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standard brachy vs hd brachy vs cyberknife for boost treatment?

RonJT
Posts: 32
Joined: Feb 2011

I thought this might be better to post as a new topic.  My original thread is here if you need history

http://csn.cancer.org/node/300336

Went today for my first dose of lupron at UCSF.  Also got the results back from my 3TMRI which showed the following:

FINDINGS:

 Prostate volume: 18.29 cc

 PSA density: 0.41 ng/ml2

 Post-biopsy hemorrhage: None

 Multiparametric MR evaluation:

 Heterogeneous appearance of the central gland is consistent with benign prostatic hyperplasia.

 Lesion 1: 

Left apex; 1.1 x 0.4 x 0.4; PACS image 41 and series #400 

On T2-weighted MR imaging, the lesion is seen as an ill-defined focus of low signal intensity (score = 3/5). 

The lesion demonstrates marked restricted diffusion (score = 4/5). ADC value: 938

Overall PI-RADS (version 2) score = 4 

No suspicious metabolism is seen in the lesion.  

Capsular margin and neurovascular bundle: Unremarkable 

Seminal vesicles: Unremarkable 

Lymph nodes: No evidence of lymphadenopathy in the field of view 

Bones: No suspicious lesions

IMPRESSION: 

- PI-RADS 4: clinically significant cancer is likely to be present as above.

- No evidence of extracapsular extension.  No evidence of seminal vesicle invasion.

- MR T-stage = T2A

- No lymphadenopathy.  No suspicious bone lesions.

While the MRI is encouraging (stage T2A), the biopsy shows a moderately aggressive pCA stage T2B. I believe the biopsy results would be more accurate than the MRI.  Is that not correct?  

My radiation oncologist is advising 5 weeks of IMRT followed by a boost.    The boost could be standard brachytherapy, HD brachytherapy, or cyberknife (EBRT).  During this time I will be on 4 months of ADT (Casodex and Lupron).  Does anyone have more info for me about the 3 possible boost therapies?  I am familiar with the 3 procedures but would like to hear from anyone who has undergone  one of them re: side effects, outcome, quality of life issues etc. Apparently I will be able to choose the boost therapy that I prefer.  I have not been able to find any studies that compare them to one another as a boost treatment.  Thanks for any and all info.

Swingshiftworker
Posts: 1013
Joined: Mar 2010

I and others have been sucessfully treated w/CK as a primary form of PCa treatment without any or few side effects.  I believe there are a few men here who were successfully treated w/ LDR (low dose rate) BT (brachytherapy) but I also recall them complaining about certain side effects.  I do not recall anyone here who has reporteded being treated w/HDR (high dose rate) BT either as a primary or secondary form of treatment.  

Here is a link which describes the CK procedure: http://www.cyberknife.com/cyberknife-treatments/prostate/how-used-treat-cancer.aspx

Since you are going to receive 5 weeks of IMRT (25 treatments) which presentss its own risk of side effects, I think that the secordary form of treatment should be as precise and accurate as possible to minimize any additional side effects and/or complications and the best secondary treatment wouild be CK which will deliver the additional radiation in the more precise method possible.  With CK, radiation can be delivered w/a sub-mm degreee of accuracy and the treatment can be adjusted to deal w/organ and body movement.  Only 3-4 additional treatments of CK are required over a week's time; no hospitalization is required.  You can walk out of the treatment room just as you can w/IMRT and you should not experience any side effects beyond what has been caused by IMRT.

The design of CK was based on HDR BT.  HDR BT involves the temporary placement of radioactive seeds in the prostate.  I believe that a catheter needs to be installed and remain in place for 1-2 days and that hospitalization overnight is required.   The accuracy of HDR BT depends on the accuracy of the placement of the seeds in terms of location, dose and duration.  All of this is done manually, not by computer as w/CK.  So, the degree of accuracy in terms of the application of the radation is not as good as w/CK. 

Here's a link which describes the HDR BT procedure in great detail: https://www.mskcc.org/cancer-care/patient-education/high-dose-rate-brachytherapy-treatment-prostate

LDR BT involves the permanent placement of radioactive seeds in the prostate.   I never liked the idea of LDR BT simply because of that.  The seeds will always be detected and may trigger magnet detectors at the airport and public buildings.  You will also be "radiaoactive" for at least a year (the 1/2 life of the seeds) and have to stay away from pregnant women and small children during that time.  Also the seeds can move and/or be expelled through the urethra and/or anus.  Catherization and hospitalization may be required. 

Couldn't find a link to describe the LDR BT procedure as precisely as the one above, but this link should be informative nonetheless: https://isoaid.com/uploads/files/isoaid_patient_guide_2015.pdf

Of the 3 methods, LDR BT is the least accurate and most likely to cause immediate side effects, which involve rectal bleeding and pain/discomfort peeing.  Longer term side effecdts can include bladder/rectal damage (proctitis), ED and incontinence.  HDR can have similiar immediate/long term side effects but such side effects are virtually non-existent for CK.

Obviously, my choice would be CK in terms of convenience, effectiveness and quality of life.  Read up on the differences yourself and talk w/your doctor to decide what you think would be best in your situation.

Good luck!

RonJT
Posts: 32
Joined: Feb 2011

Thanks swingshift worker for the info and articles.  I have a few months to wait for the RT to start so I will be spending some time looking all this over.  I have received invaluable information from the people on this site.

RonJT
Posts: 32
Joined: Feb 2011

I did find this on the use of Cyberknife as boost therapy

https://ro-journal.biomedcentral.com/articles/10.1186/s13014-016-0585-y

Old Salt
Posts: 720
Joined: Aug 2014

Results look pretty positive to me. In this study, just two CyberKnife sessions (10 Gy each) after 25 EBRT treatments.

I wonder what the best approach is, SBRT first or SBRT afterwards?

RonJT
Posts: 32
Joined: Feb 2011

It's been awhile so thought I would update the group on my progress.  I did end up choosing cyberknife for the boost therapy and was happy with that decision.  Have now been off ADT for 5 weeks.  Still having hot flashes and I expect that will continue for another month or 2.  Getting up at night 2-3 times to urinate.  Flow is good.  Had some numbness and tingling in both hands for awhile.  That has resolved on the right but not quite on the left hand.  Other than that I am symptom free.  No pain, no bleeding, fully continent and physically active. Have not had a followup PSA yet.  That is scheduled for December.  For those of you in the moderate risk category as I am, I hope you find this helpful in choosing your therapy.

Age 69
2/2009 PSA 4.3 Biopsy negative

2009-2016 PSA climbed from 4 to 6

DRE all negative

2/2016 PSA 7.5

Ultrasound and DRE indicate nodule

Biopsy with 6 of 12 cores pos

Two 4+3 Four 3+3

5/11/16 Gold Markers Placed

5/5/2016 on Lupron and Casdex

IMRT started 7/2016 25 fractions 45Gy total

8/4/16 Flomax  0.4mg  started

Cyberknife boost 8/9/16 2 fractions 19 Gy total

9/1/16 Last Dose of Casodex

 

Swingshiftworker
Posts: 1013
Joined: Mar 2010

Glad to hear that your CK boost treatment was uneventful in terms of neg side effects.  Hope the followup PSA reading is where you hope it should be. 

RonJT
Posts: 32
Joined: Feb 2011

4 months post RT therapy my PSA was <0.1.  Needless to say I'm pretty happy with that.  So far so good.

VascodaGama's picture
VascodaGama
Posts: 2988
Joined: Nov 2010

Ron,

It is super reading your good results. I hope to read remission in your next update on the treatment outcome.
The PSA will take time before reaching the lower levels. Enjoy the moment and celebrate.

Thanks for the update.

VG

update

Old Salt
Posts: 720
Joined: Aug 2014

I agree that that PSA result  is looking very good. But in contrast to what Vasco wrote, I expect the PSA to go up a bit once your testosterone fully recovers.

VascodaGama's picture
VascodaGama
Posts: 2988
Joined: Nov 2010

I agree with Old Salt opinion in regards to the testosterone. I would recommend you to check the testosterone level to pair its result with the PSA. In other words, a low PSA in a low testosterone status could mean that nadir is not yet achieved. ADT could still be masking the PSA if the Lupron dose was higher than one-month. Typically, the 3, 4 or 6 month shot can delay the testosterone recovery to over 4 months (counting from the end of of shot's effectiveness), therefore influencing the PSA result. Casodex half-life is approximately 7-10 days so that its influence on prostatic cells is over since September. I would think that the PSA can increase above <0.1 (ng/ml) but the result should not be taken as treatment failure. Bounce is typical before nadir in guys with the gland in place.

In any case, the result is to be celebrated. Most probably you knocked down the bandit for good.

 Merry Christmas,

VGama

Will Doran
Posts: 207
Joined: Sep 2015

RonTJ,

Sounds like you are making good progress. Congratulations. 

As Old Salt and VG have stated.  It takes a while for the PSA to drop.  I had robotic surgery, and mine went down to <0.010 in about 6 months.  I was on Lupron for two full years.  My Testosterone was down to 17.  Normal is 250 - 1,100.  As my last shot of Lupron wore off my Testosterone started coming back up.  When it was up to 134, my PSA still stayed at <0.010.  Then when my Testosterone came into the normal range (it was up to 320 at my last testing), my PSA did come up to 0.035. My doctors were pleased with those results.   I have more blood work in two weeks and will then see what we have to do next.  My doctor has stated that we might try intermittent Lupron.  On three months and off three months. He has also mentioned Casodex. If that doesn't work then I'll have to have some permanenet form of ADT.

Best of Luck

Merry Christmas

Love, Peace and God Bless

Will

Swingshiftworker
Posts: 1013
Joined: Mar 2010

I recently had my testosterone levels checked and the are right w/in the "normal range" at 771 ng/dl for total T (240-871 ng/dl is standard) and 65.6 pg/dl for free T (18-111 pg/ml standard).  However, my PSA level still continues to drop following CK treatment 6 years ago.

I did a little reading on the topic and it turns out that there apparently is little relationship between T level and PSA levels or PCa recurrence following treatment.  One study concluded that, while there can be a  drop in T level after radiation treatment, T levels usually return to normal and do not have any effect on the likelihood of PCa recurrence following treatment.  See: https://www.ncbi.nlm.nih.gov/pubmed/11992055.  Another study concluded that testosterone replacement therapy iniitiated after prostate removal also did not promote the recurrence of cancer.  See: http://www.medscape.com/viewarticle/764266.

So, given these results, I'm a bit confused why androgen deprivation therapy is even necessary or effective.   ADT is supposed to suppress T levels which is believed to promote the growth (or recurrence) of PCa as measured by PSA.  If there is little or no relationship between T levels and PCa recurrence, why use ADT at all?  Does ADT just reduce PSA and have no real effect on T levels?  Doesn't make sense to me.  Can anyone elaborate on this?

VascodaGama's picture
VascodaGama
Posts: 2988
Joined: Nov 2010

Swing,

It all depends on T levels. As you comment above normal T levels are considered between 240-871 ng/dL. Clinical castration (threshold used in trials) are T less than 50 and Medical castration (threshold used in ADT) are T less than 30 ng/dL (some oncologists use still a lower 20 threshold level). These are the levels aimed by physicians when treating and evaluating the patient's status. In other words, castration is what leads doctors to administer hormonal drugs or orchiectomy. Radiation does not drive T to such low level of castration. Additional means are required when combine treatment of RT+HT is the prime protocol.

By experience, I was at T<1 ng/dL during a period of six months at the end of my ADT of 18 months (PSA=0.02 ng/ml) and, when T started to recover reaching the out-of-castration level of T=56 ng/dL (at the 24 month milestone) the PSA also increased, accompanying the increase of T, from 0.02 to 0.03. this tiny climb signifies the influence of T (above castration) on prostatic cells activity as seen/interpreted by both levels; T and PSA. Six months later T reached 384 and PSA was 0.71. I was back to normal levels of T and so it was the bandit wish, enjoying daily T frenzy cocktail parties.

Surely, not all cases are equal. Also the effects may differ if the gland is or is not present. Benign cells also absorb T and produce PSA. There are also those type of cancerous cells that produce little or no PSA at all.
In regards to the trials you refer above, there is no indication of patients initial level to judge the results but in the RT patients' study the T % reached by these signifies they reached T levels above castration. In the RP patients trial, patients were supposed to be in remission levels (PSA=<0.03 ng/ml) without prostatic cells in their body. Logically any PSA variation in the scale indicated between 0.004 to 0.009 ng/ml (all levels within the remission status) would not signify that such has been produced by cancerous cells. The tiny existing levels are thought to be produced by benign cells at the urethra that were not dissected at RP. In comparison with my personal experience (no gland in place) TRT would inevitably cause a surge in cancer activity leading to recurrence much faster. I can go through TRT but should be vigilant for never loosing the grip in controlling the advancement.

Are you going for a ride to Spain this Christmas?

Best,

VG

 

RonJT
Posts: 32
Joined: Feb 2011

Thank you for your insights gentlemen.  FYI my T-level was 372 ng/dl when the PSA of <0.1 was drawn.  I suspect, based on the way I feel, that the T-level will be higher next time.  I am 4 months post Lupron therapy.  I am scheeduled for a repeat PSA and T-level in 4 months.

Swing,
I can't really elaborate on the ADT question.  What I was told by the radiation oncologist was the ADT made the cancer cells more vulnerable to the radiation. I'm not sure what studies this is based upon.  It is known to slow tumor growth so maybe that's reason enough.

http://jamanetwork.com/journals/jama/fullarticle/201192  (full paper)

CONCLUSIONS

Androgen deprivation therapy is the most widely used systemic treatment for prostate cancer. In the metastatic setting, ADT has clear quality-of-life benefits but has not been shown to have survival benefit. Patients receiving local treatment with radiation therapy for high-risk disease have proven survival benefit. However, the role and benefit of ADT in biochemical failure after local therapy is unclear.

Adverse effects of ADT often mimic testosterone deficiency due to other causes. When anticipated prior to or early in ADT, some adverse effects, such as bone loss, can be prevented. Adverse effects, such as hot flashes and sexual effects, can significantly affect quality of life. Metabolic changes also occur, some of which are risk factors for cardiovascular disease. Clearly, further study is required to help physicians carefully weigh the benefits against the morbidity associated with ADT and to optimize the management of adverse effects.

 

VascodaGama's picture
VascodaGama
Posts: 2988
Joined: Nov 2010

T-level at 372 ng/dl and PSA of <0.1 is great. The next results will just confirm the above but I think it to maintain similar levels.

Wishing you peace of mind.

VG

RonJT
Posts: 32
Joined: Feb 2011

My first PSA after radiation therapy was <0.1ng/ml on 12/6/17
Latest PSA 0n 3/6/17 is 0.2 ng/ml

Should I be concerned about the increase?

 

 

Old Salt
Posts: 720
Joined: Aug 2014

No, you should not be concerned at all. After ADT and radiation, your PSA will jump around. There may even be a spike (bounce). If that happens, your PSA hopefully will settle down again for a long time.

The PSA level that warrants attention is nadir + 2 for patients like you (and me) who had radiation therapy.

Carpe Diem!

RonJT
Posts: 32
Joined: Feb 2011

Thanks Old Salt.  I have heard many numbers around the term nadir.  How do you know when you have reached nadir?  Are we talking years?

VascodaGama's picture
VascodaGama
Posts: 2988
Joined: Nov 2010

Guys with the gland in place (RT patients) may experience the PSA bounce phenomenon after the treatment that can last years. Their nadir, which would serve to judge treatment success or failure, is the lowest PSA at the end of the bounce. At the moment you cannot be sure that the last PSA= 0.2 ng/ml is in fact the nadir. You need three constant increases to verify the value of nadir, from tests spanned at least two months (longer the better).

As Old Salt comments above, recurrence (in RT patients) is declared by a PSA of nadir + 2.0 ng/ml. Your levels are too far away to worry on the matter.

VG

RonJT
Posts: 32
Joined: Feb 2011

I am pretty much symptom free.  No pain, no bleeding, fully continent and physically active. Follow up PSA's are good (see below).  For those of you in the moderate risk category as I am, I hope you find this helpful in choosing your therapy.

Age 69

2/2009 PSA 4.3 Biopsy negative

2009-2016 PSA climbed from 4 to 6

DRE all negative

2/2016 PSA 7.5

Ultrasound and DRE indicate nodule

Biopsy with 6 of 12 cores pos

Two 4+3 Four 3+3

5/11/16 Gold Markers Placed

5/5/2016 on Lupron and Casodex

6/8/16 Lupron Dose #2

7/2016 IMRT started 25 fractions 45Gy total

8/4/16 Flomax  0.4mg  started

Cyberknife boost 8/9/16 2 fractions 19 Gy total

Weight down to 128

9/1/16 Last Dose of Casodex

11/18/16 Hot flashes end; getting up 1-2 x per noc

12/6/16 T level 372 (348-1197)  PSA <0.1

12/17/16 Weight now 140 (my normal)

3/6/17  PSA 0.2 T 288

7/17/17 PSA 0.2 T 308  

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