81:
Thanks. I did look at that site and signed up. They sent me an email. I clicked on the link and my request goes to the authors. I guess they will send me the full text

Mel

TA:

I understand. Of course, more aggressive tx. leads to more SE risk, but I guess the possibility of more rewards!
The SE issue obviously is a big concern as I have had plenty of bowel issues over the years.

I was dx. with Crohn's Disease about 40 years ago, but fortunately it improved and did not worsen to the point where colonoscopies have been totally clear the last 25 years. In fact, they eventually found that the prep I was using at the time sometimes creates inflammation that could be confused with Crohn's. That might be a red herring in this entire discussion, but it does make me worry about GI SE issues.

Your last paragraph is also important:
>>>>>>>>>>>>>>>>>

With the growing number of test sites for the new generation of high-accuracy PET scans (e.g., C-11 Choline, Ga-68-PSMA, PET/MRI, etc.), it may become increasingly possible to detect advanced prostate cancer in the oligometastatic stage. SBRT treatment centers are also increasingly available, and the treatments are brief (typically 1-3 fractions), relatively inexpensive, and apparently very safe. As long as patient expectations are reasonable – that treatment may be able to delay, but not cure - it’s hard to argue against its use.
>>>>>>>>>>>>>>>>>>>>>>>
I may have to adjust my thinking! It may still be worth it, if I can delay progression and maybe even do the wack a mole thing for a few years. More thought required!

Mel

George:

Got it.
Will look forward to perusing it.

Thanks.

Mel

Hi,

I can't add any new information, but would just like to let you know that my medical team considered both targeted radiation of identified single positive lymph node and general radiation/ADT and ended up recommending the last option for the reasons Tall Allen is referring to in his last post.

Rgs,

Tom

George-

None of those show it was helpful. How can a study show any therapy was helpful without comparing it to what would have happened?

- Allen

Mel -

In my mind, treating all the Nodes with a 20 - 30 percent of cure beats the heck out of SBRT with an unknown rate.

That said, if I wasn't going to do IMRT to the Pelvic Nodes I would go for SBRT, rather than only HT.

Bobby Mac

I had the zone highlighted in blue irradiated to 50.4 Gy. I recall these were the pelvic lymph nodes. It wasn't the whole abdomen, and it wasn't for specific nodes. It's a zone that covers a bunch of pelvic nodes. At diagnosis I had about a 40% chance there's lymph nodes involved, per nomograms, so we went for it.
imgur.com/2Zmjsnh

No side effects from this of which I'm aware. Nothing.

Thanks for all the input. Still, lots to think about.

I assume if one has SBRT to certain nodes then you can come back and do more SBRT as other nodes pop up (wack a mole).
But, yes JNF, I think general radiation over the whole area is off the table.

I have been looking at some of the studies George posted. I have the feeling that if I do the SBRT, then curative intent is pretty much a no-no. But it does appear to delay things (arguably). Delay is good, too, as it gives more time for other cures/txs to arise. But I would definitely have to alter my expectations.

Anyway, still time for reflection.

I suspect I am a month or two from restarting HT





Mel

TA:

Well, it is so confusing. I am perusing the studies George mentioned.
Clearly, there is nothing definite. But the indications seem to be that SBRT
is quite safe and seems to result in increased local control.
George listed many studies and they all seem to lead to SBRT being somewhat worthwhile.
I will be chatting with Dr. Lam on Friday.

I still don't know what I am going to do.

Mel


Here is a conclusion from one of them:
>>>>>>>>>>>>>>>>
In conclusion, SBRT for oligometastatic PCa recurrence is
safe and associated with a prolonged progression-free
interval. This is likely to result in a clinically meaningful
period without ADT in patients with metastatic disease,
particularly if they are retreated with SBRT on development
of further oligometastatic disease. This provides a strong
justification for the evaluation of SBRT in prospective
clinical studies
>>>>>>>>>>>>>>>>>>>
Then another study is not quite as rosy, but not bad for my situation, where I cannot last a year on HT vacation:

>>>>>>>>>>>>>>>>>
Overall survival was 94%. The 2-year biochemical relapse-free survival was 44%. Late toxicity (gastrointestinal) was observed in 1 patient who had a G3 toxicity.

Conclusions
SBRT seems to be safe, effective, and minimally invasive in the eradication of limited nodal recurrence from oligometastatic prostate cancer. SBRT is well tolerated by patients with low toxicity and yielded a local control of the disease.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

Then we have:

>>>>>>>>>>>>
SBRT may as well potentially prolong the time before the initiation of androgen deprivation therapy (ADT) and docetaxel chemotherapy for oligometastatic prostate cancer
>>>>>>>>>>>>>>>>>>

Then we have:

>>>>>>>>>>>>>>>>>>>>
Most other studies of SBRT for oligometastatic cancer, although retrospective in nature, have shown SBRT to be a favorable treatment modality due to a mild toxicity profile, improved disease control, shorter treatment course, and minimal invasiveness (Yamada et al., 2008; Sahgal et al., 2009; Stauder et al., 2011; Ahmed et al., 2012; National Cancer Institute, 2006). While intriguing, the results from our study should be validated in a in a prospective clinical trial. Doing so will allow for better identification of patients with metastatic PCa most likely to benefit from SBRT as opposed to other treatment options such as chemotherapy, immunotherapy, or less-aggressive localized palliative therapy such as conventional EBRT. It should also be noted that the majority of patients in this study received hormone therapy following SBRT, adding a confounding variable in our use of PSA as a measure of response to radiotherapy. Nonetheless, this study is one of few reports to assess SBRT for the treatment of PCa metastases that includes patients with HR disease.

Conclusion
These preliminary results suggest SBRT is a safe and effective treatment for PCa metastases. A subset of patients with HR disease were found to have reductions in serum PSA values, with more than half of all patients achieving an undetectable serum PSA value. This study provides data suggesting SBRT results in excellent LC with a corresponding PSA response and an acceptable toxicity profile in properly selected patients with metastatic PCa.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

>>>>>>>>>>>>>>
Our results allow us to conclude that CyberKnife stereotactic ablative radiotherapy of prostate cancer lymph node oligometastases gives good local control and relatively good prostate-specific antigen response.
© The Author(s) 2015.
>>>>>>>>>>>>>>>>>>>>>>>>>>

Cannot resist saying what a great summary The Tall One provides. My case illustrates it well I think. Zapped the para-aorta and common iliac areas with IMT for 8 minor metastases, plus 4 mths Firmagon, but after a few months PSA is rising again (from undetectable) and no way to know if things have been delayed or not. Anyway it was interesting--see signature.

George-

Temporarily reducing PSA is not a valuable endpoint in itself, as I explained. There is no high level evidence for anything on this subject. That's what makes it so risky to react to it, especially when you may be misinterpreting what the preliminary studies are saying.

The Decaestecker study you mentioned had only 2 years of median f/u. Most of the small studies you listed did not have long enough f/u to determine anything useful. LN metastatic progression is (fortunately) known to be a slow process, and the use of advanced PET scans for detection makes it seem even longer. In that study, the median progression-free interval was only 2 years. What would it have been w/o any treatment? I'd guess about 2 years. Ost, while not high-level evidence, at least increased the reliability by using a meta-analysis to build the effective sample size. Ost showed that nearly all such-treated men had distant metastatic progression within 5 years.

One has to be very careful about the lifetime dose of radiation to that area. Some bowel dose is unavoidable, and late-responding enteric tissue may show toxicity years later. This has to be very carefully planned and executed, with full knowledge of individual anatomy.

Spot treatment, even if useless, is probably safe (depending on where the spots are). The only danger is if it postpones other treatments with known or possibly better benefits.

Mel,

I had a question - when were your mets discovered? (it may be in your signature, but you never check that box).

Exactly the same rate of appearance that the study showed would have happened with spot SBRT treatment. You are a control group of one