Use of mpMRI and PSMA PET/CT to aid in salvage radiation decision-making

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Tall Allen
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Date Joined Jul 2012
Total Posts : 8951
   Posted 12/6/2017 9:56 PM (GMT -7)   
There were a couple of studies that demonstrated how advanced imaging may help inform the salvage radiation (SRT) decision. The Mayo study was able to increase the predictive accuracy of the updated Stephenson nomogram for predicting SRT success. The Australian study showed the inferior results when metastases are detected, even with metastasis-directed SBRT. They both showed the importance of SRT especially when all the findings are negative. The primary use of imaging is to rule out rather than to rule in.

/pcnrv.blogspot.com/2017/12/use-of-mpmri-and-psma-petct-to-aid-in.html
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/6/2017 11:08 PM (GMT -7)   
Very interesting and timely Allen, especially the numbers in red smile THANK YOU!

Do they ever release preliminary findings from studies like RTOG 0534??

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/7/2017 12:49 AM (GMT -7)   
Preliminary findings on RTOG 0534 will be released in 3 years, certainly not before. No one will even look at any of the data before that. Data on 1792 patients are being collected separately in 460 locations since 2008. It's a massive NCI funded project.

I couldn't imagine what you were talking about when you said the numbers in red. Then I remembered the article from a couple of weeks ago on whole pelvic SRT had some red numbers - is that what you mean?

/www.healingwell.com/community/default.aspx?f=35&m=3945767
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/7/2017 8:31 AM (GMT -7)   
Yes sir!

5-Year Freedom from Biochemical Failure....very interesting, especially the numbers you highlighted in red.
70 years old @ Dx, LUTS for 7 years
PSA's never over 3.0
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry
10 week PSA .32
12 week PSA .40
14 week PSA .42
17 week PSA .54
Persistent PSA - 1" tumor still in cavity

AZ Guy
Regular Member


Date Joined Feb 2017
Total Posts : 61
   Posted 12/7/2017 6:57 PM (GMT -7)   
Thanks Tall Allen, this was a timely post for me as I had an MRI Monday at Mayo. This is to help with mapping my SRT which is scheduled to begin on Dec 18. With my high post-op PSA I was expecting/hoping to see a tumor at the site of the the positive margin. Then there would be a definitive area to target. It doesn't appear that I have such a definitive target. Any thoughts on the findings seen below?



04-Dec-2017 14:53 *** Final *** MR Prostate WO+W/CST AZ
CONCLUSION:
1. Exam performed for radiation treatment planning.
2. Status post prostatectomy and resection of the right seminal vesicle.
3. A portion of the left seminal vesicle remains in place, but has a benign appearance.
4. No residual prostate carcinoma is perceptible.

COMPARISON: Preop MRI pelvis 4/12/2017. Radiation therapy planning CT 12/4/2017. INDICATION: Malignant neoplasm of prostate for Radiation Treatment Planning Prostate cancer, status post robotic prostatectomy 08/24/2017, with Gleason 4+3=7, pT2c, with a positive right apical margin. Review of pathology at MGH interpreting Gleason as 3+4. Review of pathology at Mayo Clinic interpreting Gleason as 4+3, and also noting positive perineural invasion. Postoperative PSA 0.4 on 11/01/2017.

FINDINGS: Image quality: Surface coil was utilized. Since no endorectal coil used, diffusion/ADC images are suboptimal.
There is a rectal tube with a distended balloon in the rectum.
The patient is status post prostatectomy with susceptibility artifact in the region of the prostate. There is enhancing T2 dark soft tissue along the right vesicorectal angle without restricted diffusion, favor granulation tissue.
The right seminal vesicle has been resected. A 2.2 cm portion of the left seminal vesicle remains in place at the left side of the surgical fossa. It contains a small amount of hemorrhagic debris.
No lymphadenopathy.
Fat-containing 1.3 cm cross-sectional diameter indirect left inguinal hernia.
No focal osseous lesion.

PELVIS MRI TECHNIQUE: Multisequence multiplanar images were acquired through the pelvis with and without intravenous contrast.
Age 49
DX 2/17: G6 2/12 cores <5% in each; one lobe
PSA 6.6 (doubling actual 3.3 due to Finasteride use)
RALP 8/24/17
pT2c R1
Gleason 7 (4+3 St. Joe's and Mayo) (3+4 by Mass General)
Margin Positive
-ECE; -SVI; +PI
Tumor <10% of gland
PSA .40 9 weeks out
PSA .40 14 weeks out
6-MO Lupron shot on 12/4/17

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/7/2017 8:25 PM (GMT -7)   
It seems unremarkable to me. My understanding (which is limited) is that in detecting recurrences in the prostate bed, dynamic contrast enhancement (DCE) is superior to diffusion weighted imaging (DWI), which is the reverse of detecting tumors in an intact prostate. It appears that only T2 and DWI were done, and the T2 was done with and without contrast, but not dynamically (watching it continuously over time). It really doesn't matter. You know there was a positive margin, which improves prognosis, and they have to treat what they can't see as well as what they can see. Just as they don't "target" areas in the prostate, it is of questionable value to target any areas in the prostate bed.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Skypilot56
Regular Member


Date Joined Mar 2017
Total Posts : 260
   Posted 12/7/2017 8:26 PM (GMT -7)   
AZ Guy I will be starting my SRT at the mayo in MN on December 18th. I have been practicing emptying the bladder then drinking 16 oz of water some days good some days not so good. We'll have to compare our treatments as we go.

Larry
Male 61 DX @ 60
Father had PC
2002. Psa. .08 Enlarged Prostrate
2014. Psa. 3.8
2016. Psa. 19
3-08-17 RP Mayo Clinic Mn
Path Report: Gleason 9, pt3b, Seminal vessels and one nerve removed, negative margins, 35 lymph nodes removed no cancer, Prostrate 45 grams
4-20-17 Incarcerated Umbilical Hernia
6-13-17 1st psa check 0.13
7-19-17 psa 0.12 MRI clear
10-11-17 psa 0.16
10-12-17 Lupron started

ddyss
Regular Member


Date Joined Apr 2017
Total Posts : 144
   Posted 12/8/2017 7:14 AM (GMT -7)   
Thanks for the positive article!

I don't need SRT yet, but when I do , would it be worthwhile to go to Mayo for treatment.

I am in chicago.
DX@ 48 Yrs PSA 03/15 4.45 DRE: Firm Right Base
04/18 Biopsy Right: Base 4+3, Middle 3+4, Apex: HPIN
Left 6 cores : -ve
5/20 MRI: Pirads 5, ECE:+ve
RALP 05/26 Mt. Sinai Miami - Dr. A. Bhandari
Path:
Gleason downgraded to 3+4 !! Stage T2C
Prostrate Size: 49grams Tumor:20%
LN/SV/ECE: -ve PNI: +ve
Cath Removed : 6/1
Full continence: 7/4
PSA History :
7/7 <0.1
10/2 <0.006

AZ Guy
Regular Member


Date Joined Feb 2017
Total Posts : 61
   Posted 12/8/2017 7:51 AM (GMT -7)   
Thanks for the response Tall Allen. I suppose nothing has changed in that we'll need to hit the entire prostate bed with the IMRT. And how about that Skypilot...both of us starting the same day at Mayo- you in MN and me in AZ? Yes let's compare notes. Since my surgery I have noticed there is less time between drinking water and the urge to urinate. So I think I'm going to wait to drink the water until I'm in the car on the way to the appointment. I'm sure that once we get into a routine I'll get it just right.
Age 49
DX 2/17: G6 2/12 cores <5% in each; one lobe
PSA 6.6 (doubling actual 3.3 due to Finasteride use)
RALP 8/24/17
pT2c R1
Gleason 7 (4+3 St. Joe's and Mayo) (3+4 by Mass General)
Margin Positive
-ECE; -SVI; +PI
Tumor <10% of gland
PSA .40 9 weeks out
PSA .40 14 weeks out
6-MO Lupron shot on 12/4/17

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/8/2017 3:55 PM (GMT -7)   
There are some bad influences around here smile

Thanks to AZ Guy, Skypilot56, the team at NIH/NCI, the Radiation Oncology group at the Lake Nona VA hospital, my University of Miami RO....and in no small measure to Tall Allen Edel, I'm starting Casodex today, a three month Lupron shot late next week, and SRT IMRT in early January. It probably increases the odds of my SRT being successful by 4 to 6%. At this point I'm all in.

Expect to hear me whining about side effects for the next six months. ;-)
70 years old @ Dx, LUTS for 7 years
PSA's never over 3.0
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry
10 week PSA .32
12 week PSA .40
14 week PSA .42
17 week PSA .54
Persistent PSA - 1" tumor still in cavity

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/8/2017 4:52 PM (GMT -7)   
Gary,
Considering your PSADT of only 2.5 months, I think you are wise to add ADT. I hope that you are using the highest dose consistent with your colitis, and including the pelvic LN area, including the common iliac nodes.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Skypilot56
Regular Member


Date Joined Mar 2017
Total Posts : 260
   Posted 12/8/2017 8:24 PM (GMT -7)   
AZ Guy i go next wed for blood test and the synchronization trying to get into the hope house as I live 5 hrs north of Rochester.
Male 61 DX @ 60
Father had PC
2002. Psa. .08 Enlarged Prostrate
2014. Psa. 3.8
2016. Psa. 19
3-08-17 RP Mayo Clinic Mn
Path Report: Gleason 9, pt3b, Seminal vessels and one nerve removed, negative margins, 35 lymph nodes removed no cancer, Prostrate 45 grams
4-20-17 Incarcerated Umbilical Hernia
6-13-17 1st psa check 0.13
7-19-17 psa 0.12 MRI clear
10-11-17 psa 0.16
10-12-17 Lupron started

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4981
   Posted 12/8/2017 8:39 PM (GMT -7)   
Gary, I know this isn't what you wanted, I really hope it makes the difference for you.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margins, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033 November .046
Decipher test, low risk, .37 score

AZ Guy
Regular Member


Date Joined Feb 2017
Total Posts : 61
   Posted 12/9/2017 8:59 AM (GMT -7)   
Glad to have you on board this train Gary! I'm kind of resigned to the ADT side effects, but a lot of my decision-making is based on perceived future regret. If Radiation alone wasn't successful I'd hate to think back that I could have done something to improve my odds but didn't. I've also eliminated red meat, chicken and dairy from my diet. I'm all in on this fight.
Age 49
DX 2/17: G6 2/12 cores <5% in each; one lobe
PSA 6.6 (doubling actual 3.3 due to Finasteride use)
RALP 8/24/17
pT2c R1
Gleason 7 (4+3 St. Joe's and Mayo) (3+4 by Mass General)
Margin Positive
-ECE; -SVI; +PI
Tumor <10% of gland
PSA .40 9 weeks out
PSA .40 14 weeks out
6-MO Lupron shot on 12/4/17

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/9/2017 10:00 AM (GMT -7)   
Thanks, guys....if I eliminated chicken from my diet, PCa wouldn't kill me, I'd starve to death!
70 years old @ Dx, LUTS for 7 years
PSA's never over 3.0
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry
10 week PSA .32
12 week PSA .40
14 week PSA .42
17 week PSA .54
Persistent PSA - 1" tumor still in cavity

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/10/2017 7:56 AM (GMT -7)   
Tall Allen said...
Gary,
Considering your PSADT of only 2.5 months, I think you are wise to add ADT. I hope that you are using the highest dose consistent with your colitis, and including the pelvic LN area, including the common iliac nodes.


That's the plan, Allen. Now looking at about 70 Gy over 34 treatments with special focus on the 2.6cm tumor and the LN's. No rectal balloon or cast planned. I'm planning to stop Casodex about several weeks after commencing radiation; and end Lupron one month after radiation ends.

All in life is a compromise smilewinkgrin

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4981
   Posted 12/10/2017 9:10 AM (GMT -7)   
garyi said...
Thanks, guys....if I eliminated chicken from my diet, PCa wouldn't kill me, I'd starve to death!


😂😂😂😂😂
Gotta know you to appreciate that one.

Gemlin
Veteran Member


Date Joined Jul 2015
Total Posts : 620
   Posted 12/10/2017 12:56 PM (GMT -7)   
Why eliminate chicken?
Lower intakes of red meat and well-done red meat and higher intakes of poultry and fish are associated with lower risk of high grade and advanced prostate cancer and reduced recurrence risk, independent of stage and grade.
/www.ncbi.nlm.nih.gov/pubmed/27651069

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/10/2017 1:52 PM (GMT -7)   
Good find, Gemlin!

Chick-fil-A or Pollo Tropical...but not fried, and no cheese. I'm sooooo relieved ;-)
70 years old @ Dx, LUTS for 7 years
PSA's never over 3.0
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry
10 week PSA .32
12 week PSA .40
14 week PSA .42
17 week PSA .54
Persistent PSA - 1" tumor still in cavity

AZ Guy
Regular Member


Date Joined Feb 2017
Total Posts : 61
   Posted 12/10/2017 2:05 PM (GMT -7)   
Wow thanks for posting that Gemlin. I'd love to keep eating chicken...seems like I've seen a number of links posted to the contrary on this forum.
Age 49
DX 2/17: G6 2/12 cores <5% in each; one lobe
PSA 6.6 (doubling actual 3.3 due to Finasteride use)
RALP 8/24/17
pT2c R1
Gleason 7 (4+3 St. Joe's and Mayo) (3+4 by Mass General)
Margin Positive
-ECE; -SVI; +PI
Tumor <10% of gland
PSA .40 9 weeks out
PSA .40 14 weeks out
6-MO Lupron shot on 12/4/17

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4981
   Posted 12/10/2017 2:46 PM (GMT -7)   
Gemlin said...
Why eliminate chicken?
Lower intakes of red meat and well-done red meat and higher intakes of poultry and fish are associated with lower risk of high grade and advanced prostate cancer and reduced recurrence risk, independent of stage and grade.
/www.ncbi.nlm.nih.gov/pubmed/27651069


Only 6% of the 971 men in the cohort were Gleason 8-10. And 41% were Gleason 6.
They say they adjusted for this, but I dunno.
Also, food questionnaires are notoriously unreliable from all I've read

In addition, this paragraph is very telling, especially the comment that men may have changed their diet after diagnosis, and with only one food questionnaire there is no way to know this...

The use of PSA recurrence as an outcome may also be a limitation. While PSA recurrence is a highly clinically relevant event for men with prostate cancer, many men with PSA recurrence do not experience clinical progression to metastases or prostate cancer–specific death. In this population of men diagnosed with localized disease, only 3 men had progressed to metastatic disease during this follow-up period, so we are unable to study metastatic or fatal disease as an outcome. In addition, we have only a single diet assessment taken at the time of diagnosis, and it is possible that men changed their diet after treatment. The study population is almost entirely white, limiting generalizability. Finally, the follow-up of an average of 3 years is short, and as a result, we had a limited number of PSA recurrence events. Because of this, we had relatively low power to detect associations, which may explain some of our null findings. Strengths of the study include its prospective design, comprehensive FFQ, and availability of clinical and follow-up data from a single treatment center.

Post Edited (Pratoman) : 12/10/2017 3:12:06 PM (GMT-7)


Gemlin
Veteran Member


Date Joined Jul 2015
Total Posts : 620
   Posted 12/10/2017 3:13 PM (GMT -7)   
WCRF (World Cancer Research Fund) collected data in 15 prospective cohort studies including over 840,000 men and wrote for advanced PC:

In contrast, a modest inverse association was observed for poultry consumption and a modest positive association was observed for egg consumption
www.wcrf.org/int/research-we-fund/what-we-re-funding/dairy-and-plant-foods-and-advanced-prostate-cancer

Eat more chicken if you like it! But maybe skip the skin and don't fry it. yeah

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/10/2017 4:04 PM (GMT -7)   
OK...no skin, no frying, and white meat only. smile

Prato, based on the telling paragraph you posted, lots of brothers may be either obsessing for nothing, or undergoing unnecessary treatment. To wit:

"many men with PSA recurrence do not experience clinical progression to metastases or prostate cancer–specific death". shocked

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4981
   Posted 12/10/2017 6:21 PM (GMT -7)   
Yup, I did note that sentence in the full paper. It's encouraging, but if only we knew which ones wouldn't progress to mets, with surety. But surety doesn't exist in the PC Business.

And along that line of thinking, nobody really knows for sure that chicken or meat, or eggs, or anything, affects or doesn't affect chance of progression. So nobody should obsess too much.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margins, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033 November .046
Decipher test, low risk, .37 score

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 315
   Posted 12/11/2017 12:30 PM (GMT -7)   
Pratoman said...
Yup, I did note that sentence in the full paper. It's encouraging, but if only we knew which ones wouldn't progress to mets, with surety. But surety doesn't exist in the PC Business.

And along that line of thinking, nobody really knows for sure that chicken or meat, or eggs, or anything, affects or doesn't
 
No poop, Sherlock. Even semi-certainty is non existent in the PCa business. The more they learn, the more the realize how little they really know.  eyes  
 
Sounds like a Chinese feast tomorrow, with zero worries.  idea
 
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