Salvage RT Dose Constraint Issues

[Haybrant]

Ive got a guy couple years out from prostatectomy that needs salvage RT. Had a + margin at the apex but was never referred then, now his PSA is up to 3. He has trouble holding his bladder and we did what we could with his sim but his dose tolerance for bladder are pretty high. Just wanted to ask for recommendations of what has worked for people in this setting. Did not use a penile clamp, not sure if people feel like that helps. Also, what kind of PTV margin are you putting on for these cases, no rectal balloon or anything special. Thanks

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[Reaganite]

I had a patient like this recently. He could not hold his bladder, and it was impossible to cover the postop bed let alone boost the gross nodule to 70+ without treating the full bladder to high dose. I sent him for hormones and did slight dose deescalation.

 

[Palex80]

I'd be cautious.
With a PSA of 3 ng/ml, chances that you will control his disease with RT are very limited. Have you checked for a macroscopic recurrence?

 

[Haybrant]

Ya I've seen the data. Catp and bone scan are clear, Given his positive margin I presume local recurrence along the apex of the bed. Would MRI lead you to boost if gross dz along bladder neck? I'm going to resim him and see what he can tolerate. Would you tx w concurrent/adjuvant hormones?

 

[Palex80]

Do you have some data on his PSA progression? Doubling time, velocity?

I'd do the MRI for one reason mainly: if sou dont see a macroscopic recurrence there, then this patient probably has systemic disease.

 

[medgator]

Do you have some data on his PSA progression? Doubling time, velocity?

I'd do the MRI for one reason mainly: if sou dont see a macroscopic recurrence there, then this patient probably has systemic disease.

Even so, with a negative metastatic wu, I think many of us would still offer salvage xrt to give him a shot if his psa was 3

 

[ramsesthenice]

This is really outside of the box and I know it would be a lot of work on your part but could you consider a cath and clamp before trx maybe every other day to keep the bladder dose down? I feel like if the metastatic WU is negative I wouldn't want to compromise tumor dosing if at all possible...acknowledging he will most likely fail.

 

[ramsesthenice]

I also completely agree with MR in this case.

 

[Palex80]

Id also treat probably, Id be however a lot more inclined to stop treatment if his PSA would not drop after something like 50 Gy. "Give the patient a shot" is a good idea, but frying the bladder in the process is a bad one.

 

[napoleondynamite]

I often use a penile clamp in this situation. Works great IMO. Patients can be taught to apply it themselves, so the therapists don't hate you either. I ask patients to wear it for an hour before treatment and drink up. They get through it fine because they understand the consequences of frying the bladder.