Use of mpMRI and PSMA PET/CT to aid in salvage radiation decision-making

There were a couple of studies that demonstrated how advanced imaging may help inform the salvage radiation (SRT) decision. The Mayo study was able to increase the predictive accuracy of the updated Stephenson nomogram for predicting SRT success. The Australian study showed the inferior results when metastases are detected, even with metastasis-directed SBRT. They both showed the importance of SRT especially when all the findings are negative. The primary use of imaging is to rule out rather than to rule in.

/pcnrv.blogspot.com/2017/12/use-of-mpmri-and-psma-petct-to-aid-in.html

Preliminary findings on RTOG 0534 will be released in 3 years, certainly not before. No one will even look at any of the data before that. Data on 1792 patients are being collected separately in 460 locations since 2008. It's a massive NCI funded project.

I couldn't imagine what you were talking about when you said the numbers in red. Then I remembered the article from a couple of weeks ago on whole pelvic SRT had some red numbers - is that what you mean?

/www.healingwell.com/community/default.aspx?f=35&m=3945767

Thanks Tall Allen, this was a timely post for me as I had an MRI Monday at Mayo. This is to help with mapping my SRT which is scheduled to begin on Dec 18. With my high post-op PSA I was expecting/hoping to see a tumor at the site of the the positive margin. Then there would be a definitive area to target. It doesn't appear that I have such a definitive target. Any thoughts on the findings seen below?



04-Dec-2017 14:53 *** Final *** MR Prostate WO+W/CST AZ
CONCLUSION:
1. Exam performed for radiation treatment planning.
2. Status post prostatectomy and resection of the right seminal vesicle.
3. A portion of the left seminal vesicle remains in place, but has a benign appearance.
4. No residual prostate carcinoma is perceptible.

COMPARISON: Preop MRI pelvis 4/12/2017. Radiation therapy planning CT 12/4/2017. INDICATION: Malignant neoplasm of prostate for Radiation Treatment Planning Prostate cancer, status post robotic prostatectomy 08/24/2017, with Gleason 4+3=7, pT2c, with a positive right apical margin. Review of pathology at MGH interpreting Gleason as 3+4. Review of pathology at Mayo Clinic interpreting Gleason as 4+3, and also noting positive perineural invasion. Postoperative PSA 0.4 on 11/01/2017.

FINDINGS: Image quality: Surface coil was utilized. Since no endorectal coil used, diffusion/ADC images are suboptimal.
There is a rectal tube with a distended balloon in the rectum.
The patient is status post prostatectomy with susceptibility artifact in the region of the prostate. There is enhancing T2 dark soft tissue along the right vesicorectal angle without restricted diffusion, favor granulation tissue.
The right seminal vesicle has been resected. A 2.2 cm portion of the left seminal vesicle remains in place at the left side of the surgical fossa. It contains a small amount of hemorrhagic debris.
No lymphadenopathy.
Fat-containing 1.3 cm cross-sectional diameter indirect left inguinal hernia.
No focal osseous lesion.

PELVIS MRI TECHNIQUE: Multisequence multiplanar images were acquired through the pelvis with and without intravenous contrast.

AZ Guy I will be starting my SRT at the mayo in MN on December 18th. I have been practicing emptying the bladder then drinking 16 oz of water some days good some days not so good. We'll have to compare our treatments as we go.

Larry

Thanks for the response Tall Allen. I suppose nothing has changed in that we'll need to hit the entire prostate bed with the IMRT. And how about that Skypilot...both of us starting the same day at Mayo- you in MN and me in AZ? Yes let's compare notes. Since my surgery I have noticed there is less time between drinking water and the urge to urinate. So I think I'm going to wait to drink the water until I'm in the car on the way to the appointment. I'm sure that once we get into a routine I'll get it just right.

Gary,
Considering your PSADT of only 2.5 months, I think you are wise to add ADT. I hope that you are using the highest dose consistent with your colitis, and including the pelvic LN area, including the common iliac nodes.

Gary, I know this isn't what you wanted, I really hope it makes the difference for you.

Thanks, guys....if I eliminated chicken from my diet, PCa wouldn't kill me, I'd starve to death!

garyi said...
Thanks, guys....if I eliminated chicken from my diet, PCa wouldn't kill me, I'd starve to death!

😂😂😂😂😂
Gotta know you to appreciate that one.

Good find, Gemlin!

Chick-fil-A or Pollo Tropical...but not fried, and no cheese. I'm sooooo relieved ;-)

Gemlin said...
Why eliminate chicken?
Lower intakes of red meat and well-done red meat and higher intakes of poultry and fish are associated with lower risk of high grade and advanced prostate cancer and reduced recurrence risk, independent of stage and grade.
/www.ncbi.nlm.nih.gov/pubmed/27651069

Only 6% of the 971 men in the cohort were Gleason 8-10. And 41% were Gleason 6.
They say they adjusted for this, but I dunno.
Also, food questionnaires are notoriously unreliable from all I've read

In addition, this paragraph is very telling, especially the comment that men may have changed their diet after diagnosis, and with only one food questionnaire there is no way to know this...

The use of PSA recurrence as an outcome may also be a limitation. While PSA recurrence is a highly clinically relevant event for men with prostate cancer, many men with PSA recurrence do not experience clinical progression to metastases or prostate cancer–specific death. In this population of men diagnosed with localized disease, only 3 men had progressed to metastatic disease during this follow-up period, so we are unable to study metastatic or fatal disease as an outcome. In addition, we have only a single diet assessment taken at the time of diagnosis, and it is possible that men changed their diet after treatment. The study population is almost entirely white, limiting generalizability. Finally, the follow-up of an average of 3 years is short, and as a result, we had a limited number of PSA recurrence events. Because of this, we had relatively low power to detect associations, which may explain some of our null findings. Strengths of the study include its prospective design, comprehensive FFQ, and availability of clinical and follow-up data from a single treatment center.

Post Edited (Pratoman) : 12/10/2017 3:12:06 PM (GMT-7)

OK...no skin, no frying, and white meat only.

Prato, based on the telling paragraph you posted, lots of brothers may be either obsessing for nothing, or undergoing unnecessary treatment. To wit:

"many men with PSA recurrence do not experience clinical progression to metastases or prostate cancer–specific death".

Pratoman said...
Yup, I did note that sentence in the full paper. It's encouraging, but if only we knew which ones wouldn't progress to mets, with surety. But surety doesn't exist in the PC Business.

And along that line of thinking, nobody really knows for sure that chicken or meat, or eggs, or anything, affects or doesn't

No poop, Sherlock. Even semi-certainty is non existent in the PCa business. The more they learn, the more the realize how little they really know.   

Sounds like a Chinese feast tomorrow, with zero worries.