Salvage Therapy after Brachytherapy or IMRT

There is a myth that there are no 2nd chances after radiation, IMRT or Brachytherapy. Many on this forum have stated that they chose surgery because if it faled there was always radiaton to fall back on.

This is not true! First for any salvage technique to work the reoccurrance must be local, approximately 25%-30% of all reoccurrances are local in either surgery or radiation; the rest are systemic and cannot be salvaged with any technique.

For failed radiation salvage surgery is difficult and should only be done by an expert surgeon, even then the results and side affects are not good. Cryosurgery and HIUF are also salvage therapies for radiation, these have good cure rates, but again the side affects are not good.

The best salvage therapy for failed radiation is HDR Brachytherapy. These are temporary implanted radioactive rods that can be precisely placed, even the seminal vessels and uretha can be treated.

The side affects are better than either cryo or HIUF and cure is in the 80% range at 5 years.

So if anyone says that there are no 2nd chances in radiation, they are dead wrong.

For Brachytherapy only patients a 2nd seeding with a different isotope can also be done; but it appears that HDR Brachytherapy is becoming the best therapy for failed radiation that is local.

JohnT

I don't recall any poster saying there is no second chance after failed radiation or seeding as a primary treatment. I have seen it said that the options are more difficult.

Surgery after radiation shouldn't even be a choice. It was would be hard to find a surgeon with a good reputation to do it. It is almost always a total failure, and I have had surgeons tell me straight up, that you can almost guaranty the man 100 incontinence for life and ED forever. My own surgeon assisted in a couple of salvage surgeries as an intern, and he said they were the most brutal operations he ever assisted. He said he would never do one for any reason, not good for the patient, and terrible liability risk.

Yes, if once's reoccurance is not local, then any of the salvage treatments are going to fail. When I was talking to the radiation oncologist I finally chose, she said it was good news that I had a positive margin. Confused me. She said that if I had psa rising after surgery with no postive margins, it usually meant that the cancer was already distant. With the positive margin, there's hope that my SRT might work. That gave me some hope.

In the more common approach of surgery first, radiation second, which many men here prescribe to, there's and added bonus in the deal, you have the extracted prostate in its entirity, lymph nodes, and other bits and pieces that have been examined and the pathology on this matter is known. It less of a guess what to do next if you know a fuller extent of the cancer .

In the radiation methods of primary treatment, you only have partial knowledge for most men of the extent of their cancer based in one or more biopsies.

Now if you have the more complex 3-D scans, more would be known, at least to the size and extent of the tumor in question

To me, my opinion, the conventional treatment method gives the removal of the prostate, where most men's cancer is contained, or at least the sheer bulk of it, you will get extensive pathology report on what you do have, and if you need salvage, you can have radiation of which most men endure well (with or without HT), and later, if needed, there is still the HT path.

David in SC

This is a good thread but don't sell brachytherapy short either. It is particularly attractive for men with relatively non-aggressive localized tumors.

Some men, for reasons of health or prior operations are simply not candidates for surgery.

Another part of the equation is quality of life. Surgery has immediate impact while the effects of radiation may appear many years later. For a man with other serious health issues, putting off side effects may make sense.

Squirm,
Radiation failures are caused by insufficient dose that fails to kill all of the PC cells. This was common when the standard dose was 6500gy. The newer machines give about 8100gy which gives superior killing power with similar side affects. A combination of seeds and IMRT will give close to 10,000 comparable gy. This should kill any PC cells in the prostate and up to 15mm outside the prostate. It will take 10 years before any hard evidence proves the higher doses reduce reoccurrances. Nothing in PC is 100% and there could be some cells that survive and grow; just as surgery cannot get 100% of all the prostate tissue or all the PC at the margins. By far the most common cause of failure in both radiation and surgery is the fact that some of the PC cells have escaped into the blood stream or lymphatic system before radiaton or surgery. There has never been a head to head study for surgery vs radiation, but all indications are that cure rates for low grade PC are similar. There is a lot of disagreement when it comes to intermediate and high risk PC, because you can't tell whether the PC is localized or matastized when treatment is done. It is generally accepted that the side affects from radiation are less than those from surgery.
JT

Purgatory said...
Surgery after radiation shouldn't even be a choice. It was would be hard to find a surgeon with a good reputation to do it. It is almost always a total failure, and I have had surgeons tell me straight up, that you can almost guaranty the man 100 incontinence for life and ED forever. My own surgeon assisted in a couple of salvage surgeries as an intern, and he said they were the most brutal operations he ever assisted. He said he would never do one for any reason, not good for the patient, and terrible liability risk.

I had 42 EBRT treatments and six years of hormone therapy when I became refractive. A biopsy of the prostate at this point showed the right side to be filled with cancer (5+4=9) grade. I was offered a prostatectomy and took it. After the catheter was removed I had 99% continence. After radiation and six years of hormone therapy you can forget about erectile function, so that was not a consideration. I gambled on incontinence and won for a while. A stricture that showed up a year after surgery has me fighting incontinence and considering an artificial sphincter.

Some of you who like to make hard statements here should rethink before you speak. Everyone's situation is different, everyone's cancer is different, and everyone's response to treatment is different. Any time you start trying to put this stuff in a neat box it's going to come back and make you a liar.

Dave

John,
Is there any data on the survival rates for HDR Brachy as secondary treatment after failed radiation? I had no idea that HDR Brachy could be used in that respect. Interesting.

John, due to my pre and post surgery psa velocity, my radiation oncologist gave me a 40% figure at best.