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Treating Oligometastatic PCa

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Posted 4/4/2019 4:09 PM (GMT -5)
There has been a lot of discussion on radiation to treat Oligometastatic PCa here in the past. One thread that i recall referred to Dr Kwon at Mayo and his strong belief in this approach. I think (not 100% sure) that was about radiating BEFORE going to ADT.
Here is a study that addresses this treatment when cancer becomes castrate resistant....

https://www.practiceupdate.com/c/81232/56

The link requires a sign on which is free. But if you prefer not to create one, here is the gist of it....

"TAKE-HOME MESSAGE

This study evaluated the impact of local radiotherapy in men with oligometastatic prostate cancer. The authors included 15 men with PSMA-PET–detected metastatic (low-volume) castrate-resistant prostate cancer. These men underwent local ablative radiotherapy to either bone or nodal metastatic sites. A PSA response was observed in 73% of patients. Mean time to PSA progression or last follow-up was 17.9 months, as opposed to 2.9 months estimated without ablative radiotherapy.
Based on this, the authors conclude that select men with low-volume castrate-resistant prostate cancer had a meaningful PSA response to local radiation to the lead metastatic site. A randomized trial should be performed to further study the utility of this modality in patients with advanced prostate cancer.
– Gautam Jayram, MD
Posted 4/4/2019 4:32 PM (GMT -5)
Wow, now that seems exciting. An increase from 3 months to 18 months for PSA progression is impressive. I don’t know much about this therapy so maybe I’m overreacting, but this could add years to some men’s lives? Can the same spot be radiated repeatedly over time to manage the progression?
Posted 4/4/2019 5:44 PM (GMT -5)
Yes, that big improvement in progression free time caught my eye.

I believe there is a limit to how much radiation a body can take, cumulatively.
Posted 4/4/2019 6:33 PM (GMT -5)
After failure of my primary treatment (Proton), I had SBRT on lymph nodes detected by a F-DCFPyL PET/CT scan in the Oriole Trial at Johns Hopkins. Haven't had ADT since April 2012. Take a look at my PCa history in the "View Image" below. I think you'll be impressed. I asked my radiation oncologist if I could have SBRT again if the metastases returned. Ans: "Shouldn't be a problem."

...Jerry
Posted 4/4/2019 9:47 PM (GMT -5)
Jerry,

That is impressive. I know that itraconazole has a similar mechanism that ketoconazole has but I was unaware of it being used for prostate cancer. I wonder how much of your response is due to the drug?

Paul
Posted 4/5/2019 5:17 AM (GMT -5)

PDL17 said...
I know that itraconazole has a similar mechanism that ketoconazole has but I was unaware of it being used for prostate cancer. I wonder how much of your response is due to the drug?


Very little of the response was from intraconazole, IMHO. I was only on the drug for 3 weeks. PSA dropped from 2.9 to 2.6 but (since I was taking triple normal dosage), I had to quit because of edema & high blood pressure. After quitting, my PSA immediately jumped to 3.4.

Here's a link... Repurposing itraconazole as a treatment for advanced prostate cancer I wasn't in the trial but was taking the drug off-label.

...Jerry
Posted 4/5/2019 5:59 AM (GMT -5)
Thanks for the info and update, Prato. I have added it to my library. smile
Posted 4/5/2019 8:32 AM (GMT -5)
A very early adapter to the oligo theory was retired medical oncologist Snuffy Myers. When I was diagnosed in 2010 I read reports from him relating management success when five or fewer mets were found and managed by spot radiation and intermittent ADT.
Posted 4/5/2019 10:09 AM (GMT -5)
This is my OLIGO journey if anyone is interested.
Sept 2016, PSMA scan at NIH in Bethesda Md showed focal intense DCBFB uptake in a left common iliac lymph node, and a subtle DCFBC-avid focus in a small sclerotic lesion in the right ischium.
March 2017, lymph node treated with SBRT, insurance not convinced ischium is a problem. PSA is 3.5
May 2017 PSA 1.4
July 2017 PSA 1.1
Sept 2017 PSA 1.2
Nov 2017 PSA 1.5
Jan 2018 PSA 2.2
Mar 2018 PSA 2.4
May 2018 PSA 3.1
July 2018 PSA 2.9
Sept 2018 PSA 5.3, SBRT to lesion in right ischium, it was a problem after all
Oct 2018 PSA 3.4
Dec 2018 PSA 1.3
Feb 2019 PSA 1.2
I have had no ADT at any time and DO NOT RECOMMEND THIS ROUTE TO ANYONE ELSE. I personally made all of my treatment decisions and accept full responsibility for the outcome. ADT was recommended by an Oncologist in 2013 and I refused then and still do today knowing there could be a price to pay in the end. I chose quality of life over length of life if it should turn out that way.
Best of luck to all, Woody
Posted 4/5/2019 10:45 AM (GMT -5)
Woodpecker
Thanks for posting. Can I conclude 'so far so good'?
As an aside, where did you get the SBRT? NIH doesn't have that instrument, I think, but Georgetown U Med Center does.
Posted 4/5/2019 11:24 AM (GMT -5)
Prato -- thanks for posting. I've linked this to my papers and studies folder for future reference.
Jim
Posted 4/5/2019 1:16 PM (GMT -5)
Bohemond, trailguy, glad you found it worthwhile.

Woody, so you were twice successful with treating oligomets. And no ADT. Forgive my ignorance, what’s the potential consequences? If it gets to a point where you can’t have more RADS, then you start ADT. Seems like delaying ADT if there is another way, is a positive, not a negative. Good on you.
Posted 4/5/2019 1:44 PM (GMT -5)
That's good stuff.

A lot of studies show one tx course over another adds to life span. It's the fine print that's the kicker. Sometimes it's measured in weeks.

Seeing this, a year or more, gets your attention.
Posted 4/5/2019 6:22 PM (GMT -5)
Jerry,
Your PCa history graph is very impressive. It really highlights the story in a comprehensive way. Maybe I’ll do it for myself someday.
Posted 4/5/2019 8:05 PM (GMT -5)
Sr Sailor

You are correct, so far so good. I had the lymph node treated by SBRT at Tulane University in New Orleans and the lesion in the right ischium by SBRT here in my home town of Foley AL, at Gulf Coast Cancer Center. My medical oncologist is at Tulane, Dr Oliver Sartor, and he helped me get treated there for the lymph node. The ischium was easier to get approved since we had earlier imaging to compare to showing the lesion was growing and needed attention.

Pratoman,

about everything I have read here and on other sites seems to say earlier ADT results in longer survival rates. I see it the way you do, waiting is a positive. Do not start the ADT clock and side effects until I have to. By the way, Dr Sartor has had nothing negative to say about my plan.

Woody
Posted 4/5/2019 8:20 PM (GMT -5)
“Do not start the ADT clock and side effects until I have to. By the way, Dr Sartor has had nothing negative to say about my plan.”

Woodpecker, that has been my game plan as well. Not necessarily based on science but also not going against science. My MO has stated there is no compelling evidence that earlier is better and he backed me on my decision to wait as long as reasonable. A lot has to do with a patient’s comfort level. Some people elect to start early to have the sense they are “doing something” about the cancer. We’re all different and can choose the path that is best for us.
Posted 4/6/2019 10:52 AM (GMT -5)

mattam said...
A lot has to do with a patient’s comfort level. Some people elect to start early to have the sense they are “doing something” about the cancer. We’re all different and can choose the path that is best for us.

True...

Many of those people are just poorly informed 'control freaks' in my experience.
Posted 4/7/2019 8:02 PM (GMT -5)
Pratoman,
Thanks much for posting that , not sure it applies to me ..but maybe, ..I shall look into it.
Jerry_Delaware,
Your PSA chart is very impressive, both in your history and the chart itself. If you look up my e-mail, I would loveto e-mail you back about maybe making up my chart.
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