Cancer is back after Cyber Knife

Well, I signed out of this (excellent) forum 18 months ago when I had my five Cyber Knife treatments. I need to reconstruct my signature so you can see a bit of the history but basically the cancer was 3+4 I believe and a couple quadrants from the previous biopsy were high volume.

My PSA went down to about 0.5 at 6 months, about the same after 12 months but was 1.2 a month ago. My oncologist put me on cipro for a few weeks to rule out in infection but the PSA still went up to 1.4. We did a PSMA scan and the good news was that what they did see was still in the prostate. Then a contrast MRI that didn't show much but had a score of 2 (1 is the lowest). After that we did a biopsy and I got the results yesterday showing four quadrants benign but two had cancer, one of them at 80% volume.

We talked about AS but my urologist didn't recommend that and I agree. I think I have to act at this point. One key variable is that the pathologist could or would not give a gleason score I guess because of the tissue damage from the radiation, so I don't know how aggressive the cancer is.

So, options... A prostatectomy now is problematic due to the tissue plane damage from the radiation and side effects apparently are very common. The procedure is difficult and my urologist who does this procedure will not attempt it in a salvage situation so I'd have to find a surgeon with a team that has a lot of experience. I'd rather not go this route but I have to balance that with the possibility that the cancer will escape the prostate if I take another option.

The only other option the urologist mentioned is cryotherapy, and I need to research that as well.

The other two options I believe are brachytherapy and HIFU. The urologist didn't like brachy because I've already been radiated and it may be too much and he didn't seem to know much about the ultrasound technology. I guess another possibility is another session with Cyberknife but the oncologist who set it up said the last two cases of a do-over didn't turn out well.

So I'm just starting my research on this but I thought I'd start by posting with you guys to get some opinions. I have three weeks before my follow-up with the urologist and I need to have a direction ready by then. No pressure here

Vic, I would have the second (most recent) tissue slides sent to Epstein for evaluation to be certain that he agrees that the cancer is present. Also, a visit to your RO is certainly in order. My care stayed with my RO and not my urologist. If your RO is not involved with a Center of Excellence I would recommend finding a RO who specializes in prostate cancer. Terry

I may be wrong but you have not actually reached the radiation failure criteria quite yet. Your PSA would need to be over 2.5 unless SBRT has different criteria than nadir + 2.0.

The biopsy is troubling as they can’t seem to understand what they have. I might expect to find cancer cells in a prostate some time after radiation and I might expect a PSMA scan to light up the prostate for some time as well. I guess what I am saying is to take it slow and keep checking your PSA and following up with experts as others have recommended.

centralPAdude said...
I’m curious about what they would expect to find if radiation was successful. The cancer cells are still there, just kneecapped?

...

See the MSK study linked above. At, say, two years post primary RT you don't want to see viable tumor cells capable of reproducing. (You can also ask how long post RT you want to see even healthy prostate cells reproducing: new lesions can arise from viable healthy cells, just as they did when your malignant leadions first formed before your diagnosis.) AFAIK Geason scores (which are based on how far the prostate tissue architecture departs from normal) cannot be accurately determined after RT). RT does not immediately render tumor cells harmless, i.e., incapable of reproducing or metastasizing; this takes time and is not always successful.

Djin

Post Edited (DjinTonic) : 6/1/2022 8:33:13 PM (GMT-6)

Vic, I am in Atlanta and can refer you to the clinic that did my HDR for an assessment. The RO that did my work is now in Macon running their Center there. Also the Emory St Joseph’s Prostate Cancer Center does HDR and they would be worth a call. There is also a clinic here that helped pioneer NanoKnife focal treatment for PCa several years ago. Let me do some digging to come up with the Doctor for you. I know that certain IRE procedures are FDA approved, but I don’t know the status for Medicare reimbursement.

Another member in Atlanta used Martinez for HDR and was pleased. He started with an exploratory telemedicine visit and sharing of the investigative reports. I encourage you to do the same as if anyone can approach your situation with HDR, Martinez can.

A note about cryotherapy:
As you can see from my signature, my prostate got 'full-service' radiation therapy. A few years after that, my PSA went up which made me and the rad oncologist nervous. I asked what he would recommend if cancer was found (MRI). He mentioned cryotherapy. I looked into that just a bit at the time and agreed that that appeared to be a reasonable option. Fortunately, the MRI showed nothing and my PSA settled down again (sigh of relief).
I haven't followed up on cryotherapy since then, but I do recommend that you look into that therapy as well for your particular situation (two sites that are cancerous).

PS: The aforementioned radiation oncologist (SP Collins) is a CyberKnife specialist with many academic publications.

Post Edited (Sr Sailor) : 6/4/2022 7:11:22 PM (GMT-6)

theswan said...
...
What interests me is the biopsy.
I mean what do they usually expect in a irradiated sample?
Is the tumor alive for lack of a better term? Or is it dead cancer cells.
I'm having late onset symptoms so of course I'm concerned that maybe the SBRT did not kill it.
Glen

From Post-radiotherapy prostate biopsies reveal heightened apex positivity relative to other prostate regions sampled (2015)

"...
Post-treatment biopsy data from several cohorts of patients treated with external beam radiotherapy indicate that residual prostate cancer cells are seen at 2–3 years after completion of therapy in 20–40% of men clinically without evidence of biochemical or clinical recurrence [7–10]. Two-year positivity is predictive of eventual biochemical failure [11], disease-free survival [12], distant metastasis, and cause-specific survival [13]."
...
Prostate biopsies after radiotherapy naturally fall into four categories: negative, atypical acini suspicious but not diagnostic of carcinoma, adenocarcinoma with treatment effect and adenocarcinoma without treatment effect.
..."

JNF said...
Djin, did you find any information on how many men using initial radiation treatment eventually get a post-treatment biopsy? My assumption is that only men suspected of recurrence would do so. The OP Vic is the only one I can recall in the last decade on the board.

I remember discussing this with my doctors early in my journey and they said the main measurement is PSA and that a biopsy would only be done in the event PSA went up to recurrence levels and there was no evidence of Mets. That so few radiation men have local recurrences would tell me the population of radiation post-treatment biopsies would be very small.

Also, did the studies you mention stratify by risk at dx and levels of radiation used?

Hi JNF. I'll see if I can get the Full Text, but my hunch is that post-RT biopsies are, for the main, a research tool, or perhaps are done in some cases of BCR with no evidence of mets, as you say. However, with the advent of PSMA scans, I would think these biopsies are becoming even less frequent. I'll post more if I come across it, but I haven't come across much in the literature.

After my G10 biopsy, one of my concerns about the RT option (aside from the whole 2-years-of-ADT plus the RT-boost issues) was what might happen to my cancer during the post-RT period when the radiation was still working and (dwindling amounts) of viable cancer were still present (we did a Decipher test only after my RP, which, fortunately, came back low risk for mets).

The Full Text for the 2021 SBRT study has:

"In summary, SBRT dose was associated with the post-treatment positive biopsy outcome after controlling for NCCN risk classification, and higher doses of SBRT were associated with lower rates of positive biopsy. While the 2-year biopsy is not necessarily a standard of care, it provides valuable prognostic information especially for patients who are potential candidates for local salvage therapies to be administered at earlier time points. In addition, the post-treatment biopsy could be helpful in evaluating new radiotherapy interventions and may serve as a valuable early surrogate endpoint to assess efficacy. Dose intensification strategies, such as the utilization of a focal SBRT or brachytherapy boost, are being prospectively studied to determine the impact of these strategies on local tumor control based on post-treatment biopsy outcomes."

I can see the role for these biopsies to help assess whether there is role for SBRT in high-risk men especially and perhaps also to help titrate the total dose (oncological outcome vs. toxicities) for other risk groups.

Djin

Vic, that's possible. As others have suggested, i would try for a consult at a leading prostate center. Every treatment will have its pros and cons. Oncological outcome is of importance clearly, but so are toxicities as you mention. Anecdotal evidence should be put in perspective. I would rely on study outcomes. If possible, try to compare stats and outcomes for patients in your situation/risk group.

Djin

Vic, I’ll see what I can find for Dr. Wong.

Regarding HDR treatment I had, the only side effects lasted about 5 days and were soreness in the perineal area where the catheters are inserted. I avoided hard chairs and sat down carefully. The tenderness left after a few days and all has been fine. Oh, and another common side effect of brachytherapy that is purely aesthetic……..the placement of the catheters cause some internal bleeding as they are basically punctures. This blood pools due to gravity in your….junk….and turns it black and blue for several days. Looks a little weird as it turns color as any deep bruise does. Simply, HDR was about the easiest procedure I have ever had and it was not even an inconvenience. I only lost a day of work to have the procedure and no other issues.

I'd be interested to know if those who have had SBRT know the total dose they've received and whether or not they have encountered a concerning rise in PSA any time after.

Thanks,

Djin

Sr Sailor said...
I am sorry you have encountered this problem.
After reading through the various comments, I will speculate that the initial radiation plan was lacking or was not executed properly. I know, this is not helpful, but you had a relatively simple (Gleason 3+4) case that was contained.
Thoughts?

That is the reason I'm asking about what total doses men are getting. According to the MSK study, doses below 40 Gy may be insufficient.

I don't know whether doses are varied according to the Gleason score of the biopsy. That poses the risk that a 3+4 man might have been upgraded were the whole prostate sampled.

Djin

JNF said...
Djin, regarding your information regarding the prostate samples of radiation treated men, were they stratified by the use of ADT before and during the radiation treatment? As I understand the main reasons for using ADT are to reduce the size of the prostate to present a better target and to radio-sensitize the PCa cells making radiotherapy more effective at killing the cancer.

No significant differences were found between the characteristics of patients who underwent a post-treatment biopsy and those who did not—based on androgen deprivation therapy (ADT) usage (26% vs. 34%,p = 0.07), age at time of treatment (median 69 vs. 70 years, p = 0.09), NCCN risk (unfavorable/high 51% vs. 56%, p = 0.22), or pre-treatment PSA (median 6.4 vs. 6.7 ng/mL, p = 0.30). The treatment characteristics of the 257 patients who underwent post- treatment biopsy are shown in Table 1.
...
In the multivariable model, a radiation dose of <40 Gy compared to higher doses was associated with 2.75-fold higher odds of a positive biopsy (OR: 2.34, 95% CI: 1.30–5.84; p = 0.008)"
____________________

SBRT dose / number of men who had that dose
32.5 Gy /11
35.0 Gy / 24
37.5 Gy / 31
40.0 Gy / 174

I think the problem may lie with the total dose ! I haven't read the Full Text in detail, but IMO this is the take-home message.

Djin

Post Edited (DjinTonic) : 6/7/2022 10:01:37 AM (GMT-6)