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Salvage Brachytherapy or Cryotherapy

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Posted 7/29/2024 4:52 AM (GMT -5)
Any thoughts on these treatments for recurring disease after primary radiation? The urologist at Duke, Dr Polascik, would do the cryotherapy; Dr Zelefsky would do the brachytherapy.
Either of these treatments would depend on upcoming tests. I have biopsy on August 29. Both doctors require positive result before treatment. I assume I would need to have PSA, blood work, and another PSMA with local recurrence only before treatment. Both doctors select patients deemed to be viable candidates for treatment based on age, general health and other factors I suppose.
Posted 7/29/2024 6:46 AM (GMT -5)
At this point it would be speculation by us amateur non-MD folk. As your post explains there is appropriate assessments to be made first.

I had brachytherapy for primary treatment and it has succeeded wonderfully. So by knowledge and experience I am unabashedly biased toward brachytherapy. Particularly High Dose Rate.

My understanding of cryo is that it is very tough on the ureter. And marginal for cancer control. My urologist often says the only thing cryo guarantees Is incontinence.

You are starting a new journey. Please don’t fall in love with a treatment and then fit
It to your situation. Confirm the actual situation and then find the treatment that best fits and is most effective for you.
Posted 7/29/2024 8:31 AM (GMT -5)
Duke is dragging out the process so long that given enough time I'll be metastatic and this will all be academic.
Posted 7/29/2024 8:35 AM (GMT -5)
Have you also looked into salvage HIFU and NanoKnife?
Posted 7/29/2024 10:01 AM (GMT -5)

hrpufnstuf said...
Duke is dragging out the process so long that given enough time I'll be metastatic and this will all be academic.

what about ADT first?
Posted 7/29/2024 12:59 PM (GMT -5)
I am guessing that ADT is what is they are trying to avoid with focal treatment?
Posted 7/29/2024 3:28 PM (GMT -5)

F8 said...

hrpufnstuf said...
Duke is dragging out the process so long that given enough time I'll be metastatic and this will all be academic.

what about ADT first?


ADT was discussed with my MO in March and it was decided then to wait 6 months, have PSA again and see where I am. If the PSADT is less than 12 months he wants another PSMA. Even if the PSMA still shows no spread and the PSADT is under 12 months he'll recommend ADT while I wait for salvage treatment.
Posted 7/30/2024 6:55 AM (GMT -5)
So, is there also a delay on brachytherapy? What is Dr. Zelefsky wanting before the procedure? As I understand, ADT may pose a potential Catch 22. Once on ADT it is very likely the tumor(s) will shrink, the PSA will drop to undetectable and salvage determination might then be lost as there will not be any disease evidence. Have you discussed this with Zelefsky? Will he treat you with undetectable PSA and, at that future time, the inability to do a confirmatory PSMA scan? Will Medicare reimburse the brachytherapy under that circumstance?
Posted 7/30/2024 7:04 AM (GMT -5)
Zelefsky is waiting on my biopsy, after which his office will request my medical records, biopsy result, and biopsy sample to do their own pathology. His clinical staff will review everything and make a determination as to whether I'm a candidate. I assume I will have had a recent PSA, blood work, and likely a PSMA for his office to request. If approved I will travel to NY to meet with him to discuss the procedure. My guess is this will be in October at the earliest.

I agree with you about the ADT effect on treatments. It may impact the PSMA too.
Posted 7/30/2024 10:00 AM (GMT -5)
Sounds good.
Posted 7/30/2024 11:03 AM (GMT -5)

hrpufnstuf said...
......I agree with you about the ADT effect on treatments. It may impact the PSMA too.

The only way that you know RT worked by itself is to have before and after PSA's. As you surmised, same issue with a PSMA scans.

However, ADT may help improve the RT effectiveness so that has to be considered, a Catch 22 like JNF indicated. Zelefsky is pretty well regarded so you will have to rely on his expertise to guide these decisions.
Posted 7/30/2024 5:34 PM (GMT -5)
You had your first bout of (proton) radiation (more than) 9 years ago. I read some time ago that a second round is possible after such a long interval. Not sure if that's true or not, but worth asking about. Or is that what Zelinsky is planning?

I am of course just an internet nobody, but I would ask Dr Zelinsky if targeted SBRT is possible. Your MRI suggests there's only one lesion. Waiting for the biopsy...
Posted 7/31/2024 3:40 AM (GMT -5)

Sr Sailor said...
You had your first bout of (proton) radiation (more than) 9 years ago. I read some time ago that a second round is possible after such a long interval.
I

I've talked with my RO several times since BCF and the scans. He's never mentioned Proton as a salvage option. He supported my interest in brachytherapy and recommended Dr Zelefsky.
Posted 7/31/2024 5:07 AM (GMT -5)
This was my MO's summary notes from our meeting in March:

I did not recommend ADT nor enzalutamide (per EMBARK) at this time given his low risk disease, low PSADT, more advanced age, lack of N1/M1 disease on PSMA PET, and risk and toxicities of therapy, and recommended observation, with treatment triggered by N1/M1 progression, symptomatic progression, or a PSA in the 10-20 range which would significantly increase his risk of metastatic disease on conventional imaging.

Handouts were given on ADT, lifestyle. He can either return here for PSA monitoring and repeat imaging when his PSA doubles (PSMA PET or CT/BS is acceptable) or monitor his disease locally. He will f/u with his local urologist for MRI if he desires and biopsy and can return to see me as needed should he progress on imaging or need ADT.

It looks like he doesn't want to see me again unless I need/want ADT. He recommended PSA, CBC, and CMP blood work in early September monitored by my local urologist and, if PSA doubles, get another PSMA. Since I have biopsy scheduled for August 29, I think I need to have the PSA before that..
Posted 7/31/2024 6:15 AM (GMT -5)
I’m not aware of Proton being used for salvage, certainly not after failed surgery. With just nine years out from ERBT it Is too soon to repeat that process.

That is why the interstitial methods are used. Much less radiation to benign tissue. HDR Brachy is the most conformal treatment you can have. So it is an excellent salvage method after the very rare local recurrence following initial radiotherapy treatment.

To my recollection in my nearly 14 years on the forum you are only the second man to have a local recurrence following initial radiotherapy. And both were low risk. Go figure.
Posted 7/31/2024 8:01 AM (GMT -5)

JNF said...


To my recollection in my nearly 14 years on the forum you are only the second man to have a local recurrence following initial radiotherapy. And both were low risk. Go figure.

My RO said UFPTI stats show 5% recurrence after 10 years for intermediate gleason 3+4 like me.
Posted 7/31/2024 10:52 AM (GMT -5)
I've talked with my RO several times since BCF and the scans. He's never mentioned Proton as a salvage option. He supported my interest in brachytherapy and recommended Dr Zelefsky.

SBRT would use those lovely invisible photons...

Post Edited (Sr Sailor) : 7/31/2024 7:56:12 AM (GMT-8)

Posted 7/31/2024 2:38 PM (GMT -5)
SBRT is external and radiates the benign tissues again. It is probably too soon to do so. Brachy gets the prostate and cancer areas without going through the previously radiated tissues. That is why it is used for salvage where SBRT typically is not.
Posted 7/31/2024 4:45 PM (GMT -5)
I met with my local urologist today primarily as a post-surgical exam for an inguinal hernia he repaired 2 weeks ago. Healing has been excellent and I'm feeling good and walking 3 miles a day again. I'm anxious to get back to the gym and resume my weight lifting routine but he wants me to wait another 4 weeks.
While there we talked quite a bit about my recurrence and how to react. We decided I would have PSA in late August before biopsy as that would delay PSA for 6 weeks. He is such an optimist. He thinks the PSA will increase modestly while I expect maybe a doubling or worse. I challenged him by asking if he agreed with studies that most recurrences after primary radiation are aggressive. He agreed but it didn't change his prediction.
We both know the upcoming biopsy and PSA will tell us a lot. A big jump in PSA and high Gleason will prompt another PSMA. If PSMA is still local then the window is surely closing fast for salvage treatment and would be a now or never situation in my mind. If by some small chance my urologist is right and the PSA increase is modest and the Gleason is 3+4 then maybe I'll change my mind temporarily about pursuing salvage treatments and have PSA every 3 months. My urologist believes the salvage treatments are outside the standard of care for me or anyone in my situation. He would not consider it for himself. He has many patients who have been on ADT for years and do quite well. He thinks it's not the end of the world as I see it now.

Post Edited (hrpufnstuf) : 8/1/2024 3:11:31 AM (GMT-8)

Posted 7/31/2024 8:41 PM (GMT -5)
Been there too, hernia recovery is 6-8 weeks of limitations and then you should not push leg presses, ab-crunches and similar. The last thing you want is a do-over so take it slow.

I am not too fond of “He has many patients who have been on ADT for years and do quite well” as I would prefer a surgeon who said he only had a couple patients smile

My wife is on one of those forever cancer drugs and I can see a lot of reasons to go for the cure prior to throwing in the towel with lifetime ADT. Every procedure and medication is not standard of care before it becomes “standard of care”. The focal procedures mentioned do not appear to have a lot of risk so it may make sense to go for it and keep ADT in your back pocket if possible.
Posted 8/1/2024 6:30 AM (GMT -5)
Similar, but I had robotic hernia repair, left side. A breeze. Only had physical restrictions for two weeks, or until something that hurt stopped hurting. Didn’t even need any pain meds. Doc was also able to check the right side in the same surgery.

My wife is in a similar situation to Mumbo’s. Thankfully using a combination of a daily oral drug and a monthly injection that has replaced cytotoxic chemotherapy to control the cancer. But it brings side effects and may not work forever.

Having had both long term ADT and two HDR-BT procedures, if you can have brachytherapy and arrest the PCa without going on forever ADT, I would jump on the brachytherapy, particularly HDR. As for procedure risk, if you can tolerate a colonoscopy, then BT is a breeze.

And I would listen to the RO, not the Uro regarding salvage treatment. By definition, the only salvage procedure the Uro is capable of is surgery and we all know salvage surgery after radiation, in practical terms, is a fools folly. On the other hand, Zelefsky probably does a dozen salvage procedures a month. And if you do go on lifetime ADT, stick with the MO.
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