Getting this message from a Urologist - thoughts?

[msbbc833]

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64M with G4+4 adeno in 7/10 cores. PSA 4.4. PSMA PET shows prostate confined disease. No ECE. Prostate size approx 40cc. IPSS of 20 with bothersome score of 5/6. Pt seeing both urology and rad onc today, got below msg from the urologist after seeing him.

Given IPSS I did not offer SBRT or brachy boost. Just moderate hypofrac 28 fx to prostate/SV/LN +Barrigel with LTADT. Said if needed can do TURP 1yr out from RT he says outcomes are not that good.

 

[RickyScott]

64M with G4+4 adeno in 7/10 cores. PSA 4.4. PSMA PET shows prostate confined disease. No ECE. Prostate size approx 40cc. IPSS of 20 with bothersome score of 5/6. Pt seeing both urology and rad onc today, got below msg from the urologist after seeing him.

Given IPSS I did not offer SBRT or brachy boost. Just moderate hypofrac 28 fx to prostate/SV/LN +Barrigel with LTADT. Said if needed can do TURP 1yr out from RT he says outcomes are not that good.

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Could consider prostate artery embolization or urolift prior to xrt.

 

[TheWallnerus]

64M with G4+4 adeno in 7/10 cores. PSA 4.4. PSMA PET shows prostate confined disease. No ECE. Prostate size approx 40cc. IPSS of 20 with bothersome score of 5/6. Pt seeing both urology and rad onc today, got below msg from the urologist after seeing him.

Given IPSS I did not offer SBRT or brachy boost. Just moderate hypofrac 28 fx to prostate/SV/LN +Barrigel with LTADT. Said if needed can do TURP 1yr out from RT he says outcomes are not that good.

View attachment 409514

Isn’t there data that high dose RT resolves high IPSSs in the long term as well as a TURP

 

[medgator]

64M with G4+4 adeno in 7/10 cores. PSA 4.4. PSMA PET shows prostate confined disease. No ECE. Prostate size approx 40cc. IPSS of 20 with bothersome score of 5/6. Pt seeing both urology and rad onc today, got below msg from the urologist after seeing him.

Given IPSS I did not offer SBRT or brachy boost. Just moderate hypofrac 28 fx to prostate/SV/LN +Barrigel with LTADT. Said if needed can do TURP 1yr out from RT he says outcomes are not that good.

View attachment 409514

Get an MRI. Not a big gland, could argue surgery if the gland were bigger and symptoms worse but would definitely get an MRI before he operates

 

[Palex80]

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Reply back with:

"His chances or recurring are about 90%, I can bill 28 fractions now or 33 fractions later on."

 

[HolySmokes]

Could consider prostate artery embolization or urolift prior to xrt.

What's the data for this? I had a patient seek a second opinion recently after his initial urologist told him he needed PAE prior to RT. Second urologist who I trust more or less said PAE was quackery, but I didn't dive into the literature myself.

 

[medgator]

Could consider prostate artery embolization or urolift prior to xrt.

Channel turp? Just need to wait a bit

 

[Ray D. Ayshun]

What's the data for this? I had a patient seek a second opinion recently after his initial urologist told him he needed PAE prior to RT. Second urologist who I trust more or less said PAE was quackery, but I didn't dive into the literature myself.

I haven't looked into data, but I will say that it has been effective in the patient's I've seen.

 

[madchemist89]

TURP then sim in 3 months

 

[ramsesthenice]

I don’t actually think RP is crazy in “some” of these situations. All of these outlet procedures can help but worsening of symptoms overtime definitely happens. Yes, they have a high risk of needing adjuvant radiation but they nay still have a better urinary QoL with upfront surgery.

That said, this usually applies more clearly to folks with obvious BPH and low volume cancer. In that setting, you know the etiology of their symptoms and know that radiation is unlikely to help.

This sounds more like small gland, high volume disease. Unless the severity of their LUTS is very long standing, their cancer is probably contributing and RT is likely to help. I’m not convinced that surgery has a clear advantage here.

It absolutely burns me up when they present a widely metastatic patient in TB with a gland completely replaced by cancer and someone recommends an immediate SPC. Palliative RT is very good at alleviating obstruction in those settings. The idea that radiation can only worsen LUTS is highly pervasive and wrong.

 

[BobbyHeenan]

I presume this guy is already on meds? I see so many elevated IPSS scores on guys that have never even been on flomax. I think sometimes the LUTS gets lost in the shuffle when the discussions area all about the cancer. Meanwhile the dude has had BPH symptoms for years but never discussed it with his PCP or urologist in much detail.

If this guy is maxed out on meds and still miserable, I don't have a major issue with surgery. You're all right though, very likely to need post op XRT and other avenues can be pursued (?pre xrt TURP), but in a surgeon that's motivated to operate good luck convincing him/her to do something less than a prostatectomy before radiation starts.

 

[communitydoc13]

64, reasonable chance of durable biochemical control (90% failure rate?) but also a high chance of biochemical failure (I was estimating 50%), likely in his 70s. I wouldn't say anything to the urologist. This is probably what I would have done myself. Folks fail non-surgical management in similar proportions. I wouldn't want 12-18 months of ADT at 64 unless necessary.

Salvage him when he's 75. That's likely to happen.

Seen a few PAE procedures. Some work wonders. Some do nothing. Not scientific, but urolift has seemed less impressive in my patient population.

 

[ramsesthenice]

I presume this guy is already on meds? I see so many elevated IPSS scores on guys that have never even been on flomax. I think sometimes the LUTS gets lost in the shuffle when the discussions area all about the cancer. Meanwhile the dude has had BPH symptoms for years but never discussed it with his PCP or urologist in much detail.

If this guy is maxed out on meds and still miserable, I don't have a major issue with surgery. You're all right though, very likely to need post op XRT and other avenues can be pursued (?pre xrt TURP), but in a surgeon that's motivated to operate good luck convincing him/her to do something less than a prostatectomy before radiation starts.

10000000% and I harp on this with residents. A given score on BID flowmax and finasteride means something very different than the same score on no therapy. The other key point is: how bothered are they.

 

[RickyScott]

Channel turp? Just need to wait a bit

ADT and turp prior to xrt is common, but could try PAE/urolift, as they dont damage the urethra. also dont have side effects of TURP, so sometimes worth trying first. Important to assess PVR in these patients as sometimes urinary bother is from overactive bladder which can be treated with gemtesa. Often components of both OAB and outflow obstruction present. Recently seen gemtesa handed out like candy by the urologists.

 

[msbbc833]

In my experience TURP prior to RT takes 6 months to heal and be cleared for RT, so I wouldn't want to wait that long to initiate RT in high risk disease, but have done this in int risk before and it works really well. Urolift is an option too but my results have been more mixed with this, doesn't seem to help a ton.

Good point re: flomax. This guy is not on anything and likely has been having these symptoms for years and would have significant improvement with medical mgmt and given small gland filled with cancer probably improve with RT. We will see what the patient decides.

I actually think RP is a good option for him, but I don't think discrediting RT here is reasonable based on his IPSS

 

[Palex80]

64, reasonable chance of durable biochemical control (90% failure rate?) but also a high chance of biochemical failure (I was estimating 50%), likely in his 70s. I wouldn't say anything to the urologist. This is probably what I would have done myself. Folks fail non-surgical management in similar proportions. I wouldn't want 12-18 months of ADT at 64 unless necessary.

Salvage him when he's 75. That's likely to happen.

I feel that this will end up being an ugly disease.
He has 7/10 cores positive (I presume non-targetted, which means quite a bit of his prostate is tumor), with a low PSA and a Gleason 8.

My gut feeling is, he will end up with a pT3-disease and perhaps even positive nodes (if the surgeons decides to take out any).

Perhaps one can do one of these fancy genetic test or the AI pathology to have a better assessment of how aggressive this disease is.

In my experience TURP prior to RT takes 6 months to heal and be cleared for RT, so I wouldn't want to wait that long to initiate RT in high risk disease

He qualifies for 18 months (at least) of ADT. You can start ADT now, do the TURP and irradiate after Easter 2026. This will likely not run away by then.

 

[evilbooyaa]

PAE can be helpful at times (but is not 100%) and doesn't require a waitin gperiod, but the max effects of it on improving IPSS.

After a TURP or HoLEP or other type of scooping, all would recommend 3 months of waiting, many would push for 6. That being said, he can start ADT in the interim, which he's going to be recommended for hard minimum 18 months anyways given VHR disease (> 4 cores of GG4 disease). I would personally do 24 months and send him for consideration of Abi internsification, although I'd have to refresh my memory if he meets the letter of the STAMPEDE, but he definitely meets the spirit of the trial.

64, reasonable chance of durable biochemical control (90% failure rate?) but also a high chance of biochemical failure (I was estimating 50%), likely in his 70s. I wouldn't say anything to the urologist. This is probably what I would have done myself. Folks fail non-surgical management in similar proportions. I wouldn't want 12-18 months of ADT at 64 unless necessary.

Salvage him when he's 75. That's likely to happen.

Seen a few PAE procedures. Some work wonders. Some do nothing. Not scientific, but urolift has seemed less impressive in my patient population.

Per MSKCC pre-prostatectomy nomogram, assuming he is T1c - 5-year risk of bPFS is 50%. At 10-years, it's 34%. Not the worst I've seen. But pretty poor chance of cure with surgery alone.

It's not wrong to do surgery. But it is not wrong to do radiation either.