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Confused about tx for bone mets

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Posted 12/25/2022 8:52 AM (GMT 0)
I am confused about typical tx in such a scenario.
Suppose someone has say 1-3 small spots on bone. Assume no pain/symptoms.
I've read that one can radiate those spots. I've also read that one should not radiate unless there is pain. Which is it?
Same question, but say more than a few spots (>5). Is radiation even in the picture?


Mel
Posted 12/26/2022 3:10 AM (GMT 0)
Hi Mel and Merry Christmas,

Can only speak from my wife’s experience and what I have read. Oligometastatic cancer is loosely described as a “few” lesions or “spots”, generally in the area of the original cancer. It is pretty loosely described from what I have read. Many use 5 “spots” as the criteria but that number is based on a guess or estimate, not conclusive research.

My wife had a lesion discovered by accident in a rib behind her breast cancer from 17 years ago. She never knew anything was going on and the single lesion was all that was found on additional scans. Both the University and Mayo said SBRT to the rib and a drug regiment were recommended. She did the radiation immediately (3 sessions) and then started the meds and it is close to 3 years now with no positive scans so she is doing well so far. Given that 2-3 years is more common for metastatic breast cancer survival, we are happy with the results so far.

If one is in the oligometastatic stage, it seems you treat immediately and hope to kick the can down the road a long ways. If one has true metastatic cancer, systemic treatments are recommended with radiation as needed for localized pain as the whack-a-mole process does little to stop the spread. There are also situations where the cancer is in places that can not be irradiated and that is that.

On the other hand, PSMA based treatments show a lot of promise for systemic treatment of cancer mets so who know what the future will bring for the metastatic cases. More options every year.
Posted 12/26/2022 8:43 AM (GMT 0)
It is going to get messy with sensitive psma scans.

It cuts both ways. Yes psma scans will find things earlier but will that change the definition of “systemic” or “ogliometasatic”?

If they find 6 tiny spots where before they only saw 2 will they treat? What will insurance pay for?

At some point there needs to be a head to head/heart to heart conversation with our dr’s on what they are willing to try and what our expectations are. Ideally those things match.

Its a changing landscape.
Posted 12/26/2022 3:57 PM (GMT 0)
Hi Mel,

Here are links to the articles I read before dismissing my first team and referring myself to another team for further treatment/support. I had 3 lymph node mets, "close to each other and close to the original tumor site". I got 106 Grey total to those mets and to my interior pelvic lymph nodes. That on top of the 72 Gy I initially got after RP + 2 & 1/2 years of leuprolide chemo. This upcoming March it will be 2 years since I completed that second round of radiation, PSA is less than 0.03 without drugs.

As I understand it, the point is not just to kill off the mets, but the release of dead tumor proteins into your blood stream alerts your immune system to the problem. That then encourages it to seek out and destroy other micro-mets that may be present, even if they are distant from the treatment site.

I got said radiation via Daniel Krauss in the Radiation Oncology Center at Beaumont Royal Oak. He has a very good track record with this treatment. If my PSA goes up I am committed to a PSMA PET and further spot treatment. Here are those links:

https://www.sciencedirect.com/science/article/pii/s2090598x16300377

https://ro-journal.biomedcentral.com/articles/10.1186/1748-717x-9-135

Best of luck.

Rich
Posted 12/26/2022 6:45 PM (GMT 0)
trailguy - Great story, hope it keeps working for you so well. Hope others can have similar results given that "we" can see things better nowadays on scans and can aim better.
Posted 12/27/2022 2:53 AM (GMT 0)
Mel, sorry you are dealing with this. IIRC, Aren’t you a patient of Dr Kwon at Mayo? And isn’t this something he’s done a lot of work on?
Posted 12/28/2022 4:22 PM (GMT 0)
Once there are more than 3 spots SBRT is less recommended. Where the spots are and how far apart they are goes into the mix.
Posted 12/28/2022 9:04 PM (GMT 0)
Thanks for your concern. This was a purely academic/hypothetical question... for now. I was just thinking about future eventualities and realized I had this confusion about bone mets txs.

My current situation: PSMA scan found 2 hot nodes in the lower
retroperitoneum/para-aortic region. Unfortunately, RO said the area was previously radiated and he did NOT
recommend radiating it. So, I am back on HT (Orgovyx). Hopefully, it will dissolve/diminish these nodes.

It was disappointing.

Mel
Posted 12/30/2022 7:02 AM (GMT 0)

trailguy said...
Hi Mel,

Here are links to the articles I read before dismissing my first team and referring myself to another team for further treatment/support. I had 3 lymph node mets, "close to each other and close to the original tumor site". I got 106 Grey total to those mets and to my interior pelvic lymph nodes. That on top of the 72 Gy I initially got after RP + 2 & 1/2 years of leuprolide chemo. This upcoming March it will be 2 years since I completed that second round of radiation, PSA is less than 0.03 without drugs.

As I understand it, the point is not just to kill off the mets, but the release of dead tumor proteins into your blood stream alerts your immune system to the problem. That then encourages it to seek out and destroy other micro-mets that may be present, even if they are distant from the treatment site.

I got said radiation via Daniel Krauss in the Radiation Oncology Center at Beaumont Royal Oak. He has a very good track record with this treatment. If my PSA goes up I am committed to a PSMA PET and further spot treatment. Here are those links:

https://www.sciencedirect.com/science/article/pii/s2090598x16300377

https://ro-journal.biomedcentral.com/articles/10.1186/1748-717x-9-135

Best of luck.

Rich

Releasing proteins post SBRT and the immune system recognizing the cancer is Abscopal effect. Less than 20% will get this immune response.
Posted 12/31/2022 5:51 PM (GMT 0)

compiler said...
Thanks for your concern. This was a purely academic/hypothetical question... for now. I was just thinking about future eventualities and realized I had this confusion about bone mets txs.

My current situation: PSMA scan found 2 hot nodes in the lower
retroperitoneum/para-aortic region. Unfortunately, RO said the area was previously radiated and he did NOT
recommend radiating it. So, I am back on HT (Orgovyx). Hopefully, it will dissolve/diminish these nodes.

It was disappointing.

Mel

Sorry to hear this Mel. I hope the Orgyvyx will be easier than the Lupron
Posted 1/1/2023 1:22 AM (GMT 0)
Mel - trailguy’s suggestion makes sense in your area. Another opinion might be helpful to resolve the radiation dosage issue.
Posted 1/1/2023 1:58 PM (GMT 0)
Thanks again for the responses. I have an appt (video) with Dr. Lam on the 19th. I might ask him if it is worth getting a 2nd opinion by some top RO. I bet Dr. Lam could recommend one. He/she could easily do the analysis remotely by looking at the pictures/reports. Then I can have this RO consult with some top State ROs (Umich, Ford Hosp, Beaumon). Due to a spinal injury, lengthy travel is problematical.

Mel

Post Edited (compiler) : 1/1/2023 6:01:18 AM (GMT-8)

Posted 1/1/2023 10:51 PM (GMT 0)
My husband has had 3 small spots radiated on his spine...sacrum, second anterior rib, and most recently the L1. Our approach has been to get rid of these small spots before they become larger or start to spread. Insurance has paid for all of them.
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