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Strange Results from Volume Study

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Posted 11/17/2018 3:02 AM (GMT 0)
I decided for "double play" treatment of 23 sessions of IMRT plus LDR brachy.

In June, after my first biopsy, my prostate size was estimated at 40 cc. In August, after my mpMRI, my prostate size was estimated at 41.5 cc. After various testing anomalies that required various retests, today was the day for my CT simulation and volume study, the last set of tests before treatment started-- or so I thought.

I was really looking forward to getting the treatment show on the road. But the RO said the CT simulation showed the prostate was much larger-- at least 80 cc and maybe 90 cc. He said I was too tight to insert the ultrasound probe all the way for the volume study, preventing an accurate final measurement, but called off the volume study in any case when it became clear that my prostate was too large for brachy.

I was floored, and asked the doctor how an mpMRI could be so off on on the prostate size. He said he didn't know, but the bottom line is that the CT simulation and the volume study are the most accurate, and supersede the MRI.

He offered 2 options: 1) a 3 month Lupron shot, to try to shrink the prostate down to an acceptable size for LDR brachy (55 cc or less); or (2) if that doesn't work, 39 sessions of IMRT, including a second 3 month Lupron shot.

I told him I was still eager to do the double play, and would go for Option 1.

But in reality, I am feeling pessimistic that more tests and procedures will just lead to more tests and procedures, and maybe I should just cut out the LDR brachy, and go for straight IMRT or (my preference) SBRT, where repeat uroflow tests, repeat CT simulations, and prostate size estimates won't derail my treatment and put me into straight IMRT anyway, except with a lot more tests and delays.

Am I missing something?

Ideas? Thoughts? Suggestions?

Post Edited (RichBinSD) : 11/16/2018 8:38:29 PM (GMT-7)

Posted 11/17/2018 3:32 AM (GMT 0)
I would go with short-term ADT (6-9 months) with SBRT in your case. The reasons I would include:
1. Having 6/6 positive cores on the right side and 2. two positive cores for PNI. I would want to maximize the effectiveness of the SBRT by combining it with the ADT. I agree with your first choice of IMRT and brachy. I am biased since I chose the same treatment. You could try your other option. You are not risking anything by using Lupron and seeing if your prostate shrinks enough for the brachytherapy.
However, I would go with the SBRT since I would want a quicker resolution and I believe there is good evidence with great results with the SBRT.

Do you know an experienced radiologist that does SBRT? Either choice would give you good results. You have hit a slight bump, but the end result will be good regardless of how you choose.

Paul
Posted 11/17/2018 3:37 AM (GMT 0)
I would go for double play still. get the shot and see what happens.
Posted 11/17/2018 4:01 AM (GMT 0)
Sorry to hear of the bump in the road. I think you got some good advise in seeing what ADT does in terms of shrinking the prostate. I'm not sure it will reduce it in size enough to get to LDR, but even if you don't reach full reduction in size you need, any reduction provides a smaller target that needs to get radiation and will thus reduce the area of your body subjected to radiation on the way to the target.

Also, the ADT makes the cancer more susceptible to the radiation to follow (probably wrong term, but right concept).

FYI, I was "there" today for CT, MRI, and RO visit -- I'm doing a separate post because I don't want to intrude on your thead ;)
Posted 11/17/2018 4:55 AM (GMT 0)
For some reason, my profile did not post, so here it is:

Age: 62
PSA, 3/18: 6.1
DRE, 4/18: Stage T2a, right side
Biopsy, 6/18: Left = 2/6 positive, G3+3; Right = 6/6 positive, 3 @ G3+3, 3 @ G3+4; PNI identified in 2 cores
mpMRI, 8/18: PIRADS 5 tumor in the right transition zone. No capsular involvement, seminal vesicles and neurovascular bundles appear normal.
MRI-guided biopsy, 9/18: 9 cores from TZ, 1 positive = G3+3
Flomax, 10/18
Posted 11/17/2018 5:37 AM (GMT 0)
I'd be tempted to do the shot then see. even if you just did short term ADT + IMRT, I think it's possible that would be good enough.

SBRT does have a good rep, so going back to that might be good.

Andrew
Posted 11/17/2018 12:36 PM (GMT 0)
Use HDR-BT instead of seeds. It can be used on much larger prostates than yours. I hope the doctor is including Avodart or Jalyn as this is what will shrink the prostate more significantly and probably more quickly than Lupron alone.
Posted 11/18/2018 2:40 AM (GMT 0)
After a good night's sleep, the disappointment has subsided, and I came out where almost of you did, which is to go for the Lupron and see what happens.

There is almost no downside, and there might be a big upside if it qualifies me for LDR brachy as part of a double play.

In the meantime, it is treatment before the main treatment begins.

PDL17: yes, we have Dr. Don Fuller here in San Diego, and Dr. Chris King up the road at UCLA, both of whom are considered pioneers in and top practitioners of SBRT.
Posted 11/18/2018 3:38 AM (GMT 0)
Don't take the Lupron. A few months of Casodex and proscar will reduce your prostate by 50%, the same as Lupron with about 1/3 the side effects. My RO wanted to do the same thing. My oncologist called him and told him about Casodex. My prostate was 60cc, at treatment it had shrunk to 32 cc.
Posted 11/18/2018 3:42 AM (GMT 0)
Not sure if you saw JNF’s post, but HDR-BT will give you the brachy boost, and can be used with larger prostates, like yours.
Posted 11/18/2018 3:54 AM (GMT 0)
JohnT: when you wrote "oncologist," did you mean either Drs. Lam or Scholz?

ASAdvocate: yes, I saw JNF's post. I will do more research on HDR brachy and what kind of results it has gotten as part of a double play combo therapy.
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