Second salvage radiation

[GregR]

Has anyone had a second bite of the cherry with salvation radiation. I had an RRP 15 years ago with psa<0.01 then 5 years later salvage radiation again psa<0.01 and now 10 years after the radiation my psa is 0.28. I had a PMSA scan showing a small lesion under my bladder. The oncologist is saying that because my radiation was 10 years ago and likely very healed I may be able to have some targeted radiation directly to the lesion guided by ultrasound. She is saying that some HDR or even seeds could be planted just at the lesion site and will discuss with her colleagues my case and see if I qualify. Has anyone been down this road?

Thanks

Greg

[ardee]

Can you get a second opinion?

 

We have heard about brachytherapy being used after IMRT salvage - but if me,  I'd want to confirm with another rad onc. How many times has she done this? 

[Patrick Turner]

I had initial treatment of EBRT and 2 years of ADT beginning in 2010 at 62yo.

Psa was 8 just before failed attempt at open RP. 2 years later after pause in ADT, Psa went from 0.08 to 8.8 in 6 months. I re-started ADT and have continued ever since, even though it began to fail in 2016.

But in 2016, I had first PsMa Ga68 PET/CT scans which showed 2 lymph nodes positive, and PG was still full of Pca. I had salvation IMRT at Epworth in Melbourne. I also began Cosadex added to ADT. Psa went from 5.6 to 0.4 in months after, but Psa went up again within 6 months so I wondered just how effective added IMRT was. It seemed it didn't kill the Pca it was meant to kill, and hormonal manipulation was all that kept my Pca suppressed, but not dead, because I got more PsMa scans and mets increased. Zytiga gave 8 months, chemo didn't work, and Lu177 brought Psa from 25 to 0.32 in a year, but Psa is now rising again.

The total amount of beam radiation I have had to PG is 101Grey, and was not enough to kill the Pca there. Chemo did nothing. Lu177 seemed to work well, but I am having scans again and now face continuing battle because Psa is rising. But Lu177 would have worked in PG, so my PG has had nuclear RT as well as EBRT+IMRT.   

Perhaps brachytherapy success is due to the skill of the surgeon who does this, but you don't want a hole in your bladder later. When I had salvation IMRT to PG the docs inserted guiding beacons for Calypso IMRT, and although that procedure is minor, the application device had large dia needle about 5mm dia and I don't know how many times they stabbed around to get beacons into wanted position in PG, which had 70Grey in 2010. I bled badly after that op, and got big blood clot but was able to drain it with catheter and I spent 2 days in Epworth that should not have occurred and it cost $1,660. I still bled a bit 10 days later, so tissue that has been radiated years before has blood vessels that never function like non radiated vessels which close off fairly quickly after being cut, and you may have noticed when you have cut yourself somewhere.

Epworth used a special pad of material 10cc to make a pad between PG and rectum to stop the IMRT they used affecting my rectum. Beam RT travels through and beyond the target. A month after my RT I had 2 months of very bad radiation colitis where I sprayed poo, and bowel contents. Not pleasant, so despite the hydrogel pad costing $2,000, my bowels were much affected by the additional 31Grey to PG.

BT may not give this side effect result. The applicator device may have a thin needle, so maybe that part of you bladder won't bleed, and the small Pca lesion will be terminated. I just hope you don't find that 6 months later, other spots of Pca turn up. After 10 years since diagnosis I am still continent. Maybe BT would have been good for me back in 2010, but it was very expensive. But it can deliver more local RT to a target than EBRT without side effects to surrounding tissues, and therefore it may work better. You need to chase that small amount of Pca now because from little things, big things grow, and you don't want that small lesion spreading, but it may already have, and scans cannot see the spread yet because mets are so small. I had a Gleason 9 in-operable in 2010, so it probably had spread widely, but ADT supressed the original Pca at PG and the mets until years later. 

Patrick Turner. 

[Barree]

Hi Greg,

I’ve had multiple small doses of salvage radiation to various parts of my body - the criteria used to determine whether or not it is advisable to have repeat doses - is the amount of radiation that has already been given to the area in question.

Hopefully, this information will be available from the organization which treated you in the first place. This will enable the radiologists to determine what risk is attached to subjecting  the area under the bladder to further radiation.

As SBRT has been suggested, depending upon the location of the lesion, it should not be too much of a problem to radiate it without causing collateral damage to the surrounding  tissue. 

 

I too have read of cases, like yours, where Brachytherapy has been used successfully after IMRT. If you have a very competent radiation oncologist overseeing your treatment - then SBRT may worthy of consideration.   One thing that needs to be considered , is whether or not there is likely to be any micro metastasis lurking in the surrounding tissue of the lesion under your bladder which will not be treated by an SBRT beam – this is one reason why brachy therapy is often used in situations like this – if there is any, micro metastasis it will might mop them up.

 

If you choose SBRT I suggest you ask your Rad Onc if your's is a case where the use of SpaceOAR hydrogel may be beneficial. You can google this for an explanation as to why this is sometimes used when treating areas near the bowel with radiation.