Admin Posted November 25, 2011 Share Posted November 25, 2011 I can't seem to find a good account of treatment of five or fewer metastases by using radiation. I seem to remember a video by Dr Snuffy Myers, but can't locate it. In the meantime, here are some snippets by Dr Myers. The key seems to be: five or fewer metastases - burn them with radiation more than five metastases - use ADT to reduce active cancer, using radiation on the last few spots the radiation to kill off the cancer is higher than the dose normally used for palliation. Well, let us start with the term “cure.” As I talk with patients, they usually think that this means that all the cancer is gone. Early in the history of cancer treatment, physicians realized that they will never know if the cancer is done as it can hang around in microscopic dormant clusters (see previous question). So, in cancer treatment, we count someone cured when they die of something else without the cancer recurring. For us, a more meaningful term may be durable complete remission. This means there is no evidence of the cancer’s presence and that this favorable state is continuing for many years. Using this definition, it is definitely possible for men with five or fewer bone lesions to enter a durable complete remission. Some of these men may well be cured. Hormonal therapy is the initial treatment of choice in men with bone metastases. Until recently, it was the only real option. In 2004, investigators at University of Rochester looked in detail at the natural history of men with bone lesions. In those with five or fewer bone lesions, the cancer would often stay limited to the initial sites of involvement for several years before rapidly spreading to new sites. They proposed that steriotactic radiation to those sites might prevent subsequent spread. Our experience since 2004 is that there are indeed men with limited bone involvement who will benefit from radiation to bone lesions when the dose is high enough. So, it would be important to know how many bone lesions he has and where they are located. In a patient with a very large tumor in the prostateand bone metastases, would you consider doing Provenge and immediately follow up with chemotherapy?[/i] in Prostate Forum 13/1'] I am going to presume you are talking about newly diagnosed metastatic prostate cancer. This is simple to answer and it would be no. In fact, of the many approaches available, those would be my last choices. Provenge is approved for patients who have failed hormonal therapy and have metastatic disease without significant symptoms. So, Provenge would not likely be paid for in your case and it would cost you more than $100,000 out of pocket. Also, I am not aware of any clinical trial evidence that suggests the therapeutic effectiveness of Provenge in that setting. Chemotherapy is even easier to dispense with. Chemotherapy has never been shown to have significant survival value as an initial treatment and it is far more toxic than any hormonal therapy program. The proper approach to your situation would be to start hormonal therapy. Unless your PSA is below 10 ng/ml at this point, hormonal therapy is likely to work for several years. At that point, you are likely to have much better treatment options than are now available. This is a very exciting time in prostate cancer research with an unprecedented number of new drugs approved or in development. Here at our clinic, we would likely start you on Lupron, Casodex, and Avodart. Once your PSA stopped falling on that combination, we would replace Casodex with ketoconazole, Leukine, and transdermal estradiol. In our hands, the latter has an 80% response rate compared with approximately 40% for taxotere chemotherapy. If you had five or fewer bone metastases, we would consider radiation to the bone lesions, prostate gland and pelvic lymph nodes once hormonal therapy had significantly reduced the size of the cancer. With this combined approach, we have some patients who enter a complete remission that can last for years. [jm:question] At age 62 I was diagnosed with a Gleason 4+5=9 prostate cancer. At that time, my PSA was just above 50 ng/ml and I had 18 bone metastases on my bone scan. I started on triple hormonal blockade and by the end of three months, my PSA had dropped to 0.3 ng/ml. In Prostate Forum Volume 12 Number 6 on page 7 you write: “In any case, we do not regard hormonal therapy as successful unless the PSA drops below 0.01 ng/ml. More recently, we have also asked that bone metastatic disease and lymph node enlargement normalize. For example, if at 6 months the PSA is less than 0.01 ng/ml, but bone metastasis show no healing, we will consider the switch to second line hormonal therapy. If the patient has five or fewer bone metastases, we will consider referring the patient for radiation therapy to the bone lesions, but will ask that the dose be 45-50 Gy, not a palliative dose of 20-30 Gy”. But how do you diagnose bone metastases that are not healing (after 6 months triple ADT)? With 5 or fewer bone metastases, you would consider radiation therapy, but what would you consider in my case of 18 ? I would like to get rid of these things…what are the limitations of this focal radiation treatment? A recent DEXA scan shows normal bone density. [jm:Answer] If the PSA has dropped below 0.01 ng/ml at 6 months, we would repeat the bone scan. If the bone scan shows healing, we would then study the involved areas with MRI with and without contrast. This shows nicely if the bone scan positive areas are just damaged bone or if there is active cancer. Our ultimate goal is a normal bone scan and MRI. At the time that I wrote Beating Prostate Cancer, we would not have considered radiation therapy. However, now I evaluate patients more carefully. Consider the situation where all but three bone lesions have healed. We know that those remaining lesions contain the most resistant cancer. We would then consult with radiation therapy about the possibility of radiating those persistent lesions, but with high enough dose to sterilize the lesion. For high Gleason grade disease, we would often add PET scan as the PET would detect the most metabolically active cancer. We would then especially focus on eliminating that active site or sites. All of this is pretty new. I can say that this approach does seem to lead to disease control durable out to two years. We do not have sufficient follow up to comment beyond that point. Our basic strategy is to try for a real durable complete remission if at all possible. Link to comment Share on other sites More sharing options...
Nev Black Posted November 26, 2011 Share Posted November 26, 2011 This post "Five or fewer or fewer metastases - durable remission" is very relevant to my particular case which we discussed during the teleconference yesterday, the 25.11.2011. I would like to thank Jim for collecting that information. I also had a call from David A after the teleconference. Jim's post and the talk with David A have confirmed for me that further medical opinions outside the doctors and specialists that I am currently seeing is a necessity. I would like to thank the members of the teleconference for their imput. This is an extremly valuable forum from my perspective. Thank you all. Nev Link to comment Share on other sites More sharing options...
Bruce Kynaston Posted January 3, 2012 Share Posted January 3, 2012 With regard to "The key seems to be: five or fewer metastases - burn them with radiation more than five metastases - use ADT to reduce active cancer, using radiation on the last few spots the radiation to kill off the cancer is higher than the dose normally used for palliation." I would like to explain that for growth restraining EBRT, one could consider something of the order of 50 Gray units in 4 weeks but if the focus was near the spinal cord, one would not wish to exceed 45 Gy in that time as it would exceed cord tolerance with a risk of paraplegia if the vertebra concerned was below the neck. For palliation of pain, a lesser dose in fewer doses would be suitable, as it could be repeated later. (Well, that was my attitude when I practised radiation oncology.) Link to comment Share on other sites More sharing options...
Paul Edwards Posted March 17, 2013 Share Posted March 17, 2013 There was a paper on oligometastatic (the oligo-prefix comes from the Greek word for “few”) prostate cancer by Drs Myers, Dattoli and Bravo in the February 2012 issue of the PCRI Insights newsletter: http://www.dattoli.com/publication/PCRI%20INSIGHTS%20Oligometastatic.pdf Dr Farshad Foroudi of the University of Melbourne is currently conducting A pilot Study of patients with Oligometases from Prostate cancer treated with Stereotactic Ablative Radiosurgery (POPSTAR) with a grant from the Prostate Cancer Foundation of Australia. A lay summary of the Study is as follows: “We propose to research a new, non invasive, high-precision radiotherapy technique called "stereotactic ablative body radiosurgery" (SABR) in the context of patients with up tothree tumours that have spread from the prostate to the bone or lymph nodes. At present, these patients have no curative treatment options. SABR is delivered as a single, high dose, precision treatment which is a radical departure from conventional palliative radiotherapy which is delivered daily for one or more weeks.The treatment is convenient for patients, painless to deliver, non-invasive and delivered whilst the patient is fully awake. While SABR has been used in other cancers as well as for prostate cancer confined to the prostate, our trial will be one of the first in patients whose prostate cancer has spread. Most importantly, SABR is potentially curative compared to conventional radiotherapyto such tumours.” Link to comment Share on other sites More sharing options...
Paul Edwards Posted September 3, 2013 Share Posted September 3, 2013 Dr Faroudi spoke to the monthly teleconference on 23 August 2013 about the POPSTAR trial. There is another clinical trial regarding stereotactic ablative body radiosurgery for oligometastatic cancer about to begin at the Prostate Cancer Research Centre at Epworth Hospital in Melbourne. Link to comment Share on other sites More sharing options...
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