We had a man with T1cN0M0 prostate cancer with a GS of 7 (3+4) and a PSA of 100 presented at Tumor Board. CT scan says no LN, Bone Scan says no M1(OSS). He is aged 73 and is fit and healthy.
Is there any prospect of cure?
How would you treat him?
Difficult one…. finding it difficult to understand what my intention of treatment is really……….Palliative or Radical
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
My apologies…
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 !
Hi
I would first like to repeat biopsy and PSA. The GS changes in about 40% patients that we see in consultation for LDR brachy, we repeat biopsy in all tricky cases that come to us from community physicians. Discuss the case in Tumor Board.
If this is truely a T1C with that high PSA—-he will need hormones with RT. Dose you and "amar" have already commented on. You know I am a brachy guy so will boost with HDR brachy others may choose IMRT. These days Canadians are trying HDR 15Gy single fraction boost (abstract to be presented at CARO). I will not treat the LN.
Some further clarification
this is a common situation encountered. the standard teaching is any PSA> 50, higher the risk of microscopic mets and hence treated as metastatic disease.
in the first instance he needs neo adjuvant zoladex probably for at least 6-12 months ( as opposed to the normal 3 months) and see how his PSA drops. if he has a good biochemical response then he can be given the benefit of the doubt and considered for radical approach.
this guy can have a Lap pelvic LN dissesction to see if there are any LN involved.
i will include the pelvic LN's as well as the risk of nodal involvement is >30%.
for RT there are 2 options.
1) EBRT alone.
a) 3DCRT -50/25 - ph1 ( prostate+SV+LN), 14/7 - ph2 pros+SV), 10/5 - ph3 ( pros only).
b) IMRT SIB - 72/32 fractions. ( 50 gy to LN, 64/32 to pros +SV, 72/32 to pros only.)
in our institute we take the ph2 till 64Gy.
2) EBRT +HDR brt.
46gy/23 to pelvic LN and 12.5Gy in single fraction with HDR.
continue hormones through out and till 2yrs after completion of RT.
Elaboration please:
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. Sorry , but you d have to hunt the Stampede Protocol on that link , its a small link in the centre of the page.
The Stampede Trial does not have a RT arm.
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, !
