pelvic varices/high risk prostate cancer

[BobbyHeenan]

I'll try to keep some things a little vague for anonymity...

High volume gleason 9 disease, no mets/lymph nodes on scans. Child Pugh A cirrhosis, some portal hypertension, well compensated though with no current clinical issues as it relates to this....other than a TON of pelvic varices seen on staging scans.

Would those varices change your decision to go +/- elective pelvic nodal irradiation?

I'm getting partin nomogram values around 8-10% of lymph node involvement. I often do give pelvic nodal XRT in high volume G9 disease (he has G9 disease all the way from apex to base).

Would those varices impact your pelvic nodal radiation decision? I'm on the fence about it.

I know the data on pelvic LN's. My personal clinical experience is that it does slightly increase acute loose BM's during treatment over that of prostate/SV only radiation. Don't know about the varices. I did counsel him that he may be at higher risk of proctitis/hemorhoidal bleeding from his radiation.

Any input greatly appreciated.

---

Members don't see this ad.

 

[Palex80]

I am surprised you get only 8-10% lymph node involvement with a GS9 disease in apparently many biopsies of the prostate.

Perhaps you should not rely on PSA values in this case for your calculations (I presume the PSA is low), perhaps it's a undifferentiated tumor which produces little PSA?

 

[thecarbonionangle]

Yeah low PSA with that volume of disease and grade screams bad prostate cancer. would do HDR boost and EBRT to pelvis + ADT

 

[seper]

I am not sure if varices confer any additional risk, but it is OK not to radiate nodes given lack of data, obviously

 

[BobbyHeenan]

I am surprised you get only 8-10% lymph node involvement with a GS9 disease in apparently many biopsies of the prostate.

Perhaps you should not rely on PSA values in this case for your calculations (I presume the PSA is low), perhaps it's a undifferentiated tumor which produces little PSA?

your intuition is correct. PSA not real high - like 8 or something if I"m remembering correctly.

That's sort of why I was not "trusting" the nomogram here.

 

[BobbyHeenan]

Yeah low PSA with that volume of disease and grade screams bad prostate cancer. would do HDR boost and EBRT to pelvis + ADT

He has a pretty big gland around 60 cc and already on flomax. I don't think he's a great brachy boost candidate but noted.

Thanks everyone for input!

 

[thecarbonionangle]

He has a pretty big gland around 60 cc and already on flomax. I don't think he's a great brachy boost candidate but noted.

Thanks everyone for input!

60cc gland on flomax would not scare me. Can give ADT first and shrink. What is his AUA/IPSS?

 

[BobbyHeenan]

60cc gland on flomax would not scare me. Can give ADT first and shrink. What is his AUA/IPSS?

IPSS was 12 on flomax.

I don't (and no one within 3 hours of me) have HDR prostate capability. I'm pretty selective about LDR boost, so I didn't push that. I fall on the Dan Spratt side of interpretation of the ASCEND trial.

If I was an LDR or HDR wizard though, certainly I think boost here is reasonable. Just don't put a needle in a varcies 🙂

 

[TheWallnerus]

IPSS was 12 on flomax.

I don't (and no one within 3 hours of me) have HDR prostate capability. I'm pretty selective about LDR boost, so I didn't push that. I fall on the Dan Spratt side of interpretation of the ASCEND trial.

If I was an LDR or HDR wizard though, certainly I think boost here is reasonable. Just don't put a needle in a varcies 🙂

*a varix

(I’m that guy)

 

[BobbyHeenan]

*a varix

(I’m that guy)

I thought I had it wrong...but didn't take the time to look it up. I knew you'd be there for the save.

 

[evilbooyaa]

I treat LNs on ALL very high risk patients regardless of nomograms. If the patient has more than 4 cores of Gleason 9 (GG5) in his biopsy, he is automatically very high risk. Agree that this may be an undifferentiated PCa patient who have very poor prognosis (mostly due to distant failure). I'm not sure that nomogram works all that well in this scenario.

I don't think brachy boost is mandatory at all in this situation, especially given lots of data that suggests bPFS and hard endpoints are not clinically concordant. I would really push for this gentleman to get the full 2 years of ADT however, given his potentially undifferentiated histology.

In regards to the varices, do you mean that the pelvic vessels (that you would normally contour around) are larger in width than normal? I wouldn't worry too much about that, just make sure a CTV and appropriate PTV are covered properly. If you mean you see varices around OARs that are affecting them, then maybe counsel on increased risk of toxicity, can consider conventional fx if you're really nervous. I'm not sure if I'm completely understanding what you mean by pelvic varices here. Can you maybe post a de-identified slice of his CT scan? For the most part though, I would offer him standard treatment options. Fields might be slightly larger and encompass a bit more bowel than normal but attempt to meet dose constraints and beam on.

 

[BobbyHeenan]

@evilbooyaa



That tangle of stuff on the R side is dilated vessels/varices. It is not bowel.

So far prelim plan of 70Gy to prostate, 50.4 to nodes (SIB VMAT) looks ok to me.

 

[Neuronix]

What's the worry about the varices? That RT will cause them to bleed? There's no evidence for that to my knowledge.

 

[BobbyHeenan]

What's the worry about the varices? That RT will cause them to bleed? There's no evidence for that to my knowledge.

I guess...I'm just being paranoid bc it was such an unusual scan for me. I think it too might also be a sign the patient is at risk for hemorrhoid bleeds or fissures if he gets into a bunch of diarhea/XRT GI toxicity.

Clearly, his high risk cancer warrants treatment, but just trying to think it through.

Needed a little hand-holding.

 

[Palex80]

I guess...I'm just being paranoid bc it was such an unusual scan for me. I think it too might also be a sign the patient is at risk for hemorrhoid bleeds or fissures if he gets into a bunch of diarhea/XRT GI toxicity.

Clearly, his high risk cancer warrants treatment, but just trying to think it through.

Needed a little hand-holding.

I think it's ok to be concerned.

Would you encompass those vessels completely in your CTV-creation if you are going to treat pelvic nodes?

I would have him consent to an increased risk for relevant lymphedema in the lower extremities because of his underlying conditions and the varicosis. He may experience some more GI/GU toxicity due to the pelvic volumes being larger than usual.

I'd also watch out for cytopenia because of his cirrhosis with possible splenomegaly and the bigger pelvic volume. It's seldom, but can happen.

 

[evilbooyaa]

@evilbooyaa



That tangle of stuff on the R side is dilated vessels/varices. It is not bowel.

So far prelim plan of 70Gy to prostate, 50.4 to nodes (SIB VMAT) looks ok to me.

Thanks for linking.

Yeesh that looks like nothing I've ever seen before.

IDK on increased risk of lymphedema, but yes increased risk of bowel and bladder toxicity compared to normal based on a likely much larger nodal CTV (and thus PTV) compared to someone without pelvic varices.

I get the concern now. Might not meet all constraints given size of nodal CTVs, but counsel on potential increase in risk of side effects and beam on.

I'm not sure about even increased risk of hemorrhoids unless, maybe, he has varices extending like into his rectal lining (which would need a contrasted scan to potentially show).