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High Risk Radiotherapy Options

User
Posted 30 Nov 2020 at 17:44

Is it normal to have curative radiotherapy to only the prostate rather than pelvic irradiation for high risk group (T4)?


My dad has a 'probable T4' according to MRI and gleason 4+3. Original presenting PSA before hormones was 9.6 and after 4 months of lupron, PSA down to 0.5. Due to a missed PSA due to covid (after 7 months) PSA up to 4.2 so bicalutamide added.. After a month on bicalutamide (on top of lupron) , CT and Bone scan requested due to PSA rise the month before. CT and Bone scan clear, so PET scan requested to have a closer look. This is after 2 months on bicalutamide (on top of lupron) PET scan comes back clear. Doctors have changed treatment plan from pelvic irradiation radiotherapy (before looking at PET scan) to just prostate radiotherapy (after looking at PET scan). I am concerned that since the PET scan was done 2 months after the addition of bicalutamide, this might hide any visible cancer cells in nearby lymph nodes as in it could have shrunk them so the PET might not pick them up, or worried that microscopic cells aren't picked up on PET scan.


I would have thought it is safer to do radiotherapy to nearby lymph nodes just in case? even if not visible on scan?


He has urinary symptoms and is on tamsulosin and mirabegron which are helping his urinary symptoms. Was wondering if HDR brachytherapy can still be given in addition to EBRT? I heard that an ideal candidate for this treatment should not have urinary symptoms, but is there any way around this?


He has been offered EBRT using VMAT. Does this have good rates close to HDR brachytherapy and EBRT combined? I have heard different opinions.


What is considered an ideal PSA with hormone therapy before radiotherapy? Anything <1?

Edited by member 30 Nov 2020 at 18:07  | Reason: Not specified

User
Posted 30 Nov 2020 at 19:17

I'm not understanding the diagnosis.


T4 is a stage, not a risk, and is advanced cancer and not curable. But I suspect you don't really mean T4.


Gleason 4+3 is grade group 3.


So, what's the staging, and what does the 4 relate to (PIRADS)?


Difficult to answer the rest without understanding the diagnosis.


You mention Lupron, but that's a brand of Luprorelin sold in the US (it's called Prostap in the UK). If your dad is in the US, treatment customs can be different.


We don't have accurate data comparing VMAT alone, with HDR Boost (VMAT + HDR), both plus hormone therapy. HDR Boost is intended for high risk patients with local or locally advanced cancer and no mets. It's thought to be at least as good as VMAT alone but with fewer side effects, but the data to prove this doesn't exist. This will be the results of the PIVOTALboost trial, when it completes. (I had this treatment.)


HDR Boost isn't suitable if there's any lymph node involvement - in that case you would have VMAT alone (plus chemo, plus hormone therapy).


I aimed to get my PSA ≤ 0.1 before starting radiotherapy, but you mustn't delay radiotherapy unless PSA is dropping at a significant rate, and not everyone will be able to get their PSA that low on hormone therapy. In the US, neoadjuvant hormone therapy (hormone therapy before radiotherapy) sometimes includes Abiraterone to get PSA lower, but that's never done in the UK.


Really need to know your dad's diagnosis better, to know his staging and which risk group he's in, and hence if HDR Boost would be viable.

Edited by member 30 Nov 2020 at 19:32  | Reason: Not specified

User
Posted 30 Nov 2020 at 20:51
There is no point irradiating the pelvic lymph nodes if they believe that the cancer is already active in the wider lymphatic system, you would need to ask the doctors whether that applies in your dad's case.

Brachytherapy can make urinary hesitancy or retention much worse; if he already needs tamsulosin and mirabegron, that is probably one reason it has been ruled out.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 03 Dec 2020 at 13:11

Thanks for the reply Andy62. It is T4 size tumour (locally advanced). Grade group 3 and the current plan is to give curative radiotherapy to prostate. We're in the UK so prostap then . There is no lymph node involvement on any scans including PSMA (Gallium-68) PET scan which was done when PSA went up due to lockdown. Hopefully I have been informative now than the first description 😀

User
Posted 03 Dec 2020 at 13:17

Thanks for the reply LynEyre. I believe they won't be covering nearby lymph nodes because they think there is no real reason to do this, as the Gallium-68 PSMA PET scan has even shown no involvement. But it is just for our peace of mind and because I heard that it is quite common to do pelvic irradiation for high risk cases even with nothing visible on scans. Also I have seen online reports of people having HDR brachy boost even with urinary symptoms and that any urinary symptoms that get worse, get better over time and return to the normal - how it was before this treatment. It is very hard to understand some things as reports over the internet can vary. Also that highly specialized people can carry out HDR brachy boost for people with unfavourable characteristics for this kind of treatment. Internet can be so confusing!

User
Posted 03 Dec 2020 at 14:17

Although we can help in a general way and offer constructive thoughts and possibilities, you really need to have in depth personalised talks with you consultants because they have your complete histology and scans and can suggest appropriate treatment options for you. Sometimes there might not be much advantage of one treatment over another but in some cases you will be strongly steered along a certain path.

Edited by member 04 Dec 2020 at 01:58  | Reason: Not specified

Barry
User
Posted 03 Dec 2020 at 14:29

Originally Posted by: Online Community Member
But it is just for our peace of mind and because I heard that it is quite common to do pelvic irradiation for high risk cases even with nothing visible on scans.


 


But it also introduces the risk of unnecessary side effects such as lymphodema - should only be done where there is a likelihood that it is necessary. Perhaps dad already has some issues with water retention / odema that could be exacerbated? 


 


Also still some confusion here as T4 means that it has already spread into other organs. Is it possible that the result of the MRI was PI-RADS 4 and the T has been added by accident? 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 03 Dec 2020 at 15:20

Thanks for you the reply Old Barry. Yes, I do agree with you - I am in discussion with the team treating him but I thought that I would use this forum to see whether other people think my opinions are reasonable and make enough sense to be brought up to discuss with the team. Or even somebody might make a suggestion which makes me think more logically about my opinion. But I do understand your overall point you are trying to make - thanks

User
Posted 03 Dec 2020 at 15:37

Hi LynEyre. The radiologist said 'probable T4' on the report with possible invasion of a pelvic muscle on one side. They have done all scans and the upcoming radiotherapy is for curative purposes. He doesn't have any other conditions/issues apart from why I am here. 

Edited by member 03 Dec 2020 at 15:38  | Reason: Not specified

User
Posted 03 Dec 2020 at 18:44
Worth discussing that again with the consultant then - perhaps they decided that the diagnostic report was over-cautious or that the invaded pelvic muscle needs to be included in the RT zone; otherwise, the RT would not be with curative intent. If they still believe that it is a possible T4, I think I would be more concerned about the RT not including the muscle than I would be about it not including the nearby lymph nodes.

Also possible that what was originally thought to be a T4 on the MRI was later downgraded to a T2 / T3 following the G68 scan?
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 04 Dec 2020 at 19:26
Let me commence this by saying I know next to nothing about RT, as RT was never an option for me (I have colitis), but you haven't said how old your Dad is, nor what his general health is like, e.g. is he overweight; have high blood pressure; does he smoke?

You mention numerous scans, but probably he has also had at least one biopsy. Was this where the 4+3 came from? If so, there should be more information on the report, like the prevalence and number of cores. These things will not be pointed out for most of us, you have to hunt through the paperwork - copies of letters to the GP usually have all the salient details.

You also need to understand that this part of the messageboard is for localised cancer. T4 would suggest that it isn't localised, but your other data is within the range we would expect to see - I was Gleason 7 (albeit 3+4) and had a PSA of 9.3, when I was confirmed as having PCa. But I was T2, not T4. I don't think we'd expect to see T4 on a Gleason 4+3, but there are no hard and fast rules.

This is why all the questions.
User
Posted 04 Dec 2020 at 21:49

LynEyre - Thanks for you info - that is a new point that I did not know about. Is extending the RT beam to include the pelvic muscle within the treatment description of radiotherapy to prostate? So are you saying that they could rather be trying to get more dose to cover the pelvis muscle area which is harder to reach, so that there isn't enough dose left to do nearby lymph nodes? I understand that there is a maximum dose rate to the body but was wondering whether the dose can be calculated appropriately to cover all (prostate, pelvis muscle and nearby lymph nodes)? or whether you are saying it is more effective if they try to use a lot of the dose go all out on the nearby pelvic muscle. I am still waiting to hear back from the team so these extra bits of info can help a lot.

User
Posted 05 Dec 2020 at 11:07

Peter51 - thanks for the reply. My dad is 78 but as soon as I mention age, I feel as though he automatically gets put into a category for more limited kinds of treatment because of age (the way I see it) . He is very active, exercises everyday, still works and is very independent - acts at least 20 years younger! (Age is just a number). He has a very good diet and has no other medical conditions, so we want to got all out with this treatment. It is a probable T4 with curative treatment. For anyone who is confused with a T4 here is a link, https://prostatecanceruk.org/prostate-information/just-diagnosed/locally-advanced-prostate-cancer . They did an MRI and then a biopsy (targeted biopsy) with minimum cores 2/2 ,both showing gleason 4+3. Hope this everyone understand the situation better.

User
Posted 05 Dec 2020 at 14:29
That isn't quite what I was trying to say although it is true that there is a maximum amount of RT that can be delivered to the pelvic area and once this RT is over, he will not be able to have any further radiotherapy to the pelvic cavity. What I was saying is that it cannot be T4 and curative RT - the two things just don't go together. Either it is not a T4 OR it is a T4 so the RT cannot be curative OR they are offering RT in the hope that it turns out not to be a T4 after all OR it is a T4 and they are planning to zap the muscle in the hope that it turns out to be successful. It doesn't seem right if your expectations are raised falsely.

As I said, best to clarify with the oncologist whether they have decided that it is a T2 / T3 instead, or whether it is a T4 and the likelihood of the RT being curative is slim.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 05 Dec 2020 at 14:33

Originally Posted by: Online Community Member


It is a probable T4 with curative treatment. For anyone who is confused with a T4 here is a link, https://prostatecanceruk.org/prostate-information/just-diagnosed/locally-advanced-prostate-cancer . They did an MRI and then a biopsy (targeted biopsy) with minimum cores 2/2 ,both showing gleason 4+3. Hope this everyone understand the situation better.



 


Sadly, I think we all understand what a T4 is and it is you who either doesn't have all of the information or has been given some duff info. I hope you get some clarity from the medical team soon. 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
 
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