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Biochemical Recurrence: Questions about PSMA PET scan & radiation

Posted by rad62 @rad62, Aug 12, 2022

After robotic RP in April 2019
PSA pre op 7.5
Gleason (4+5) pT3a evidence of perineural invasion , clear margins no additional treatment after RP
1 year later PSA began to rise from 0.02 ,in April 2022 PSA 0.12 and is now 0.25 doubled in around 3 months, when I spoke with urologist he said he wasn't so concerned about PSA doubling when smaller numbers are involved also that 0.4 was the number to signify recurrence ( I'm confused I thought it was 0.2)and also said if there is a recurrence it is most probably in the prostate bed and can be cleared up with radiotherapy. I Have been scheduled for a pet/psma scan for next week at a cost of 3000€ although he states there is only a 60% chance of locating it. I read that pet/psma scans can also cause damage to tissue and has the possibility to cause it to become cancerous,not sure if I should wait a little longer ,if nothing is found I probably won't be able to have another scan for 6 month's,
a bit of a dilemma,.

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kujhawk1978 | @kujhawk1978 | Dec 12, 2022
In reply to @rad62 "Hi, thanks for your previous reply, very informative. Results of pet/Psma showed activity in 1 lymph..." + (show)
@rad62

Hi, thanks for your previous reply, very informative.
Results of pet/Psma showed activity in 1 lymph node but not 100% conclusive. PSA dropped from 0.22 to 0.13 three weeks after pet/Psma scan,now back up to 0.24.
Radio oncologist in the same private clinic recommends regular surveillance with PSA testing if PSA continues to rise to 0.3 -0.4 then make new pet Psma scan to update imaging and treat with proton therapy to all lymph nodes in the necessary area and prostate bed and says that the proton therapy has minimal side effects compared to conventional radio therapy.
However he doesn't advocate using ADT yet , saying the proton therapy can still be curative at this point, but this treatment will cost me in the region of €50.000euros.
On the other side the public social health system (free treatment) radio oncologist recommends I start straight away with
25 -30 radiotherapy treatments (not advanced proton type) together with hormone therapy and described various side effects from mild to severe that I could experience but also most would disappear after treatment stopped. I am nervous about making the wrong decision and also about the life changing negative side effects that hormone therapy and conventional radio therapy can have.
Do you have any insights to offer me , thank you.

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Well, I'll give you my thoughts as a fellow traveler on this journey.

I have had zero side affects during and after treatment with IMRT, 39 treatments to the prostate bed in March 2016 with 70.2 Gya and 25 treatments to the PLNs in July 2017.

Both times were with the rapid arc and the use of 3D software to design a treatment plan.

My radiologist showed me the software and treatment plan using her laptop. Much of it was technically beyond my layman's understanding but I grasped the concepts. The four sites identified would receive higher intensity and wider margins as the Rapid Arc rotated around me the software would control the length, intensity and time of the beam so as to deliver the planned dosage and avoid going through and hitting other parts of my body. In addition, there was real time imaging done to show where organs such as the bladder, kidneys and liver were as I breathed and adjusted the radiation beams accordingly.

I don't know about the Proton Beam therapy so can't really comment.

There is some data which supports using only radiation in your case, of course, there is data supporting the radiation and short term ADT.

You are likely familiar with the concept of micro-metastatic PCa . Using that theory argues for combining therapies , radiation to the site(s) identified in the scan and six , 12 and some say 18-24 or even 36 months of ADT, preferably https://www.pcf.org/news/breaking-news-fda-approves-first-oral-hormone-therapy-for-advanced-prostate-cancer/ which has no flare, quicker and sustained castration., lower CV and metabolic profile and faster recovery of T.

So, my thoughts...

I would consider waiting until PSMA rises to .5-1, image and then based on the results, decide. That may allow for more definitive clinical data thus driving a more informed decision. It would also help you determine if your PSA is continuously increasing and if so, calculate doubling and velocity times.

If and when you do decide to treat then in the hands of a skilled radiologist and the supporting team, conventional radiation may be able to treat you with the degree of accuracy to minimize any side affects and kill the PCa.

You can do radiation to only the identified site and see what happens. This approach is generally not considered a curative approach, more of a whack a mole... Here's an article supporting MDT only - https://ascopubs.org/doi/full/10.1200/JCO.22.00644

That leaves the combination approach. I am personally an advocate of aggressiveness in my treatment decisions. That would lead me to wait on more definitive imaging, that in turn would enable me to have more clinical data - continuous increase in PSA, PSADT and PSAV. Informed by that type of clinical data I would be aggressive, radiation to the entire PLNs, six months of the new oral ADT agent.

Kevin

REPLY
bettwils16 | @bettwils16 | Dec 26, 2022

Hi, thanks for your comments. My husband will be starting 40 sessions of Radiation Treatments, Rapid Arc, next month. I've been reading about SpaceOar. Did you use it? I'm relieved to know you went through all this with zero side effects. My husband is so depressed about side effect comments. Thank you.

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