 2009 PSA = 0.1
Can still get erections okay, and almost no leaking of urine, but since December 2009 I don't have orgasms, instead I just have intense pain in place where prostate used to be.
Mar 17th 2010 PSA = 0.4!!! referred to radiation therapist
April 13th 2010 CT scan.
April 28th 2010 Started Radiation Therapy (66Gy - 33 sessions)
June 11th 2010 finished RT - main side effect tiredness, but also the occasional small leak


Galileo
Veteran Member


Date Joined Nov 2008
Total Posts : 697
   Posted 6/20/2010 11:06 AM (GMT -6)   
Alfred, that was essentially my strategy as well. I consulted with a medical oncologist and radiation oncologist before salvage RT. The medical oncologist said "Get the radiation. Your PSA should fall. If not, come back and see me--hopefully you will never need my services."
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 and thereafter <0.1
pcabefore50.blogspot.com


Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 6/20/2010 12:53 PM (GMT -6)   
Good post!

I just wanted to mention to the high risk guys to look into adjuvant therapies before a relapse. ART is proving to be more effective than SRT. The issue is knowing who would be a good candidate for ART. For me it was my Gleason and post-op stage pT3b (bilateral seminal vesicle invasion).

For anyone waiting to begin SRT, at least know this option is very effective...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 47 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
LARP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino


John T
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Date Joined Nov 2008
Total Posts : 4269
   Posted 6/20/2010 1:32 PM (GMT -6)   
Tony,
I'm not a doctor but I feel that anyone considering adjuvant RT would be better served by conventional IMRT or seed and IMRT combination. I could make a case for combination surgery and RT for very large tumors that would benefit from debulking. In all other cases the radiation should take care of all the margins without the necessity of 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

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