Need radiation advise (positive margin)

CS53 · Regular Joined: 13 Apr 2009 Posts: 15

Had my RP on 2-3-09 approx. 10 weeks ago. Had the nerve sparing procedure that ended with a positive margin on the right posterior of my prostate. Prior to surgery my psa was 1.7 with a gleason score of 3+3=6. My current psa is .26. Just had a bone scan and MRI last week and both were clear.

I am looking for advise on which of the following would be the best course of treatment for my situation. I live in the San Diego area. (IMRT/IGRT using Varian Trilogy at UCSD), (IMRT Novalis Shaped Beam at Sharp Mem.) or Proton beam at Loam Linda. Loma Linda is 1 1/2 drive but I have a friend I can stay with that lives close to there.

Not sure if one treatment or facility is better than the other, but I want the best chance I can get of being rid of this stuff. Any help or advise is greatly appreciated.

Replicant · Moderator Joined: 01 Nov 2006 Posts: 741

My layperson's take on it is that you will probably have the same odds of successful cancer control or cure whichever way you go--protons or IMRT/IGRT.

While protons are famous for low side effects in primary treatment, I'm not convinced the same holds true for salvage. I've never seen evidence to that effect. You could ask Loma Linda if they have any data on that.

Whichever way you go, time is now of the essence. Researcher Andrew Stephenson has shown that the very best odds of success in SRT (salvage radiotherapy) are when the patient starts at or below 0.5 ng/ml. The next cut point is 1.0 ng/ml.

My advice? Gather your information, decide soon, and get moving with treatment, assuming that your doctors agree that salvage is the right course of action.

http://jco.ascopubs.org/cgi/content/abstract/25/15/2035

Just my 2 cents.

Best wishes.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

CS53 · Regular Joined: 13 Apr 2009 Posts: 15

Thanks Replicant. I have met with both radiation docs down in San Diego (initial consultation) and both have said they thought I would see similar results with either IMRT or Proton treatment. I will probably meet with the folks from Loma Linda to see what they have to say.

I have met with two radiation docs so far. One said he intended to use the maximum dosage of 74GY (UCSD Moores cancer center) and the doc I met with today (Sharp Mem hospital SD) who was recommended by a friend who is a local surgeon along with my urologist is intending to use 68GY (2GY/day over 34 days).
I have read that 72-74GY is a more aggressive approach yet still safe. Should I request the higher dosage?

How do I choose the radiation doc that is best? Both seem to be very experienced and competent. After having this positive margin I am really gun shy on choosing who to use.

Thanks

Replicant · Moderator Joined: 01 Nov 2006 Posts: 741

I think Hawk did some research on higher doses--maybe he'll jump in here?

It's beyond my limited scope of knowledge.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

Hawk · Senior User Joined: 22 Nov 2006 Posts: 406

I have read and been told that Relicant is exactly correct in his conclusions. In fact I have had 2 radiation docs tell me there was no advantage to IMRT over 3D conformal radiation in a salvage situation. They said the main advantage is they get to charge the insurance company more but that since there is no gland present the advantage is lost.

My Radiation Oncologist opted for using the IGRT using the Trilogy to deliver 3D radiation.

What is probably an issue is the dose. Studies suggest that 68 is better than 60 Gy and that 70 is probably better than 64 Gy.
_________________
History: PSA's 6.7 neg. biopsy - PSA 16.6 neg. biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy. 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests (all in 2008) showing:
Feb .06, May .09, Jun .10, Aug .10, Nov .15 -SRT

mkane09

Not to hijack the thread, but, Hawk, have you gotten a post-radiation PSA yet?

mkane09
_________________
PSA 6.48, biopsy Gleason 3+4, robotic prostatectomy 9/17/08, pathology Gleason 4+5, pathologic stage T2c, positive margins, first post-op PSA 10-15-08 0.10; 2nd post-op PSA 0.18; SRT completed May 22, 2009. 1st post-radiation PSA, 8-4-09, <0.06.

Hawk · Senior User Joined: 22 Nov 2006 Posts: 406

A month prior to radiation my PSA was .15
The day after the last treatment my PSA was .10

My next PSA is 3 months after radiation and that is in June.
_________________
History: PSA's 6.7 neg. biopsy - PSA 16.6 neg. biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy. 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests (all in 2008) showing:
Feb .06, May .09, Jun .10, Aug .10, Nov .15 -SRT

slkret

I don't pretend to be an expert here but when I was running my numbers in the nomogram on the Sloan Kettering site I found that for my situation, the percentages improved as the radiation dose increased to 6500 rad (65 Gy) after that point the percentages decreased and beyond about 7500 rad (75 Gy) the percentages drop pretty fast. That seems to be in conflict with a lot of posts / sites that say 70Gy or more is the right amount. It's worth asking the doc how the amount is calculated.

Steve
_________________
Age = 62
Psa spring 2007 2.6
Psa fall 2008 3.9
Biopsy 11/09 6/6 positive cores
Gleason 3+3 and 3+4
Staged as pT1c
Robotic surgery 3/4/09 Henry Ford Hospital
Post surgery pathology:
Gleason 3+3 and 3+4
Positive margins
Perineural invasion present
Negative seminal vesicles
1/6 nodes positive (iternal iliac)
re-staged pT3a N1 MX
1 month psa <0.1
Dry at 1 week
ED: bimix not working...starting trimix

CS53 · Regular Joined: 13 Apr 2009 Posts: 15

After much reading it seems that 70GY-74GY seems to be most effective yet safe.(more is better to a point) That is the conclusion I have come to anyway's.

I am now trying to decide if there is any advantage to using Proton instead of Photon radiation for salvage (or combination of the two). I have met with the two IMRT docs and am ready to go with one of them if I'm not sold on Proton.

I have an initial consultation with Loma Linda next Thursday. I will listen and see what they have to say.(my third opinion) Looking at the testimonials on Proton Bobs web site certainly make proton look good. Higher GY dosage with the potential of less side effects seem like a good thing to me.

I guess the big question is whether it will really make any difference in salvage or not. I need to make a decision pretty quick as I am 10 weeks out of surgery now and want to get moving with treatment. I will let you know what Loma Linda says if your interested.

Thanks

Hawk · Senior User Joined: 22 Nov 2006 Posts: 406

I will be interested in your consultation.

I will try to find the link that indicates proton or IMRT offer no advantage for SRT. I will also say the the Harvard Grad Radiation Oncologist at Sloan-Kettering told me that IMRT requires much more precise mapping to be sure you do not miss spots within the field for SRT.
_________________
History: PSA's 6.7 neg. biopsy - PSA 16.6 neg. biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy. 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests (all in 2008) showing:
Feb .06, May .09, Jun .10, Aug .10, Nov .15 -SRT

CS53 · Regular Joined: 13 Apr 2009 Posts: 15

Thanks Hawk. It would be nice if you can find that link. Are you saying that the SK oncologist says IMRT requires more precise mapping than say Proton radiation would?

Both the IMRT guys I have met with seem good. One uses the pubic bone as reference and the other uses surgical clips or CBCT to localize the prostate bed daily prior to treatment. Any thoughts on this?

Here are two links to the facilities and docs I am considering for IMRT. Do you see anything that would make you choose one over the other?

Thanks

{links deleted by admin}

CS53 · Regular Joined: 13 Apr 2009 Posts: 15

Got my third opinion yesterday up at Loma Linda. Here is a brief synopsis on my initial consultation.

The office staff and nurse were great. Very friendly, helpful, and professional. The doc spent over 2 hours with me going over my history, salvage situation, side effects possible, a brief physical exam, and a tentative plan. He has been at Loma Linda for 21 years.

For salvage he plans on targeting the prostate bed, seminal vesicles, and close surrounding area building up to 70-72 GY total (will shrink the target as treatments progress). Will then target my positive margin(right posterior) with up to 74GY. This is all just preliminary and will depend on what my CT scan looks like, along with other factors put together in the mapping and planning of treatment.

I do realize that the overall results appear to be similar whether using proton or photon in a salvage situation. The doc seems to think proton is the way to go if you have access to it. He has the ability to use either IMRT or proton. Higher GY dosage with potentially less side effects and very precise targeting are all plus's in my mind.

Since I live within driving distance of Loma Linda I will am planning to choose proton radiation for my salvage treatment since I have the option. Can't think of any reasons not to? I am scheduled for my CT scan with them next Tuesday unless I see a reason to change direction. Any feedback or input is appreciated.

Skippy · Regular Joined: 24 Apr 2009 Posts: 10

CS53: "For salvage he plans on targeting the prostate bed, seminal vesicles"

Hang on CS53, your prostate bed - certainly, but wouldn't your seminal vesicles have long ago landed in an enamel dish, together with your prostate? I've always thought they are removed together with the prostate proper during RP?
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Skippy (Australia): age at dx 53, PSA 6.0, biopsy, dx Aug 2007: T2aNxMx Gleason 7 (3+4); open RRP + PLND 01Nov2007, both bundles spared, pathology pT2aN0Mx, Gl.7 (3+4), margins negative, no perineural involvement, lymph nodes clean. PSA since surgery undetectable (below 0.04). Continence back to 100% of pre-op state within 2 mths of surgery; erection initially nil, 30% at 12 months, 70% at 18 months with regular tadalafil + sildenafil before practical attempts.

CS53 · Regular Joined: 13 Apr 2009 Posts: 15

Hi Skippy

I asked the radiation doc about that also. He said sometimes they are not removed. Apparently my surgeon didn't see a reason to remove them?

CS53 · Regular Joined: 13 Apr 2009 Posts: 15

Just an update here. I decided on adjuvant treatment. I start hormone treatment(ADT3) on Tuesday. Going to give the hormones approx. 8 weeks to weaken the cancer and then start radiation.

Any idea how important it is to find a radiation doc that is well versed in salvage? Most I have talked with do very little for obvious reasons. Not sure there is any magic strategy that is employed? Thanks for all your input and suggestions.

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