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PSA uptick to detectable

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Posted 1/16/2018 1:24 AM (GMT -5)
Now at 0.09 ng/mL, up from <0.05 in October. Looks like I'm heading for a little ADT/SRT journey. Meeting with Dr Abramowicz at Sylvester next week and Dr Biagioli in Orlando the following week.
Posted 1/16/2018 9:25 AM (GMT -5)
Sorry to hear this SP. I guess with your pathology, it's not unexpected, but still not what you (and we) hoped for. I hope the radiation knocks the beast out and eliminates it forever.
Posted 1/16/2018 9:39 AM (GMT -5)
Sorry Saipan. Sounds like an early detection, though. My hopes also for getting it all.
Posted 1/16/2018 10:04 AM (GMT -5)
You will be getting two different perspectives, Richard. Abramowitz is traditional and aggressive. Biagioli will offer cutting edge SRT with brachy boost, I'm guessing. Two very accomplished RO's. You've got some time.

We'll talk about it...
Posted 1/16/2018 10:29 AM (GMT -5)
Losing the < and seeing the upward march of PSA is discouraging, to put it mildly. Looking for a ray of sunshine amidst the clouds, I believe that it is a very good sign that your PSA went to undetectable at one point, however briefly. I did IMRT for my SRT, and it was a breeze. Please report back what your ROs say about ADT in your case.
Posted 1/16/2018 11:11 AM (GMT -5)
Thanks for the support, guys.
Pratoman, I was so mentally prepared for it that I was more upset by an unexpected rise in my glucose (had other blood work done too) than by the PSA uptick.
Gary, that’s interesting about the different approaches of Drs A & B. It’s exactly what I want — options. Was afraid I wouldn’t be getting it when the nurse at Sylvester told me the other day that B was once A’s resident! Anyway, looking forward to meeting you in SoFla next week.
Posted 1/16/2018 11:52 AM (GMT -5)
You sound well-prepared for it. I'd be interested to hear if either offers a hypofractionated protocol or has increased the dose, and whether they have expanded the pelvic LN field. I can't imagine a brachy boost - what would they do it on?
Posted 1/16/2018 12:31 PM (GMT -5)
Yeah, Allen, I’m wondering the same about brachy. Maybe Gary can say more.
I’d be very interested in a hypofractionated protocol given that I’m going to have to leave Saipan for an extended time for treatment. Tough on work. Do you know anyone in FL who’s offering it? A while ago you mentioned Dr Mantz to me. His location isn’t near family like Abramowitz and Biagioli are, but if he has a unique approach worth considering I’ll try to get in to see him.
The RO on Guam has TrueBeam, back in November he was was proposing 74 Gy over 40-42 sessions, with Lupron, starting with a 1 month injection to make sure I tolerate it ok.
Posted 1/16/2018 1:11 PM (GMT -5)
Biagioli sometimes suggests a shorter course of external radiation (~5 weeks) and then doing an HDR brachytherapy implant to a nodule, IF one is seen on a sensitive scan. As I understand, it's a bit outside the box, but there is some experience with it (although limited overall see references below). The rationale is to escalate the dose to the PSA spewing nodule in as safe a way as possible. When doing brachytherapy he sometimes considers a shorter potential duration of hormone therapy.

You will get a MUCH better explanation and diagnosis of your condition from Dr. Biagioli. The above was specific to my situation.


Brachytherapy. 2014 Mar-Apr;13(2):123-7. doi: 10.1016/j.brachy.2013.09.008. Epub 2013 Oct 23.
High-dose-rate brachytherapy with or without intensity modulated radiation therapy as salvage treatment for an isolated, gross local recurrence of prostate cancer post-prostatectomy.
Strom TJ1, Wilder RB1, Fernandez DC1, Mellon EA1, Saini AS1, Hunt DC1, Biagioli MC2.

Abstract
PURPOSE:
To evaluate the use of high-dose-rate (HDR) brachytherapy ± intensity modulated radiation therapy (IMRT) as salvage therapy for patients with an isolated, gross local recurrence of prostate cancer after radical prostatectomy.
METHODS AND MATERIALS:
Between October 2009 and May 2013, the authors treated six patients with salvage iridium-192 HDR brachytherapy ± IMRT for biopsy-proven, recurrent prostate cancer post-prostatectomy. In each patient, a pelvic MRI scan or CT scan demonstrated a nodule (range 1.6, 4.7 cm) in the prostate bed. Although prostate-specific antigen values were 0.2-9.5 ng/mL at the time of salvage brachytherapy, there was no pelvic adenopathy on CT or MRI scan, and a bone scan was negative in all cases. Five patients were treated with IMRT to 4500-5040 cGy in 25-28 fractions to the prostate bed followed by two 950 cGy HDR brachytherapy fractions separated by 1-2 weeks. A sixth patient underwent HDR brachytherapy monotherapy consisting of 3800 cGy in four fractions over 3 days. Toxicities were graded according to the Common Terminology Criteria for Adverse Events, version 4.0.
RESULTS:
Median followup was 9 months (range 3, 40 months). All six patients have been free of androgen deprivation therapy and have an undetectable prostate-specific antigen. One patient developed late Grade 2 urinary incontinence. There was no late grade ≥2 gastrointestinal toxicity.
CONCLUSIONS:
HDR brachytherapy ± IMRT is a safe and effective salvage therapy option for an isolated, gross local recurrence of prostatecancer after radical prostatectomy and merits further study.
Posted 1/16/2018 1:23 PM (GMT -5)
I forgot to add that Dr. Constantine Mantz, another well regarded RO, is in Ft. Myers at 21st Century. He has done brachy for women's breast cancer, and was involved in a brachy SBRT clinical trial a while ago.
Posted 1/16/2018 1:25 PM (GMT -5)
Thanks a bunch, Gary.
Posted 1/16/2018 2:15 PM (GMT -5)
Saipan Paradise-

It sounds like your RO in Guam has what you need. I don't know anyone in Florida who is doing salvage hypofractionation. I know Dr King in LA has designed a salvage SBRT protocol (in 5 treatments), but he is waiting for IRB approval before that can start, and that can take many months.

Garyi-

Your case was unusual in that you had persistent PSA that seemed to be attributable to a large tumor in the prostate bed, so it made sense to give it a boost dose. Saipan has very low PSA, so it is highly unlikely that he has a large enough focus of cancer that could be identified. They just have to treat the whole prostate bed with an adequate dose.
Posted 1/16/2018 2:34 PM (GMT -5)
Copy that, Allen. Thanks!
Posted 1/16/2018 5:41 PM (GMT -5)

Tall Allen said...
It sounds like your RO in Guam has what you need.


That's good to hear. Still, psychologically I'd be more comfortable with an RO who came recommended. Dr Ko has fine credentials, but a couple months ago I asked on the forum if anyone had been treated by him when he was chairman of the RO dept at IndianaU, and no response. I remember reading in some threads that the RO matters more than the machine and the facility, and that's stuck in my brain. Dr Ko told me he trained with Alan Pollack when they were both at MDA, so maybe I'll give Pollack a call. I'll certainly ask Abramowitz and Biagioli about him. ... Even though Guam's close to Saipan, logistically it wouldn't be much easier than if I were halfway around the world, so all options are in play.
Posted 1/16/2018 5:52 PM (GMT -5)
Sorry to hear, man. I know what a shock that can be, even if you're prepared. If it's any consolation, for me SRT was a piece of cake compared with surgery. I just scheduled it around my gym time.
Posted 1/16/2018 5:59 PM (GMT -5)
Hey reachout....very nice results!

Did you have HT with your SRT?

Saipan, I'm sure you know that Alan Pollack is world class!
Posted 1/16/2018 6:15 PM (GMT -5)

garyi said...
Saipan, I'm sure you know that Alan Pollack is world class!


You bet. I was gonna schedule a consult with him but then you, Gary With an I, recommended Abramowitz, and Deerfield is sooooooo much easier to get to than freakin' downtown Miami and that dystopian nightmare drive down I-95.
Posted 1/16/2018 6:25 PM (GMT -5)
Understand....you won't be disappointed smile
Posted 1/16/2018 6:28 PM (GMT -5)
Head of the RO department at Indiana University is a very impressive credential. What really matters is the care he takes on your plan - did he set tight dose constraints and were they all achieved? How does he do his interfractional image guidance?
Posted 1/16/2018 6:50 PM (GMT -5)

Tall Allen said...
What really matters is the care he takes on your plan - did he set tight dose constraints and were they all achieved? How does he do his interfractional image guidance?


I had to google "dose constraints" and "interfractional image guidance" to understand what you were asking. Clearly I have more homework to do before next week.

BTW, Reachout -- thank you for your encouraging words.
Posted 1/16/2018 8:52 PM (GMT -5)
Better yet - ask the RO to explain - that is a conversation worth having. Here are some questions to ask:

/pcnrv.blogspot.com/2017/12/questions-for-adjuvant-or-salvage.html
Posted 1/16/2018 9:02 PM (GMT -5)

Tall Allen said...
Better yet - ask the RO to explain - that is a conversation worth having. Here are some questions to ask:
/pcnrv.blogspot.com/2017/12/questions-for-adjuvant-or-salvage.html


Molto bene. Mille grazie.
Posted 1/17/2018 10:25 AM (GMT -5)

Saipan Paradise said...

Tall Allen said...
Better yet - ask the RO to explain - that is a conversation worth having. Here are some questions to ask:
/pcnrv.blogspot.com/2017/12/questions-for-adjuvant-or-salvage.html


Molto bene. Mille grazie.

Idem.......

.......and we can compare answers smilewinkgrin
Posted 1/17/2018 10:34 AM (GMT -5)

garyi said...
Hey reachout....very nice results!
Did you have HT with your SRT?

No I did not. Went round and round with my urologist and RO and decided that, from what we knew at the time, it was better to have the PC cells healthy and trying to divide when they got zapped. We now know more but my numbers would still have fallen in the no HT zone. I did great both during and after SRT, with really low PSA but my numbers are once again creeping up. I found a good article, which I posted, that found good 10 and 15 year survivability even after SRT failure so at the moment I'm not panicked.
Posted 1/17/2018 10:56 AM (GMT -5)

reachout said...

garyi said...
Hey reachout....very nice results!
Did you have HT with your SRT?

........ I found a good article, which I posted, that found good 10 and 15 year survivability even after SRT failure so at the moment I'm not panicked.

No reason to panic! I read both that article and many more like it as I debated having ADT with my SRT. What I came away with my opinion that there are too many early interventions in fear of BCR. Especially true for us septuagenarians.

Good luck reach out...
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