Radiologist this week.. 1 Lesion found in pelvis. Advice?

Every patient is different, but in very general terms, the latest approach for oligometastatic PCa seems to be to radiate the metastasis then begin or continue systemic therapy with both ADT and an ARSI (typically a -lutamide) at the same time. Your prostate is already removed, but they might also suggest doing some salvage radiation around where it was to deal with any undetected local spread (if it's not too close to the metastasis).

Best of luck!

Hi...I don't have treatment option advice, but I can relay my experience. I did not have surgery as my PCa was significantly metastatic at discovery, including bone lesions, but my current treatment plan (after IMRT to prostate) is ADT/ARSI, followed by targeted radiation to specific lesions as necessary.

You don't list ADT/ARSI as part of your treatment plan. If you are not on it, that's probably next. Best wishes.

ETA - Ha...North types faster than I do. 😊

@mjp0512
Thank That’s the plan..

Looking at this in order:
> Prior to your RALP, did your PSMA PET scan show any metastasis, or was there any ECE, intraductal carcinoma or Cribriform pattern of the prostate noted? (If so, this may help better understand the severity of your original diagnosis and determine where to go from here.)

> Did “watch mode” mean “watchful waiting” or “active surveillance”? How severe were the other numbers you were tracking (besides PSA)?

> How many oligometastatic lesions are there?

> Is the metastasis only to bone or to both bone and soft tissues/organs?

> What does your current PSMA PET scan report show the SUVmax scores of those lesions as?

> What are your genetic (germline) test results?

Treatment options should depend on a full and complete understanding of the recurrence.

begreat99, you might ask about Prolia or Zometa. I don't know if it is better before radiation or after. But it can prevent further bone metastasis and prevent skeletal related events like fracture.

When the prostate cancer has spread outside the prostate, they usually like to use radiation. They can radiate the prostate as well as the bones to try to eradicate the cancer.

In my case, 14 years after I had surgery and radiation, I had to have a metastasis on my spine zapped with SBRT radiation. Seems to have worked quite well since my PSA has become undetectable for the last 24 months.

I know a lot of people that have had there bones zapped with SBRT to remove metastasis. I know one guy that had at least a dozen treatments, Three different sessions, But it seemed to have worked for him.

Yes, you can have surgery, but they will still have to do radiation to get the metastasis on the bones. They also use radium 223 to handle bone mets. If you only have one radiation makes more sense, Though it depends on the extent of the damage.

@brianjarvis Thank you for insights. I am just now entering this next phase of treatment which was a surprise. My scan and MRI in December were both clear before surgery, offering hope for a clean surgery with Dr. Pow-Sang at Moffitt here in Tampa. Upon surgery cancer was found in the seminal vesicle and thus we knew radiation was in front of us. PSA rose from .1 to .14 to .203 so we started planning radiation. The next scan prior to starting treatment showed the small lesion in the bone only. I am meeting with the radiologist this week after getting genetic tests. Taking Orgovyx now and starting Nubequa in 2 weeks per Urologist. Oncologist was concerned about rapid rise in PSA and aggressive form of cancer. I am healthy and want to hit it hard as possible now.

My PSA went from “watch” 4.6 in 2021 with one doctor to 9.7 in 2023 with new doctor who immediately sent me to urologist.

@begreat99 From that scenario you sound like a candidate for adjuvant radiation /ADT and SBRT to the single pelvic lesion.
You probably have cells in your prostate bed and pelvic nodes so SBRT alone probably won’t solve the problem
Phil

@begreat99
The doctors I have experience with want to do salvage radiation when your PSA hits .2 after you have had surgery. That’s what happened to me 3 1/2 years after surgery I hit .2 and had salvage radiation. It worked for 2 1/2 years.

While your scan shows that there is a spot on the bone, they’re very likely smaller spots elsewhere that can’t be seen yet. That’s why they like to do salvage radiation in order to treat the prostate bed and the pelvic lymph nodes. The spots where it’s most likely to have growing metastasis that are too small to be seen.

You could have SBRT radiation on that bone mets, But since you are on Orgovyx Your PSA is probably too low to do a PSMA PET scan soon. And your PSA will probably go down to undetectable so you won’t be able to tell if that alone is the problem Based on your PSA.

Here’s some information about when you should have salvage radiation after surgery

From Ascopubs about what PSA to do salvage radiation.
≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

This article discusses the above;
https://ascopost.com/news/march-2023/psa-level-at-time-of-salvage-radiation-therapy-after-radical-prostatectomy-and-risk-of-all-cause-mortality/