Salvage surgery or salvage radiation?

@jeffmarc I was able to get the PSMA PET/CT scan report. There is not evidence of any metastasis on other parts of body. Only one lymph node on the right pelvic is infected (SUV mean 25.3). Could you please explain what SUV mean 25.3 is? I have no clue.

@prettypass2000

I've posted these before...

If even today's most sensitive imaging cannot see micro -metastatic disease, not sure what a surgeon can do to outdo imaging...

As I said, my urologist, who was very experienced and skilled, was opposed to surgery to remove lymph nodes when I had BCR.

I was thinking I had responded to this post but scrolling through didn't see it.

So, he's high risk given the clinical data you describe minus one perhaps critical piece, his PSADT and PSAV.

I don't think his medical team has laid out all his options:

Do nothing, continue to monitor. It could be some time before treatment is "necessary..."

MDT mono therapy which may delay the need for systemic therapy.

Doublet or triplet systemic therapy though in low volume cases the latter is generally of marginal value.

ARI mono therapy, EMBARK

There is the PATCH trial with the use of Estrogen.

I think the outcomes of treatment that drive the decision are:

PFS
RPFS
Patient preferences:

Desire to delay systemic therapy

Concerns with radiation side effects.

What would I do were I he?

MDT + short term systemic therapy, 6 months. I would likely use Orgovyx. I would hold on the ARI and add only if PSA did not drop to undetectable. Of course if you have to do that you are likely pushing systemic to 18-24 months...

If his PSA drops to undetectable in the first 3-6 months then that is a favorable sign for longer PFS and RPFS..

From my foxhole he is now managing this as a chronic disease, I'm in the "advanced PCa is incurable"...camp, rather it is manageable.

I think the group discussion provides a great degree of information to inform your discussions both you and your husband as well as his medical team.

Try not to go down the Alice in Wonderland rabbit hole with the horror stories about treatment surfaces. They are statistical, population based and historical, often not reflecting changes brought about by medical research and consequent advances. Where will your husband fall in the side effects impacts, unknown.

There are mitigating strategies, diet, exercise, managing stress, his medical team has options too.

The other thing I throw out because of the difficulty of measuring OS impacts of treatment is change the thinking from day 10-15 years to say 3-5, will this work for the next 3-5 years? Yes, great, we likely have more choices by then.

The good news, he had choices, the bad news, he had choices. I am also in the camp that says with a plethora of choices there are many good ones, there is no black and white checklist that says if that then this. "Plethora" can also lead to "paralysis by analysis."

After surgery and SRT failed using SOC from the NCCN guidelines my subsequent treatment decisions have been "hybrid" combining the guidelines with changes from CTs entering mainstream clinical practice and my preferences.

Like I've said about radiation, 69 treatments, SRT, WPLN and SRT, 155 Gya, side effects, none. I didn't lose my libido during ADT, still could achieve erections and orgasms. So, I may not be the one to ask...as I'm one or more standard deviations outside the "mean!"

Kevin

@prettypass2000
Generally, an SUV max greater than 2.5 is often considered for malignancy. However, the exact significance of a specific SUV number is determined by a radiologist in the context of the patient's entire scan, comparing it to surrounding tissue and previous imaging.

An SUV of 25.3 is almost definitely malignant. Something that must be treated.

@heavyphil

Here you go

@prettypass2000
Generally, an SUV max greater than 2.5 is often considered for malignancy. However, the exact significance of a specific SUV number is determined by a radiologist in the context of the patient's entire scan, comparing it to surrounding tissue and previous imaging.

An SUV of 25.3 is almost definitely malignant. Something that must be treated.

@jeffmarc Update: First, my husband and I thank you so much for helping us with all of your valuable insight. I'm able to get two appointments scheduled with two different reputable radiation oncologists here. We will see one on this Friday and another one on 2 March. Both said that my husband should consult the uro-oncology about ADT very soon. Unfortunately, the chief urologist, who's also the uro-oncology, is out of town til 27 Feb. I was able to get the earliest appointment with him on 4 March. Meanwhile, I have to deal with CIGNA. So far, they've been helpful. They verified that both appointments are covered. They also assigned us a case manager like they did when my husband first diagnosed in 2021.

@prettypass2000
Ask your PCP to prescribe ADT, Though many radiation oncologist will do it. You can contact the office of the urologist, They should have a backup person that can prescribe it for you, A doctor like that can’t leave the office completely without assistance if an emergency comes in.

@prettypass2000
Ask your PCP to prescribe ADT, Though many radiation oncologist will do it. You can contact the office of the urologist, They should have a backup person that can prescribe it for you, A doctor like that can’t leave the office completely without assistance if an emergency comes in.

@jeffmarc
Update on my husband's radiation oncologist consultation today! The visit went remarkably well and has totally different atmosphere. Both doctors were great at answering questions, giving us information that we didn't think of, and presenting their findings, views, and recommendation. They even showed us the PSMA scan files, including where exactly the infected lymph node is. They also show the photos of their two different SBRT machine.

Their recommendation: 5 sessions of SBRT with or without ADT.

There are two types of machine:
SBRT with MR-Linac Elekta
SBRT with CBCT

Have you had any experience with SBRT with MR-Linac? How was your experience of SBRT? What are the side effects? What should we know before choosing this option? Thank you in advance. ❤

P.S. They wanted my husband to speak with uro-oncologist on ADT in depths since he has pre-existing hypertension and family history of Alzheimer's.

@prettypass2000
Definitely would prefer the MRI Elekta machine, more accurate and less chance Of other organs being radiated.

I’ve had SBRT radiation on my spine. Three treatments to remove a metastasis. Had no side effects at all.

SBRT to the prostate is a little different. It can cause proctitis, A burning sensation when you pee and maybe reduced flow. It can also in some cases cause rectum problems like diarrhea or they need to go Frequently. These things are usually temporary and only last a few weeks. My brother had 5 sessions of SBRT to his prostate when he was 77, It was not MRI guided, It did cause some urinary issues, but Flomax was all he needed. He is now 80 and doing fine.

You still need to consider surgery. They can usually remove the lymph nodes that have tumors. It depends on where they’re located, Something you need to speak to a surgeon about. Even if they can’t remove them during surgery, they can use SBRT later to zap them.

You may want to get a Prostox test to see if your husband has a problem with SBRT. For some people that can cause serious problems in the future.