SBRT for oligometastasic recurrence

We would like to believe that PC remains curable when just a few mets are found after recurrence. The studies on this subject have been very small. A new analysis pooled together data from several studies to see if there were any valid conclusions. They found that the metastasis-directed SBRT treatment (and, BTW, PLND) did an excellent job at eradicating the specific metastases at which it was directed, and the toxicity was remarkably low. However, that did not halt the cancer’s progression, except in 15 percent at 5 years, and presumably in fewer after longer follow-up. The question remains, however: did the treatment slow down the cancer, allowing for many extra months and perhaps years of survival, and especially of symptom-free survival? The answer is maybe.

Here's a link to the article:

SBRT for oligometastatic recurrence

- Allen

Fairwind, that's the least of the worries. Insurance will usually approve SBRT for mets - it's commonly used for pain palliation. The problem is in getting approval for the advanced imaging required to identify such mets -- it's rarely covered.

- Allen

Mel, I believe Mayo has a monopoly on C-11 Choline which is sometimes covered by insurance but there are several facilities that do C-11 Acetate that is rarely if ever covered by insurance.

Probably not the least expensive but coming with a guy who is an expert at interpreting them is where I had mine performed by Dr Fabio Almeida at AZ Molecular Imaging.

He normally charges $3000 but since I was having the F18 sodium (Covered by insurance) that same week he discounted it to $2500.

Thanks to Tall Allen mentoring, I had SBRT by Dr. Chris King at UCLA 11 months ago and so far no adverse side effects, but as a G9 with radiation to the prostate and the entire pelvic girdle, one never knows how it shakes out long term.

Mine was the initial treatment rather than recurrence which is your case, but very pleased with Dr. King and with UCLA in general.

If the procedures above provide a period of remission without drugs longer than those remissions from treatment with drugs alone and reduce the tumor volume and eliminate the site of a future metastasis then I would call such a treatment a success. This was my experience.
It may also eliminate large pockets of faster growing tumor cells, those more likely to metastasize elsewhere leaving a greater percentage of slower growing cells.
It is at least possible that this means longer time to drug resistance and perhaps greater survival.
Add that this treatment may be repeated and I believe the risks are worth the known and potential rewards

When we were considering this for my Dad 3 years ago, I took him to a reputable clinic in Germany and spoke with the head of radiation oncology there. He told me that the trial in Europe was just being prepared at the time for exactly that type study (radiating oligometastatic sites in PC). He said "we won´t knwow the results for a long time...."

The concept does make sense mostly because PC is a slow-progressing disease. I wonder if it benefits some patients more than others, depending on the route or stage of the PC spread (blood, bone marrow, lymph). It is definitely worth keeping an eye out on this approach.

compiler said...
Nomar (ie: Lupron Jim).
Your post above answered one of the questions I just emailed you.

I am going to reconsider all of this, if I get a second chance, hopefully after another HT vacation!

But, another question: you did quite a bit of stuff, treatment-wise. How do you even know what did what? Of course, you might not really care, if things are better, as they appear to be.

Mel

Mel - I personally only understand part of what Dr. Chris King at UCLA did, but Tall Allen whom I gave a copy of my dose volume histogram understands it all. In fact the toxity to my rectum was so small that he followed up with Dr King who said it was a perfect storm of general anatomy and visceral fat. He's the only doctor who ever told me I did not have to lose weight, at least not until after the SBRT since the fat protects against unintended radiation to vital areas.

It's been 11 months and still have not gotten serious about losing weight. Hoping my IHT vacation that started at end of April will build up some testosterone eventually, without increasing DHT or PSA and weight loss will be easier.

Fortunately on the cardio metrics my bad cholesterol is about 20 and my good cholesterol just broke 40 for first time in my a decade.

Alas that T recovery takes a lot longer than I had hoped with good news being my PSA remains <0.02, and DHT <5 but with it my T remains <3 after 5 months. If they are have to go the same one way or the same other way together, low end of course is preferable.

I was on Lupron 28 months and Zytiga 9 months and have heard a rule of thumb that T recovery is length of Lupron times 150% but sure like everything else PCa it varies by individual. Since I had been treated for years for low T pre-PCa, it will take a while with the only saving grace being no libido means I do not think about what I am missing other than when I reply to a thread about T.

My SBRT was to the prostate, to what we would call the prostate bed had it been removed, and to the entire pelvic girdle not just to the 3 micro Lymph nodes identified on the C-11 Acetate scan that was out of pocket but well worth it. The F18 bone scan changed my diagnosis from stage 4 bone mets palliative only, to locally advanced potentially curable with radiation. F18 showed suspicion of lymph node involvement but no bony mets, and C-11 Acetate confirmed there were 3 LN's not being masked by Lupron and PSA of 0.27 at time (recommended scan PSA is >=2)

Again thanks to Tall Allen I went for the abscopal effect of Provenge Immunotherapy in conjunction with SBRT.

I figured there were most likely more mets being masked by Lupron but SBRT would zap anything in the pelvic girdle whether the best scan could see them or not. Dr. King was diligent about limiting the toxity that many other nationally renowned RO's said would be too toxic.

That's why there are only 3 RO's I know of that do high Gleason SBRT for initial treatment (I assume there are more that do high Gleason spot radiation but that was not my scenario), the others being Dr Allen Katz in Flushing NY and a group of doctors in Toronto that a poster named Houseboy used.

I have little to add to Nomar's excellent explanation. The other treatments he had (Provenge and Zytiga) were adjuvant treatments to the SBRT. That means that no one would have expected them to be curative on their own, but they would be probably enhance the efficacy of the basic SBRT treatment. No one really knows if they do, and if they do, by how much. But since the adjuvant treatments were safe, well-tolerated, and Nomar and his doctors got them paid for, why not have that insurance?

- Allen

This hits close to home as I am seven months post oglio-met SBRT.

I took a look at the study in the first post and reviewed a Snuffy Myers discussion from last December.

The study said that the adjuvant ADT might be an advantage, but not statistically so. It is likely to be, given the primary treatment studies to that effect.

Myers thinks that radiation causes T helper cell depletion, which would work against abscopal advantage. He is hesitant in recommending immune system depleting radiation. This is more likely in broader doses of radiation. It seems abscopal may work if a strong dose is delivered to a small area such as a small bone lesion. He also says that T cell count should be monitored, especially going into Provenge.

https://askdrmyers.wordpress.com/2014/12/05/treating-oligometastatic-disease-with-radiation/?mc_cid=2114e4da59&mc_eid=d9d4beb2ae

At the 2015 PCRI, I met a patient who was on his fourth whack-a-mole radiation, each one lasts 16 months, suggesting multiple oglio treatments are feasible.

Going forward: it seems to me that the longer local treatment can be employed the better, perhaps a future local treatment will be enduring. When local treatment fail, then chemo with an adjuvant would be next but the treatment landscape may be different by then.

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Age 64 in 2015
12/02 PSA 2.9 age 51
9/03 BX/DX, Gleason 6, 4 of 12 cores
9/03 Brachytherapy
5/08 PSA nadir 1.1
12/08 PSA 1.8
2/09 BX/DX, Gleason 8, 1 of 12 cores
6/09 Hyperthermic Radiation, Hormone (short term), IMRT (10 fractions) spring 2009
10/09 PSA nadir < 0.1 10/09 through 01/12
4/12 PSA 0.2
3/14 PSA 2.9
5/14 C11 Acetate PT/CT, found 2.0 cm lymph node
5/14 Lupron/Casodex (9 months)
8/14 nadir <0.01
2/15 SBRT to node, at UCSD
3/15 PSA 0.02,T=0
6/15 PSA<0.015,T=105 (yippee!)
9/15 PSA<0.1 (Quest), T=278