New research on salvage radical prostatectomy after radiation treatment has failed

Pros,
There are also other salvage treatments for failed radiation that have equal success and are not as invasive or prone to complications. Reseeding with low or high dose brachy, cryosurgery, HIFU, and there are studies now going on with cyberknife that look promissing. These all have success rates in the 30% + range, about the same as SRT after a failed surgery.
JT

Fairwind, what in the article led you to conclude that beam radiation alone can't reliably destroy prostate cancer? I read it, and I may just be tired, but my mind didn't go there.

Also, a certain percentage of these men (those treated in the earliest years of the study) almost certainly had EBRT, not today's IMRT. Could that have made a difference in outcome? I know we talk a lot about EBRT and side effects, but what about its accuracy and success compared to IMRT/IGRT?

If my husband's IMRT fails (still waiting on the results of the first PSA blood draw), we would probably consider cryosurgery first. I doubt he would even consider surgery. I had wanted him to do the brachy/IMRT combo but straight IMRT was his choice. Hope we won't regret it. :(

Juliet

Fairwind, what in the article led you to conclude that beam radiation alone can't reliably destroy prostate cancer? I read it, and I may just be tired, but my mind didn't go there.

If beam radiation by itself could destroy cancer completely, there would be no need for salvage surgery...On the bright side, the number of patients who need salvage surgery and for whom it's successful is very small...

With radiation it's a tricky balance..A high enough dose to kill the cancer but not enough to cause unacceptable side-effects. It's a real tight-rope. The combined Brachythearpy/IGRT treatment can deliver 150Gy safely and this shows up as higher cure rates..But for various reasons, it is not appropriate for all PC victims..

To add some clearity:
The older ERBT conformal radiation was delivered in a dose of 61 -65 gy. In many cases, especially with a large prostate and a large aggressive tumor it was not enough to do the job. The newer primary treatment dose is 78 to 81 gy and is much more successful in controlling cancer. Doses higher than this result in unacceptable side affects.
The failure in seeding comes from seeds being unevenly distributed and causing dead spots.
Combination treatments vary somewhat in that 85 to 100 gy is delivered by the seeds. This dose rarely affects other organs because the radiation from each seed extends only about 1mm. It is topped off by 45gy of IMRT to the prostate and about 10mm into the bed for a total of 145 gy. The side affects are comparable to 81 gy delivered by IMRT alone.
Local radiation failures are caused by either too low a dose or dead spots in the delivery or planning. In rare cases mutated cells can develop a resistance to radiation. Salvage radiation always uses a different isotope because of this. In combination treatments different isotopes in the two different kinds of radiation delivered eliminate this problem; that's why it is used in high risk cases. I'm not aware of any local failures from combination treatments, but there must be some out there, because nothing is 100%. My treatment was 85 gy seeds and 45 gy IMRT for a total of 130gy. I have heard of others getting 150 gy.
Radiation is all about dose and accurracy. The higher the dose the greater the killing power and the greater the accurracy the less side affects.
JT

The amount of radiation given in a fraction is also important. When using HDR versus permanent seeds, less total gy are delivered, but they are delivered in an extremely short period of time. As John T explained, his seeds provided a total of 85 gy over a period of some 90 days. This was delivered continously during that time.

With HDR I had two procedures where radiation was introduced then withdrawn throughout the gland and seminal vesicles using one small pellet attached to a wire. The radiation cloud also extended around the gland and was specifically targeted to deliver more radiation to the cancerous areas. Each radiation procedure took a little over 15 minutes. The two procedures delivered about 50 gy in a total of 30 minutes. Additionally I received 45 gy through IMRT in 25 fractions. The HDR procedures were one week apart and were delivered in the last third of the IMRT sessions.

The more radiation you can deliver in the shortest period of time inflicts a higher rate of damage to the cancer cells. Thus the excellent high dose brachytherapy treatment results. To contrast with permanent seeds, the dose is high enough that my rad-onc said if the one small pellet was left in me that I would be terminally poisoned within three days.

HDR can be used as salvage and my doctors said that, if needed, I could easily undergo a few more procedures. I could also use seeds, nanoknife, cyberknife, HIFU, cryo, surgery, etc.

As John T said, IMRT with brachytherapy rarely fails because it treats a much larger area than surgery. Generally, if the psa rises after the IMRT/BT nadir is reached, it is because the cancer was systemic at the time of treatment and was thus outside the area of radiation.

I may be facing some sort of salvage therapy as my PSA is rising. The dilema I have is "where is the cancer?". Are there any imaging techniques that have a reliable record of locating the cancer? Combidex was one but not available in the US and no longer available over seas either. Prostacint is deemed unreliable and inaccurate. Scans either CT or MRI are limited. CTC tests are available but rarely prescribed. I also find that my doctors are more interested in providing a treatment than in characterizing the disease. Sort of shotgun approach.

As far as radiation's curative properties there are many research papers that indicate IMRT has as good a result as surgery for LOCALIZED cancer. I know of one gentlemen who was treated at age 70 with EBRT thirty years ago and recently celebrated his 100th birthday. Oh, he still lives on his own. He is the father of one on my friends.

Proscapt, thanks for the article posting.

Don

David,

She told me he has slowed down a bit after falling off the roof while doing some repairs at age 92.

Don