SBRT 18 mo. ago and cancer is back

Thanks for the inputs guys. I did have a PSMA (F-18) on 4/15/22 and it indicated that the cancer is still confined to the prostate, probably the best news out of a bad situation.

My urologist was not keen to start me on Lupron at this stage and confined his recommendations to RP and cryo. I asked him about brachy and he was concerned about too much radiation. My RO thought that between cryo and brachy that HDR would be the best approach and I have read many articles where SBRT followed by HDR is an acceptable choice. I read recently that HDR actually delivers more radiation to the tumor than SBRT while delivering less to the surrounding tissues that we care about. But you make a good point which I will bring up with the HDR specialist tomorrow. That concern could be a positive for cryo.

VGama, you make a great point re: waiting. I've actually been thinking about that for a couple days. I'm also posting on a PC forum at healingwell.com and there's a guy who had Cyberknife and a PSA progression that went: PSA’s post SBRT 1.1, 1.1, .9, 1.8, 2.7, 1.0, 0.3, 0.6, 0.8, 0.4. His team did not rush to do a scan or biopsy at 2.7 and were confident that it would come down. However, his pre SBRT biopsy volume was lower than mine, which was 80% in one of the cores. So my recent biopsy showed 4 of 6 cores benign but one core at 80% so it appears to be growing and I'm a bit nervous going back on AS. If by 'disregarding spread' you're referring to volume?

My urologist thinks I should proceed with one of the therapies and not wait and I'm concerned about the cancer escaping the prostate which seems to be a much worse issue.

My biopsy was on 5/16 and I may just get a PSA from a local lab even though it's a bit early after the biopsy to do that. In any event

So I will put the AS/bounce question to my RO as well as the HDR specialist that I'll talk with tomorrow.

I copied the update just posted on healingwell.com:

Well, I had a consultation with Dr. McChord in Atlanta re; HDR as a focal therapy and he declined to move forward because of my history before the Cyberknife therapy of high volume on the right side and now after my recent PSA rise and subsequent biopsy of one section on the right side also up to 80%. He said that he could attack the existing tumor but is concerned that at some point I'll need whole gland therapy and the total dose will be too hard on surrounding structures such as rectum and bladder.

He recommended I look into proton therapy because its ability to better control beam length, so I have a consultation set up at Emory Proton Therapy in Atlanta in two weeks.

On the possibility of me just going through a post-SBRT PSA bounce, he was skeptical as is my RO but said he would support a 3 month period of AS.

So back to the research. I also need to get a consultation with the cryo expert as it's still a candidate as well as HIFU and I guess even IRE/Nanoknife. I'm already stressing with the cancer 'escaping' the prostate and just don't know how to gauge when that could happen. I guess at some point I may submit to RP, though I hope later than sooner...

I've talked with four docs who've reviewed my scans and they all say it's contained, thanks.

However, in the course of my research, I've recently had 2 specialists in the radiation field say that my pathology report from the recent biopsy has the notation of 'radiation effect' for the two (of 6) areas labeled as adenocarcinoma. They both say that it's almost certainly cells still in the process of dying, that it can take 3 or more years for the process to complete. I guess if true (and of course I hope it is), there could still be active cancer cells in there that have not been radiated, we'll see.

The other thing is I had another PSA test on 6/13 and it dropped from 1.46 to 1.09. Both specialists said this is a bounce and to wait and monitor the PSA. So my urologist agreed that I go back on AS. I think my local docs did jump the gun.

I'm also waiting for my 2nd opinion of the biopsy report from Epstein at John Hopkins. His view should be interesting.

Epstein report arrived. As with the local biopsy report, no gleason score was assigned. He did bump down the volume of the smaller tumor sample to 10% from 20% and left the following note:

NOTE: The tumor in this case shows treatment effect in that there are individual cells with abundant vacuolated cytoplasm where the nuclei show smudged chromatin and absent nucleoi. Cancers which show radiation therapy effect have in some cases been associated with a better prognosis than tumors which appear unaltered by radiation (CANCER 115:673-9, 2008).

So I don't think this changes anything either way except for confirmation that radiation effect is indeed going on here but without any assurances that cells without radiation effect are gone (for now).