Brachy Dosimetry G9 T3 - too low? What to do?

I finished HDR Brachy Boost two weeks ago. The next step is EBRT.

The Brachy protocol followed a single fraction 15 Gy recommendation described in 2022 GEC ESTRO ACROP Prostate Cancer Guidelines, p.246 in Radiotherapy and Oncology 167 (2022):
CTV Prostate D90 > 100% (15 Gy).

The results of the Dosimetry Report show CTV Prostate D90 at 92% (13.8 Gy).

The Patient Report did not mention SV. When I asked about the SV treatment we agreed upon, first I was told that there is no SV involvement and that the Patient Report is "provisional" and the SV details will appear in the Dosimetry Report, which I finally received yesterday. CTV SVI was added to the Dosimetry Report manually and show V 0.4 with D90 74% (11.1 Gy).

Were SVs really treated?

CTV ECE was also added manually to the Report, showing V 0.7 with D90 95% (14.2 Gy).

Should I be concerned about the overall Brachy treatment?

What are my options?

Should I request to increase the EBRT dosage that is about to start. The original plan was 15 fractions * 2.8 Gy = 42 Gy ?

How soon should I start the EBRT part of the treatment?

Is there any way to correct that now?

Unfortunately, I'm not nearly knowledgeable enough to answer this. If they do think you were under-dosed (that's not clear to me), I don't know if the solution is another fraction of brachy or it's compensated with the IMRT. Wishing you the best as you try to get answers to this.

As to timing, like Sr Sailor, my IMRT started a week or two after my HDR brachy.

Regarding the timing between BT and EBRT from SFRO Brachytherapy Guidelines 2021:
"No formal recommendations are available regarding the timing of brachytherapy and external beam radiotherapy (approxi- mately two to four weeks in most studies, but some teams perform brachytherapy during external beam radiotherapy)."

I was treated back in 2013 and I can only find the docs for the IMRT portion of my treatment, not the HDR brachy. For my IMRT, the plan specifically calls out that lymph nodes and seminal vesicles were targeted. 25 treatments with a total of 45 Gy. Not sure if this is helpful at all for you.

From what my uro/surgeon told me and what I've read, invasion of one or both seminal vesicles can be anything from microscopic to total, going all the way the blind end of the vesicle. Invasion by PCa is almost always continuous, meaning it rarely skips sections. Your first post up top says "possible SV invasion," and it may be that only a small segment was even in question. The blind ends of each SV can be near other structures, so I don't know what the protocols are and how much irradiation can be done there. On the other hand, since invasion can be microscopic and not seen at all on imaging, I don't see how the SV can be totally ignored, even in men with no evidence of invasion on workup.

Djin

Quietleaf, I suggest you have a consult with Dr. Alvaro Martinez at Beaumont in Detroit. He is the best HDR oncologist at the present time and over the past 3 decades has developed the current protocols in common use. I have referred several men to him and they have all been pleased with his assessment, advice and for some, successful treatment. He will do a teleconference with you based on reviewing the work that has been done. He is a very straight shooter and easy to talk with.