2. The asymmetric margins is probably empirical but is well established in extensive big clinical trials. Have a look at any of these RT trials, RTOG, EORTC, Prostate IMRT trials, etc.
We did have a tough time answering loads of these questions before this below mentioned article was published.

http://www.ncbi.nlm.nih.gov/pubmed/19624299?log$=activity.
But have a look at the small table in this article (its only a link - try n get full access, and hunt for the answers for asymmetric borders, if the international community are doing it. especially big International groups, i dont think i need to know why do it, but i would rather do it —.as there s gotta be some logic why its been done for the last 50 years)
The 0.7 mm post certainly tell us about the rectum being there, hence the caution. I personally think we should concentrate on the mgt issues of this gentleman, we all may have different techniques of doing things.

3. Dose: 74 Gy is the standard dose, which is the minimum recommended. If you have IMRT go for higher doses i have no objection, but the technique i mentioned was for 3 DCRT (we do not offer IMRT on every pt here, and i will probably not offer it to him as he has PSA = 100 and we all know his prognosis in 5 years time, its not exceptionally brilliant.
we all also know, where is his greatest risk of relapse. and take it from me, he is not going to relapse locally. I bet $ 100.

3. I m not a big fan for Pelvic LN RT as i do not have any convinicing high level data to show its gonna improve OS or DFS, etc
The added toxicity can be substantial.
But i m not saying definitely Not ( If you have IMRT —- may be, but certainly not if 3 DCRT)

4. I agree GS of 3+3, 3+4, 4+3 or 4+4 does not change mgt if you are considering Ext RT. Nikhilesh would it change your mind regarding HDR Brachy boost ( i dont think so).

5. The choline PET and Prostascint are both experimental and not standard investigations to influence mgt decision, but if you ve got access to it , go for it … I ve got no idea about their sensitivity and specificity.

6. Recently, there was a randomised trial done by Prof Hoskin ( Mount vernon cancer centre) RT alone + / - HDR Boost.
The conclusion reads: The use of high dose rate brachytherapy in combination with external beam radiotherapy resulted in an improved biochemical relapse-free survival compared to external beam radiotherapy alone with less acute rectal toxicity and improved quality of life in this randomised trial.
Have a look at the eligibility criteria, your man may be eligible i think.
Three of the UK centres who have a strong hold on prostate brachy, are routinely offering this HDR boost as a means of dose escalation and Prof Hoskin claims, no IMRT, no IGRT or any technique in the world can escalate doses to the prostate apart from brachytherapy ( if you are a believer that there exists a relationship between dose escalation and improved outcome).
No wonder Nikhilesh jumped for it —— Is your boss doing this routinely then, !

http://www.ncbi.nlm.nih.gov/pubmed/17531335

1. for option 1.a. you use a total of 74Gy. Why not higher?
2. for option 1.b. what margin do you use on prostate? what margin on LN?
3. for option 1.b., if you mark up peritoneal cavity, what is the kind of DVH you can achieve? (a picture of 'your' peritoneal cavity markup would be appreciated to see if it matches 'my' peritoneal cavity!)

actually I have a superb pelvic CT picture showing peritoneal lining as clear as day as well as ovaries. I'll post here soon hopefully.

1. PSA of 100 was the repeat, previous was 95 and antibiotics were prescribed.
2. thanks for heads up in STAMPEDE Trial - where do they get these names? I am still waiting for TLC chemotherapy!
   1. I just have a superficial look at STAMPEDE (can't see protocol), you'd put this guy on a chemo trial? Does STAMPEDE have a RT component as well?
3. if you assume 'healthy' means just that, no co-morbidity, playing golf, swimming, very fit walker (10km/day on hills), no meds,etc - which option of your four do you default to?
4. we need to have a discussion of asymmetric margins in prostate cancer, specifically why and how does the prostate decide to move 1cm ant but only 0.7cm post. This has always perplexed me. (new topic)
5. any details on pelvic node treatment decisions? if this one doesn't fall into the net, what does?
6. sorry but I can't see how a GS of 3+3, 3+4, 4+3 or 4+4 is going to change decisions when the staging scans are negative?
7. anyone got experience with Prostatascint or choline-PET in these scenarios?
8. our Tumour Board fell into one of 2 camps - "it's metastatic" and then "treat for cure" but with many illogical methods differing from high risk treatment protocols used for GS8-10 PSA 10-20. Seen similar behaviour in your world?
9. what advantage is HDR boost over 80Gy?

continue hormones through out and till 2yrs after completion of RT.

I would lable this as HIGH RISK EARLY LOCALISED CA PROSTATE

hence
Ph 1 CTV = Whole Prostate + Whole of SV

Remaining would be same as mentioned above…

The only thing which i cant decide on … Treat Pelvic nodes or Not
If you have IMRT - probably i would go for it
If its simple 3DCRT - probably i would not treat even though there might be a high risk as per Roach formula

In UK, they say that treating LNs has not shown to improve survival
In US, i think they would be more keen to go after the LNS as well

Would be interested in reading comments from other isocentre members !

First i would repeat his PSA to confirm PSA=100 , and not a typo 10.0 ng/ml

Assuming it was PSA=100, T1c (needle biopsy confirmed) N0 M0 Gleason= 3+4 = 7
Presumably, there is no h/o Prostatitis, no UTI, PSA reading not done immediate after needle biopsy or DRE
Any other causes of false PSA elevation. i ve forgotton…. ?

Treatment options i would consider personally

1. RADICAL RADIOTHERAPY + Hormones (3 years) [can use neoadjuvant while organising your RT planning + adjuvant]

2. Hormone therapy Alone (Intermittent) —— [ Palliative, but with a good QOL i would ensure ]

3. Participation in STAMPEDE Trial

http://www.stampede.bham.ac.uk (there is a pdf format on the trial on that page to be hunted)

4. Active surveillance (wont push very hard at all….would be biased to offer something)

usually in my MDT: surgeons would chicken out on this one ( i m being practical rather than theoritical)
i would probably not offer RADICAL Brachytherapy either …. but nikhilesh would be able to opine on this one…as his boss is the final word.

If Radical Radiotherapy: [I would not treat Pelvic nodes in this scenario]

Ph 1: CTV = Whole prostate + base of SV
PTV = CTV + 1 cm all around except post (0.7 mm)
Dose: 56 Gy / 28# / 5 and a half weeks

Ph II: CTV = Whole prostate ONLY
PTV= CTV + 1 cm all around except post (0.7 mm)
Dose: 28 Gy / 14 # / 3 weeks

Is there any prospect of cure?
How would you treat him?

• Hormone therapy?
  • how long?
• Radiotherapy?
  • prostate?
  • SV?
  • Pelvic nodes?
• Surgery?