Radiation again after original imrt treatments ?

Original and only treatment was 2 months of imrt (79gy)
done in 2011. (there was 6 months of concurrent adt then)

Below, I am NOT talking about salvage radiation for someone who originally had surgery, nor am talking about spot radiation for specfic metastases.

No surgery was ever done.

The psa starting rising last year and is at recurrence level.

One oncologist seen mentioned to look into having radiation done again -
if bone scan and ct imaging were negative, with assumption that it might not have spread outside prostate -

(rather than just starting ADT)

(They mentioned another biopsy would be needed in this case,
since no radiation could/should be done unless verified cancer seen)

===> I was really shocked and confused by this "re radiation" suggestion
since in all my reading on reputable sites and in books, etc -
I'd never seen any reference to doing imrt again for someone who had
imrt as their original treatment. I guess I assumed reasons for not having
it again would relate to damage/effects already done by original treatment
and not wanting to exacerbate things even more.

I'd always read that even if it might still be in prostate, then at some point the standard thing was to start ADT, even if imaging was still negative
(with exactly when to start ADT discussed by patient and doctor)

Thus wondered if anyone had any thoughts or feedback or pointers to info
about is this re radiation ever a standard of practice or done at times ?

Again, am not referring to someone who had surgery and is lwho ooking into
salvage radiation, and not referring to spot radiation for specific metastases.

Thanks.

From the EUA guideline: Following local recurrence after previous definitive RT there is no indication for salvage EBRT as the total dose is limited and therefore the chance of cure is low. For carefully selected patients with primary localised PCa and proven local recurrence, high- or low-dose rate (HD/LDR) brachytherapy remain an effective treatment options with an acceptable toxicity profile.

I don't think that salvage IMRT after IMRT failure is a good idea, however, let me suggest a few alternatives.

First - it has to be confirmed as a clinical local-only failure. That entails 2 parts:

(1) a full body search must be made to look for evident metastases outside of prostate. The best way for doing that is with one of the advanced PET scans, like a C-11 Choline or Acetate PET, or one of the newer PSMA-directed PET scans available now in several clinical trials. If distant mets are found, it would be futile to pursue local salvage of any kind.

(2) It has to be confirmed as a clinical failure and not just a biochemical failure. Don't forget that PSA can still rise that high owing to prostatitis or urinary retention. The best way for detecting a clinical failure is with an mpMRI-targeted biopsy, read by a radiologist who is adept at reading such things.

You may be interested in this article about local-only IMRT failures:
Site of cancer recurrence after first-line (primary) radiation therapy

So, if it has been confirmed as a local-only failure, you have several alternatives:

• Salvage SBRT. In the US, I am only aware of Don Fuller in San Diego who is doing this. This is relatively new and he only has two years of followup so far, but his cancer control is high and toxicity rates are low. You can read about it here:

Salvage SBRT for local recurrence after first-line (primary) radiation therapy

• Salvage brachytherapy. This has been done in several ways: focal LDR brachytherapy (seeds), focal HDR brachytherapy (temporary implants), and whole gland HDR brachytherapy. In my estimation, the top doctors for doing this would probably be Joe Hsu at UCSF or Michael Zelefsky at MSKCC.

• Salvage focal ablation. Both focal salvage cryo and focal salvage HIFU have been used after radiation failure. However, HIFU was only recently approved in the US and no one here has extensive experience in using it for focal salvage. There are a few doctors who may be able to deliver focal salvage cryo, notably, Aaron Katz, Gary Onik, and Duke Bahn. I'm not a fan of salvage whole gland ablation.

• Salvage surgery. There are a very few doctors who get good results with this, notably, Scardino and Eastham at MSKCC (see this link). Few surgeons have the adequate experience it takes to successfully perform this delicate operation.

It matters A LOT who you choose to do salvage. Experience counts!

- Allen

I met the criterion mentioned by TA. Suspicious lymph nodes found by MRI which were not radiated previously. See my signature for what I had done at Dattoli Cancer Center where Dr Dattoli treats only prostate cancer. It apparently is controversial but not at Dattoli. So far so good.
Bob

Allen is correct. The reocurrance must first be identified as local, confirmed by a PET scan or a biopsy. This is a rare occurrence as the vast majority of radiation failures are systemic and not local.
For a local reocurrance radiation treatment with a different isotope is most likely the most viable option. Dattoli in Sarasota Fla does a lot of these and would be on the top of my list for a consult. I have never heard of IMRT on top of IMRT. Most salvage treatments are either LDR Brachy or HDR Brachy.

Tomhw
If I were you I'd Call Dr Dattoli for a free phone consult. You sound like a candidate for scans to find where recurrence is located and if in area not previously radiated, he has a system of IMRT and or brachy to radiate the mets.
Bob

Tomhw
You can ask me here. Basically the IMRT I had after failed RP was the cause of my rectal damage. Not the radiation I had to lymph nodes since rectum was not touched. I had abdominal pain and rectal bleeding a year after SRT. I took antibiotics which stopped the abdominal pain then I had a colonoscopy to see what was going on. They found mild diverticulosis (the cause of abdominal pain) and radiation damage. Dattoli is an expert at precise treatment whereas the local RO who did my SRT was a newbie. I had bleeding even back then and it got worse a year later. When I was having rad at Dattoli I got the name of a GI doctor in Sarasota who did the ablation which is basically cauterization with radio waves. If you have more questions please ask.

I chose radiation to pelvic lymph nodes to try for a cure or at least durable remission. I was not willing to give up and submit to long term HT. So I disagree with your doctor who said to wait until your PSA increases then do what? Scans? ADT? Rad? I got my scans when PSA was 1.22 at Sand Lake Imaging in Orlando which Dattoli uses. Guys here at HW directed me to Dattoli. I knew nothing about him before then. His entire team are the best!
Bob

Newton -

You will be getting so much (hopefully curative) radiation to the local area that it is highly unlikely you would have a local-only recurrence after that. If it is in the prostate only, salvage ablation would probably be preferred. There is no salvage if the cancer is already systemic, but there is long-term management.

- Allen

Break60/Bob,

Thanks for replying. I'm sorry you had to go thru that situation as to the
first IMRT and the side effects.

And in context that its ok to reply here to you on topic not directly
about my original post, here are some comments or explanations re your reply:

1. I can see that I misread your sig history originally - I think you had the salvage RT
to prostate itself, but the DART was to the lymph nodes, thus you did not have
radiation to the same area ? Or was it all or some radiation to same area,
but using a different technique or machine ? (I don't know what the DART is).

I think that possible rad to same area was what I'd viewed as being suggested
as one possibilty to me and thats what led me to doing this post


2. The reason I'd asked about the colonoscopy and the bleeding was I was wondering
if thatbleeding came from colonoscopy itself but I think you mention that was as result of the original RT.

that is -

I'm overdue for a colonoscopy and rather worried about possible effects of just
the colonoscopy itself on the rectal or other areas touched by the original
IMRT. I was told by rad dr to not allow or have any biopsy or other things
done to the anal area during colonoscopy and have seen that echoed in past
forum postings. The doctors office first wanted me to get some letter from
rad dr but they are not there anymore, and I then asked them why not just believe me,
since other colonoscopy places i'd called in other cities said they would not
require some letter; finally they said they would believe me.

So thats why I asked about the bleeding in your sig on same line as
colonoscopy.



3. I also see in your sig that you are taking adt3 - is that just for the time during
and after the imrt or is that ongoing or intermittent ?
(you'd mentioned in post you were trying to avoid the long term HT)

(I'm guessing you are seeing one of the independent pca doctors or others
who prescribe the adt3; I realize thats a controversial topic among drs
and patients and am not trying to start that debate here, but am often
confused as to the divergent opinions of the expert on this.

4. As to the estradiol patch, is that related to controlling side effects of HT or for itself
as another treatment medicine ? am asking since I'm trying to understand more about that topic, though with my recent thyroid problems and needing to start
thyroid rx, I've read and been advised that estrogen (or soy with some similar
components) can cause thyroid problems.
(Thus I've even stopped the soy milk I've been having due to possible neg affect on
thyroid, which has removed much of my calcium and protein intake due to
other dietary problems that preclude me having other normal protein sources
like meat or dairy.


5. I see you had f18 bone scans. I see so often it seems like
everyone goes to mayo or arizona for the choline scans, which I've heard can
be more accurate at lower psa levels, but I don't think everyone can afford
or otherwise make those trips, which I think leaves the f18 scan as perhaps
the next best type of scan - though realize this might be controversial
statement.


I'm still confused conceptually on why patients or doctors want to find
metastases - if its to use that as a basis to start adt or other treatments
and/or if its to see if there are any that can have spot radiation on them.
finally,



6. As to what med oncologist dr I saw suggested - I don't think it was that different
than what have read about, in that waiting until phoenix recurrence value of
2.0 to do bone/ct scans and see if treatment is warranted then vs waiting
until psa gets to some higher point, except for suggestion of possible additional RT -

which is what led me to posting this topic and with Allen and yours and other
comments, I am more clear on that, though still need to do a lot more reading
on the topic.

I did have scans last summer when psa was 0.6 and were negative but realize
that could be just cause psa was so low then (f18 scan).

Thanks again for your comments and questions.

My situation sounds similar to yours, tomHW. From Feb. - April of 2011 I received IMRT (79gy). It was low grade, and Gleason 3+3. I did not have adt , as you did. I did not realize the very real possibility of recurrence. Last year, I realized the PSA was going up. I had an MRI and it looked as if the cancer was in a very similar spot as last time. The biopsy confirmed it. A couple of places suggested the prostate be removed. One suggest whole gland cryosurgery. Instead, I have chosen Dr. Onik in the Ft. Lauderdale area to work on me in late April. He seems to treat a lot of recurrent situations. I am keeping my fingers crossed. It is a lot to think about, but at least there are options. I believe they may treat certain kinds of distant mets at Mayo, although I may be wrong.

As has been pointed out, this can be very tricky. It is possible to do some remedial or secondary radiation, but it depends on many factors including the original dose, planned dose and passage of time.

My wife had full breast EBRT (following a lumpectomy and chemotherapy) for breast cancer in 1996. This was before the more precise IMRT was developed. In 2010 she had another cancer occurrence in the same breast. After her surgery, the surgeon suggested some radiation to an area she could not get an adequate margin and referred us to a radiation oncologist know for his expertise in difficult situations. He did very focused IMRT on a relatively small area, not a general radiation as in the first case. It has worked wonderfully. At the time it was explained that with the 14 year time difference that the area could take on additional radiation that wasn't possible in the first few years after the original treatment.

So, I agree, just to repeat the IMRT doesn't make sense. But to use very focused radiation like SBRT, HDR, etc. only on the known cancer area might be considered. As TallAllen points out, this is not general protocol and very few radiation oncologists would have measurable experience. I also agree that it starts by actually finding the cancer.

Allen,

Thanks for the recent post about the study related to doing imrt again
(and the ptr to it).

Since the original posting and your helpful replies, I'm a lot more clear on this
as to what things might be available and what testing would be needed
in any case to confirm it has not spread outside of prostate and that its
still really in prostate.

From what I can see, for myself, it would only be the brachytherapy as a possible
treatment even if the requirements were met.

Thanks again for this reply and your original analysis and ptrs to articles
about the possible treatments for this kind of situation.