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Treatment options for metastases post Radical Prostatectomy

sipan
Posts: 1
Joined: Feb 2018

Hi,

I am writing on behalf of my father (Age: 65). My father was diagnosed with prostate cancer in 2015, following which he underwent radical prostatectomy (2015), hormone therapy (2015), and radiation therapy (2016). This year his PSA level started rising and PET CT scan has revealed metastases in right iliac bone. Please find below a detailed case history with PSA levels at different points in time.

We’d be grateful if you could share what are the potential treatment options and implications on quality of life because of the disease. Thank you!

 

Case History:

+ 2015 Jan: Diagnosed with carcinoma prostate cancer (PSA: 9.3) through fusion biopsy of prostrate (Gleason score-8) – age at the time of diagnosis: 62

+ 2015 Mar: Surgery done; histopathological report post operation: Tumor 2C reported (Surgery methodology - Robot Assisted Radical Prostatectomy with Extensive Pelvic Lymph Node Dissection) 

+ PSA post operation: 0.11 in May 2015; 0.50 in August 2015; and 0.82 in Nov 2015

+ 2015 Nov: Hormone therapy (Firmagon) started  - loading dose (240) followed by five maintenance doses (80) at monthly intervals

+ 2016 May: PSA .07

+ 2016 May: Bone scanning done – no traces found, MRI done - no issues found

+ 2016 May: Radiation given (IGIMRT – 30 times) between May 2016 May and Jun 2016

+ PSA post radiation: < 0.07 in Oct 2016; <0.07 in Jan 2017; <0.07 in May 2017; 0.11 in Aug 2017; 6.6 in Jan 2018

+ 2018 Jan: PET CT Scan done – metastases detected in right iliac bone à one dose of Hormone given, Doctor have suggested Orchiectomy to contain growth

slickjy
Posts: 26
Joined: Jan 2017

Yor father's case mirrors my own (age, prostate tumor size & severity, treatments thus far, etc.).  My surgery was in June 2013.  My PSA is currently 116.  Since surgery I have had radiation, androgen deprivation therapy (Lupron and Casodex), 3 Xofigo injections (radium 223) in combination with Zytiga (aberaterone), and, since Nov 15th & currently, enrolled in phase 3 of clinical trial administering daily Xtandi (enzalutamide) in combination with Tecentriq (atezolizumab) infusions every 3 weeks. I also get a Zometa infusion (bone strengthening agent) every 4 weeks and I continue (since Feb 2015) with a Lupron injection every 3 months.

Other than occaisional fatigue, I have had virtually no side affects from any treatments (though never recovered a sex drive after surgery), just no success stopping metastatic spread, which, like your father's metastasis, also started in iliac bone.  Metatsasis was discovered last April, 2 sets of scans since have shown continued metastatic progression.  Despite that, I have minimal pain, though it has been worsening a bit as of late.

I have not had an orchiectomy (no doctor ever suggested it), though I am "chemically castrated", with an undetectable testosterone level.

Throughout all this, I have maintained an otherwise healthy lifestyle, little changed from original.  My wife is a rock of support - hopefully your father has that type of support as well.

I am no doctor, for sure, but my own experience tells me that there are several treatment paths preferable to further surgery.  One or more of these can be effective.  I have just been an unlucky case so far. I suggest research, research, research and discuss ALL options with your oncologists.

Good luck to him and yourself!

 

 

  

VascodaGama's picture
VascodaGama
Posts: 2961
Joined: Nov 2010

Sipan,

Welcome to the board. The histology of the events you describe above is typical in sequential treatments for PCa progression. Unfortunately the RT of 2016 did not cover the area at the iliac or it did but the timing of administration of the rays did not fit the right life cycle phase of some of the cancerous cells assuring its killing. It happens so that one can never think being totally cured even after such attack.
In continuing the sequential treatments since 2015, doctors usually recommend chemo. This is a systemic approach but it is linked to many side effects which makes us to try avoiding it choosing instead the palliative hormonal weaponry (ADT) to try controlling the advancement of the cancer.

In any case, after radical failures, some oncologists have introduced a newer sequential they call oligometastatic treatment. This refers to a fewer number of metastases located in propitious areas that can be radiated, which may lead to a successful end of the left cancer. To such intent one must firstly try locating those metastases. And in this regard I believe that your dad’s doctor has done well in getting the PET/CT to locate the relapse. I wonder what tracer was used in the PET exam. Can you tell us if it was the F18 Flurocholine? Or was it a PSMA radiotracer?
The trustfulness judgment of the result depends much on the type of tracer or the isotope (radiopharmaceutical) technique used in the nuclear testing.

According to your shared info, the test found metastases in bone at the iliac but his doctor is just recommending a palliative attack with hormonal manipulations. I wonder why he didn’t recommend spot radiation of such affected bone. Is it due to the risks that an attack of “radiation over radiation” could cause? Did you discuss the matter with the radiologist that did RT in 2016? Was the area covered back then?

Orchiectomy may contain the growth but it will not cure the case and surely will affect the quality of living of your dad (relatively young). Orchiectomy is a cheap permanent intervention which (castration) status can be achieved via drugs, intermittently. While on drugs one experiences a series of side effects but these can be recovered once one stops taking the drugs (off-drugs period) and its effectiveness vanishes.

Traditionally ADT is done with a combination of two drugs, an antiandrogen (like Casodex) and a LHRH agonist (like Lupron). Some guys manage control with just a Lupron shot (once every three/four months). I have been in similar treatment for the past 7 years since failed RP and RT but I still want to try cure via the oligometastatic treatment approach (I am 68 yo). I need clearance from my radiologist if cancer is detected again at previously radiated areas (it seems to be the case as bone is not affected in the image study).

I would do some research on my above comments. Try googling “oligometastatic prostate cancer”. Above all, get second opinions from due specialists.

https://www.verywell.com/oligometastatic-prostate-cancer-part-i-4019543

 

 

Best wishes and luck in your dad’s journey.

VGama

 

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