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Salvage options after failed brachytherapy

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Posted 9/9/2014 8:29 PM (GMT 0)
As the stats below show, I am facing salvage procedures following brachytherapy in 2008. The best options presented to me have been cryotherapy and removal of the prostate. I am trying to discern the best options with the lowest SE (aren't we all). Can SBRT or Proton therapy be salvage options after brachytherapy? Can anyone share their experiences? I can't find much info online for salvage after brachytherapy and appreciate any input. I live in Pennsylvania and would be open to traveling for the best treatment. Thanks.
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Age 59 at diagnosis (biopsy 1/4/08)
Gleason 7 PSA 6.3 at time of biopsy
Brachytherapy 5/08 - 86 Cesium 131 seeds
PSA nadir .36 12/11
6/13 PSA .37
12/13 PSA .62
6/14 PSA .77
Repeat biopsy 7/9/14
Gleason 7 - brachytherapy failed
9/14 PSA .96
Posted 9/9/2014 8:59 PM (GMT 0)
I had cryoablation as primary treatment , outpatient, at Cleveland Clinic system. They may have burned my bladder neck or urethra somewhat. Something caused some irritable bladder. I get up about once or twice a night to pee now. Seem ok cancer wise so far.
Good luck.
Posted 9/9/2014 9:08 PM (GMT 0)
Reseeding, IMRT, or SBRT are all options. Dattoli in Sarasota does a lot of salvage and you should at least talk to them to see what he has to say.
Posted 9/9/2014 9:14 PM (GMT 0)
I would suggest getting a choline 11 pet scan if at all possible. It sounds like you have just a small spot that can be treated with SBRT. I know they do this at UCLA. LupronJim may be able to help you.

Otherwise, any other modern imaging would be useful as well.

I was just at the PCRI conference and they discussed situations similar to yours. There was concurrence that surgery and cryo for this may have too many SEs for such as small spot, if that is what it is.
Posted 9/9/2014 9:27 PM (GMT 0)
I'm sorry to hear about a recurrence after so long. Salvage cryo and RP usually have lots of side effects, so I agree that salvage radiation may be a better option. I hope Epstein or Bostwick read your biopsy slides as the radiation affects the cellular architecture and you really want some expert eyes on this. As part of whatever kind of salvage you decide upon, you might want an mpMRI to look for signs of cancer in the prostate fossa and pelvic LNs, as well as to localize the place in the prostate for an intraprostatic boost.

SBRT can be used as salvage. Donald Fuller in San Diego has been using it for that purpose.

Salvage HDR brachy is also a good option. I know Mack Roach III at UCSF has used it for salvage after LDR failure, and he uses salvage LDR brachy as well.

I imagine Jeff Demanes at UCLA has done a few salvages with HDR brachy, but I can't say that for a fact. Worth a call, though.

I'd prefer SBRT or HDR as salvage because of the possibility of dose painting to avoid excess dose to bladder and rectum and to help avoid urethral strictures. They might do a rectal hydrogel spacer too.

I haven't ever heard of proton as salvage - maybe call UFJacksonville or MD Anderson to inquire.

Please let us know as your inquiries progress.

- Allen
Posted 9/10/2014 10:40 AM (GMT 0)
From a fellow BT patient, I'm curious as to what you're PSA nadir was, and when it started trending up. Much luck to you in finding a suitable salvage option. I've often wondered myself what the options were, especially PBT. I'll be following this thread with interest
Posted 9/10/2014 7:57 PM (GMT 0)
Thanks for all your input! Is the choline 11 pet scan only available at the Mayo Clinics? Are there any such tests available on the East coast? I did contact the NIH about a trial of the radiotracer F-DCFBC but I may not have a high enough PSA to qualify. Does anyone have experience with SBRT in the Philadelphia area? Tall Allen, our son lives in Los Angeles - would you recommend your doc/sbrt guy? Does he do salvage sbrt? Powellst, my PSA nadir was .36 in 2011 (took 3 years to go below 1 after BT which was stressful) then it stayed there for 2 years and began the slow rise.

________________________________________________________________________________________

Age 59 at diagnosis (biopsy 1/4/08)
Gleason 7 PSA 6.3 at time of biopsy
Brachytherapy 5/08 - 86 Cesium 131 seeds
PSA nadir .36 12/11
6/13 PSA .37
12/13 PSA .62
6/14 PSA .77
Repeat biopsy 7/9/14
Gleason 7 - brachytherapy failed
9/14 PSA .96
Posted 9/10/2014 8:59 PM (GMT 0)
The C11 Choline or Acetate PET scan is useless at your PSA level -- save your money. You need a PSA of at least 2 to show anything useful. That's probably true of most PET tracers. An mpMRI is probably your best bet to determine whether you can go for focal salvage, or whether there is locoregional spread that has to be addressed.

Here's a reference on its use:
MR-guided Prostate Biopsy for Planning of Focal Salvage after Radiation Therapy.

I don't think Dr King at UCLA has actually done any salvage SBRT, but you can call and ask. Dr. Demanes is at UCLA as well, but I can't speak to his experience with HDR salvage. Dr. Fuller is about a 2 hour drive from LA, and he has done them. And I know that Mack Roach has done brachy salvage.

- Allen
Posted 9/10/2014 11:54 PM (GMT 0)
Have you talked with your BT guy about LDR salvage?

Being a BT recipient I discussed salvage options just to be prepared. Here is a site I keep just in case: http://prostate-cancer.org/PDFs/Is14-3_p18-21.pdf
Posted 9/24/2014 5:56 PM (GMT 0)
We talked with the RO at the hospital where I had the original BT. He said SBRT is a good salvage option for me and it can be done there. He initiated the conversation stating that SBRT as the best option (in his opinion). What specific questions should we ask him?

________________________________________________________________________________________

Age 59 at diagnosis (biopsy 1/4/08)
Gleason 7 PSA 6.3 at time of biopsy
Brachytherapy 5/08 - 86 Cesium 131 seeds
PSA nadir .36 12/11
06/13 PSA .37
12/13 PSA .62
03/14 PSA .68
06/14 PSA .77
Repeat biopsy 7/9/14
Gleason 7 - brachytherapy failed
09/14 PSA .96
Posted 9/24/2014 6:14 PM (GMT 0)
As I said in my earlier post, I think it's wise to use some kind of advanced imaging, such as mpMRI, to assure that the recurrence is only in the prostate itself and not in the prostate bed or local lymph nodes. It may also help define areas within the prostate for dose painting. Or does he just intend to focally treat the biopsy-identified focus of cancer?

Also ask how many SBRT salvages he's done and what the outcomes were, both in terms of re-recurrence and side effects.
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