Prostate case: What is appropriate for reirradiation and how?

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TheWallnerus said:
Believe it or not didn't want to debate. Just wanted to know: am I too cynical? If someone else wants to treat, I say do it, especially if you have lots of experience. I do not.
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In these situations, I usually ask the patient: "what keeps you up at night... the fear of the cancer progressing, or fear of treatment toxicity"?
 
Retreatment is too high risk of potentially catastrophic toxicity for my blood -- the kind of toxicity that will haunt the patient (and his family) the rest of his life, much less haunt you the rest of your life. And is there really a 50% "cure rate"? Who knows. The smartest minds on SDN don't know and I respect their opinions.

A catastrophic outcome very well might lead to a rad onc being run out of town. Are you prepared to leave your home? And when you try to get a license in another state you will be explaining these events to every medical board wherever you go. The same is true for when you try to apply for privileges at a new hospital.

And if you are asking for advice on SDN if you should do it, then it tells me that you really shouldn't be doing it.

I guess if one of my partners came to me and asked if they should do this, my answer would immediately be "no". Remember, if your partner has a catastrophic event occur it soils the rest of the program. For years, most likely. Possibly forever.

I would explain to the patient that reirradiation is an extremely high risk treatment option and that I don't recommend it but can send him to the ivory tower if he wants a second opinion.

If he does choose reirradiation elsewhere you will still be liable for any subsequent toxicities that might occur. His lawyers will find an "expert" that will condemn you no matter how wonderful the initial treatment plan was.

Don't think it can't happen to your patient. Wasn't it Wallner that wrote a piece in the Red J about the malpractice of prostate brachytherapy many years ago. I think he said he had 4 or 5 malpractice cases for fistulas, or something along those lines - I could look up the reference if you really want it.

Hope this helps.
 
‘If he does choose reirradiation elsewhere you will still be liable for any subsequent toxicities that might occur. His lawyers will find an "expert" that will condemn you no matter how wonderful the initial treatment plan was.’

Living in this type of fear is unhealthy, my friend.
 
SneakyBooger said:
Retreatment is too high risk of potentially catastrophic toxicity for my blood -- the kind of toxicity that will haunt the patient (and his family) the rest of his life, much less haunt you the rest of your life. And is there really a 50% "cure rate"? Who knows. The smartest minds on SDN don't know and I respect their opinions.

A catastrophic outcome very well might lead to a rad onc being run out of town. Are you prepared to leave your home? And when you try to get a license in another state you will be explaining these events to every medical board wherever you go. The same is true for when you try to apply for privileges at a new hospital.

And if you are asking for advice on SDN if you should do it, then it tells me that you really shouldn't be doing it.

I guess if one of my partners came to me and asked if they should do this, my answer would immediately be "no". Remember, if your partner has a catastrophic event occur it soils the rest of the program. For years, most likely. Possibly forever.

I would explain to the patient that reirradiation is an extremely high risk treatment option and that I don't recommend it but can send him to the ivory tower if he wants a second opinion.

If he does choose reirradiation elsewhere you will still be liable for any subsequent toxicities that might occur. His lawyers will find an "expert" that will condemn you no matter how wonderful the initial treatment plan was.

Don't think it can't happen to your patient. Wasn't it Wallner that wrote a piece in the Red J about the malpractice of prostate brachytherapy many years ago. I think he said he had 4 or 5 malpractice cases for fistulas, or something along those lines - I could look up the reference if you really want it.

Hope this helps.
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I take no issue with you decision not to treat and completely agree you shouldn’t do something you think is too risky. Also agree if you are asking for advice on a forum like this you probably should be referring out. This isn’t like adding a couple fractions or making your nodal volume a little bigger.

I do think your legal theories go too far. We can agree that the risk of complications is high and there is not prospective data suggesting retreatment is the “right” thing to do so there would be some risk to you (won’t quip about how much). But 100% if someone else retreated them you are off for the first treatment. That is getting into the far reaches of plausibility. It’s more likely that you would get sued later for not treating them when they see me for palliation of some bone Mets and get real angry when they find out that I would have treated them and the feel like you “wasted their chance of cure.” I think they would have a snowballs chance in hell at winning in that scenario (and for the record I would not testify for the defense in this situation because I don’t believe saying no is a mistake) but my point is that if you take the fear of getting sued too far you quickly end up in a lot of no win situations. We as a discipline just don’t get sued that often.
 
jondunn said:
‘If he does choose reirradiation elsewhere you will still be liable for any subsequent toxicities that might occur. His lawyers will find an "expert" that will condemn you no matter how wonderful the initial treatment plan was.’

Living in this type of fear is unhealthy, my friend.
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Until you get sued.....
 
medgator said:
Until you get sued.....
Click to expand...

if you are walking around afraid that someone you didn't treat with re-irradiation is going to sue you, then that's too far.

If this impacts your decision to refer for a second opinion to someone else, even worse
 
jondunn said:
if you are walking around afraid that someone you didn't treat with re-irradiation is going to sue you, then that's too far.

If this impacts your decision to refer for a second opinion to someone else, even worse
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Not how i interpreted it, @SneakyBooger was getting at being sued for retreating and causing severe toxicity i think?
 
This was the quote :


‘If he does choose reirradiation elsewhere you will still be liable for any subsequent toxicities that might occur. His lawyers will find an "expert" that will condemn you no matter how wonderful the initial treatment plan was.’
 
jondunn said:
This was the quote :


‘If he does choose reirradiation elsewhere you will still be liable for any subsequent toxicities that might occur. His lawyers will find an "expert" that will condemn you no matter how wonderful the initial treatment plan was.’
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Agree, That seems a bit far fetched.
 
SneakyBooger said:
Retreatment is too high risk of potentially catastrophic toxicity for my blood -- the kind of toxicity that will haunt the patient (and his family) the rest of his life, much less haunt you the rest of your life. And is there really a 50% "cure rate"? Who knows. The smartest minds on SDN don't know and I respect their opinions.

A catastrophic outcome very well might lead to a rad onc being run out of town. Are you prepared to leave your home? And when you try to get a license in another state you will be explaining these events to every medical board wherever you go. The same is true for when you try to apply for privileges at a new hospital.

And if you are asking for advice on SDN if you should do it, then it tells me that you really shouldn't be doing it.

I guess if one of my partners came to me and asked if they should do this, my answer would immediately be "no". Remember, if your partner has a catastrophic event occur it soils the rest of the program. For years, most likely. Possibly forever.

I would explain to the patient that reirradiation is an extremely high risk treatment option and that I don't recommend it but can send him to the ivory tower if he wants a second opinion.

If he does choose reirradiation elsewhere you will still be liable for any subsequent toxicities that might occur. His lawyers will find an "expert" that will condemn you no matter how wonderful the initial treatment plan was.

Don't think it can't happen to your patient. Wasn't it Wallner that wrote a piece in the Red J about the malpractice of prostate brachytherapy many years ago. I think he said he had 4 or 5 malpractice cases for fistulas, or something along those lines - I could look up the reference if you really want it.

Hope this helps.
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With this level of fear, I’m surprised you have no worries about being sued for a surgical complication after RT for osteoarthritis.
 
Krukenberg said:
With this level of fear, I’m surprised you have no worries about being sued for a surgical complication after RT for osteoarthritis.
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Surgical complications after arthritis XRT have not been reported and would not be expected. Still could happen.

I cannot say the same for prostate reirradiation.
 
EUA ESTRO Guidelines


1638803041928.jpeg


I don't see a consideration for EBRT in the following table:

1638803087746.jpeg
 
Here is some trial data from Mass Gen.

I don't want to become an expert on fistula management myself.

DOI: 10.1002/cncr.22934

1638803307692.jpeg


3/25 fistulas/colostomies

1638803370063.jpeg


1638803438601.jpeg
 
jondunn said:
if you are walking around afraid that someone you didn't treat with re-irradiation is going to sue you, then that's too far.

If this impacts your decision to refer for a second opinion to someone else, even worse
Click to expand...

Just because someone else is doing it doesn't mean I would recommend my patients consider it.
 
More data out of Boston:


1 of 11 patients developed fistula. With spacer. I guess it is better than the prior 13% rate of fistulas.

1638806618855.jpeg


1638806720626.jpeg
 
ramsesthenice said:
It’s more likely that you would get sued later for not treating them when they see me for palliation of some bone Mets and get real angry when they find out that I would have treated them and the feel like you “wasted their chance of cure.” I think they would have a snowballs chance in hell at winning in that scenario (and for the record I would not testify for the defense in this situation because I don’t believe saying no is a mistake) but my point is that if you take the fear of getting sued too far you quickly end up in a lot of no win situations. We as a discipline just don’t get sued that often.
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What data is there that reirradiation increases a patient's "chance of cure", especially when he is 78YO and appears to have an indolent recurrence?
 
SneakyBooger said:
What data is there that reirradiation increases a patient's "chance of cure", especially when he is 78YO and appears to have an indolent recurrence?
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None! I intentionally used that word to be provocative in reference to the fear of litigation. Just because someone tries to bring something against you doesn't mean it would hold water.

This is actually a critical issue that we agree on and I am very careful in how I explain it to patients. They already thought they were cured once (since I only even consider this if they have a very long disease free interval) and obviously were not. All I can tell them is that in the most recent series the PSA remains undetectable in 60-70% of men for at least 5 more years. Will it stay that way? We don't know. For some guys it just helps them sleep better and they are ok with the risk. There are actually a lot of series with much better toxicity outcomes than you cited above such as this:

pubmed.ncbi.nlm.nih.gov

Salvage brachytherapy for locally-recurrent prostate cancer after radiation therapy: A comparison of efficacy and toxicity outcomes with high-dose rate and low-dose rate brachytherapy - PubMed

These findings show that both HDR-BT and LDR-BT yield comparable efficacy and toxicity outcomes in patients undergoing salvage treatment for locally-recurrent prostate cancer after primary radiotherapy. Predictors of worse outcomes after salvage BT were post-salvage nadir PSA and time to BF from...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

And several meta-analyses:

pubmed.ncbi.nlm.nih.gov

A Systematic Review and Meta-analysis of Local Salvage Therapies After Radiotherapy for Prostate Cancer (MASTER) - PubMed

In a large study-level meta-analysis, we looked at treatment outcomes and toxicity for men treated with a number of salvage treatments for radiorecurrent prostate cancer. We conclude that relapse-free survival at 5 years is equivalent among salvage modalities, but reirradiation may lead to lower...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

I have never personally known or heard of someone needing a colostomy after primary or salvage BT so I am skeptical the true incidence is anywhere near what you cited above. Its also absent from most of the published literature. The GU toxicity is real though. If you look across all of the series (even the good ones) the risk of grade 3+ GU toxicity is probably around 20% and we absolutely consent people for that. As I said above, I am extremely selective in who I will do this for. Already have LUTS? No way. Have periurethral or apical disease? Not going to happen.

We agree that there is no high level evidence supporting re-irradiation. We disagree on the specifics and how it affects our personal calculation. And that's ok.
 
So 8/11 patients who got fistulas were in cases without prior radiation.

So I’m assuming you never do brachytherapy in the first line and also will not let any of your patients go seek an opinion about Brachy, because of fear of being sued?
 
Is it possible to place space oar after course of failed ebrt? I would think fibrosis would get in the way,
 
RickyScott said:
Is it possible to place space oar after course of failed ebrt? I would think fibrosis would get in the way,
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I would agree. Also, I don’t like them for BT. Moves the prostate anterior and if trying to cover the whole prostate can force you to increase anterior dwell times which means higher urethral dose.

SneakyBooger said:
Here is the 2004 brachytherapy article for clarification. Interestingly, first author is an attorney.

3 of the 11 referenced cases are salvage treatments.



10.1016/j.brachy.2004.07.003

View attachment 346534

View attachment 346535
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Honestly, this raises a lot of questions. Most notably, one person caused 8 rectal fistula using BT in a 4 year period (only one was before 1997)? I don’t care how many implants you are doing something is very wrong here. That smokes my GYN rate which should be at least an order of magnitude higher. When I see something like “delivered the wrong patient plan” it makes me think this place was ripe for problems. This scary example is an extreme outlier.

As an aside, this is partially why I prefer HDR to LDR for either setting. Even though the tox rates in reality are probably not all that different, with HDR you have a lot more control over the final dosimetry. Using 2-3 fx courses I have never had a plan which as a composite exceeded rectal tolerance.
 
jondunn said:
So 8/11 patients who got fistulas were in cases without prior radiation.

So I’m assuming you never do brachytherapy in the first line and also will not let any of your patients go seek an opinion about Brachy, because of fear of being sued?
Click to expand...

I've done somewhere around 900-1000 prostate implants in my life. I haven't done one in 5 yrs or so mainly because we (rad onc's and urologists) have found IMRT to have significantly less toxicity risk. I discuss that experience and the published literature with my patients, covering the pros and cons.

I would gladly release a patient from my care if they decide they want brachytherapy. However, I cannot recall a patient leaving my practice in the past 10 yrs to go have brachytherapy elsewhere.

Regarding fear, I recommend not throwing all caution to the wind. Have a healthy respect for what may happen. Even in "the best of hands" and using strict protocols one will find that catastrophic toxicities have occurred. As I said above, don't be misled into believing it can't happen to one of your patients.
 
RickyScott said:
Is it possible to place space oar after course of failed ebrt? I would think fibrosis would get in the way,
Click to expand...
Here is a sober podcast regarding SpaceOAR I heard this weekend:



BTW, I posted a study looking at spacer in reirradiation above...
 
Obviously, doctors need to do what they feel is best for their patients. Lots of selection criteria apply in these situations. My previous partner and I had roughly 40 patients who were reimplanted without a single serious complication. It was this experience that led me to begin cautious re-irradiation with IMRT about 9 years ago. To date I have 23 patients treated and in close follow-up without a single serious complication. I cannot comment as to why the results in the literature are so alarming, but it clearly is not my experience. Also, my serologic control rate is much better than 50 percent.

That said, as I approach retirement, my enthusiasm for such risky endeavors wanes. Maybe I need to get my T checked.
 
SneakyBooger said:
I've done somewhere around 900-1000 prostate implants in my life. I haven't done one in 5 yrs or so mainly because we (rad onc's and urologists) have found IMRT to have significantly less toxicity risk. I discuss that experience and the published literature with my patients, covering the pros and cons.

I would gladly release a patient from my care if they decide they want brachytherapy. However, I cannot recall a patient leaving my practice in the past 10 yrs to go have brachytherapy elsewhere.

Regarding fear, I recommend not throwing all caution to the wind. Have a healthy respect for what may happen. Even in "the best of hands" and using strict protocols one will find that catastrophic toxicities have occurred. As I said above, don't be misled into believing it can't happen to one of your patients.
Click to expand...
My experience with IMRT vs HDR brachy has been the opposite but in either case severe toxicities are rare. Other than that...you and I 100% agree on everything else. Can't and shouldn't throw all caution to the wind. Everyone will have catastrophic complications. So far, all of mine have happened in very standard cases. But its important to remember even when everything is very "standard" the risk is never zero. I remember my first grade 5 toxicity like it was yesterday. A patient with unresectable pancreatic cancer who did great with chemo and only had localized disease. I took the pancreas to 50 Gy with no real ENI. Max point dose to the duodenum was 5240. Three months after treatment she developed a GI bleed and had severe ulceration of the antrum and proximal duodenum. They tried everything (even a partial gastrectomy) and nothing could stop the oozing blood loss and they died. I delivered hundreds of these plans and never seen anything like it before or since. I have done Crane style dosing before a few times too. Imagine if I had used it in this case and the family were not so understanding...

Thats the real danger of stepping outside of SOC. There is always a baseline complication rate and if it happens when you do something outside of SOC you can't prove that your "experimental (thats the accurate legal term)" didn't cause it. Anytime you consider doing something even a little outside of SOC you absolutely have to document like hell and clearly articulate that you explained the limitations and risks. Its not a 100% guarantee of protection but without it you have absolutely nothing to stand on.
 
Thinking of SpaceOAR -- as an aside, came across this just published article that reminded me of the SpaceOAR trial. Recall, SpaceOAR did not meet its (real) primary endpoint.

It's worth checking out the supplemental information where the goodies are, including hypofractionation for larynx (aghast! how dare they!).

Unfortunately (or fortunately, depending on your partiality), most patients don't understand this concern:

doi:10.1001/jamanetworkopen.2021.35765

Read the editorial too: doi: 10.1001/jamanetworkopen.2021.38695

1638965336665.jpeg


1638965737269.jpeg
 
The journals should not be publishing articles that have inappropriate statistical conclusions. It is their job to ensure statistical rigor prior to publishing.
 
Just ran across this MAUDE database entry on 2/1/22 submitted by Boston Scientific regarding fistulas in salvage HDR and thought it would be a good addition to this thread. I searched for the publication as mentioned below but was unable to locate it. Perhaps it isn't published yet? Who knows...

"BOSTON SCIENTIFIC CORPORATION BECAME AWARE OF AN EVENT THROUGH THE ARTICLE "REVIEW OF RECTO-URETHRAL FISTULAE FOLLOWING FOCAL SALVAGE HIGH DOSE RATE BRACHYTHERAPY" WRITTEN BY DOCTOR ROBERTO ALONZI . IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT SPACEOAR DEVICE WAS USED IN 7 SPACEOAR PLACEMENT PROCEDURES PERFORMED ON UNKNOWN DATES. THE SPACEOAR DEVICE WAS INSERTED PRIOR TO SALVAGE BRACHYTHERAPY IN ALL SEVEN PATIENTS. THE PATIENTS EACH DEVELOPED A FISTULA 4-7 MONTHS AFTER SALVAGE HIGH DOSE RATE (HDR) BRACHYTHERAPY. IN 2 OF THE PATIENT'S THERE WAS EVIDENCE OF RECTAL WALL COMPROMISE. IN 3 OF THE PATIENT'S THE SPACEOAR GEL WAS DIFFICULT TO VISUALIZE AND DISPERSED THROUGHOUT THE PERI PROSTATIC, PERI RECTAL TISSUE. THE PLACEMENT OF THE SPACEOAR GEL WAS DEEMED THE CAUSE OF THE FISTULAE. THE PATIENT RECEIVED A COLOSTOMY AND BILATERAL NEPHROSTOMY AS TREATMENT. BOSTON SCIENTIFIC HAS BEEN UNABLE TO OBTAIN ADDITIONAL INFORMATION TO DATE, DESPITE GOOD FAITH EFFORTS. Manufacturer Narrative: AGE AT TIME OF EVENT: PATIENT 1: (B)(6) YEARS, PATIENT 2: (B)(6) YEARS, PATIENT 3: (B)(6) YEARS, PATIENT 4: (B)(6) YEARS, PATIENT 5: (B)(6) YEARS, PATIENT 6: (B)(6) YEARS, PATIENT 7: (B)(6) YEARS. THE EXACT DATE OF THE EVENT IS UNKNOWN."
 
SneakyBooger said:
I've done somewhere around 900-1000 prostate implants in my life. I haven't done one in 5 yrs or so mainly because we (rad onc's and urologists) have found IMRT to have significantly less toxicity risk. I discuss that experience and the published literature with my patients, covering the pros and cons.

I would gladly release a patient from my care if they decide they want brachytherapy. However, I cannot recall a patient leaving my practice in the past 10 yrs to go have brachytherapy elsewhere.

Regarding fear, I recommend not throwing all caution to the wind. Have a healthy respect for what may happen. Even in "the best of hands" and using strict protocols one will find that catastrophic toxicities have occurred. As I said above, don't be misled into believing it can't happen to one of your patients.
Click to expand...

IMRT for low-to-intermidiate risk PCA is much easier to do for the physicians, but seeds are IMHO better for the patients (superior potency rates, less second malignancies). Correct me if I'm wrong
 
seper said:
IMRT for low-to-intermidiate risk PCA is much easier to do for the physicians, but seeds are IMHO better for the patients (superior potency rates, less second malignancies). Correct me if I'm wrong
Click to expand...
I don't know if you are wrong, but I know how I look at it.

I think with modern IMRT/IGRT that potency rates are no better with LDR.

Nor am I convinced that second malignancies are less.

I suspect the LDR cohorts suffer from selection bias. Example - smoker with COPD less likely to get anesthesia/LDR and therefore joins the EBRT cohort which increases the rate of 2nd malignancies of EBRT. Example #2 - pt with BPH has large gland less likely to get LDR and therefore gets EBRT which increases the risk of toxicities such as ED.


Risk of erectile dysfunction after modern radiotherapy for intact prostate cancer
Prostate Cancer and Prostatic Diseases
Received: 10 March 2020 / Revised: 5 June 2020 / Accepted: 30 June 2020

"Conclusion ED is a common side effect of RT. Risk of post-RT ED is similar for both LDR brachytherapy and external beam RT with advanced prostate targeting and penile-bulb sparing techniques utilized in modern RT techniques."

"Our multivariate analysis notes a marginally significant trend where LDR BT is associated with a higher rates of ED development."

"no consensus exists regarding the definition of erectile dysfunction, particularly amongst patients."

***The above statement is why I believe there will likely not be sufficient data to convince me that LDR has (more or) less ED.***

1659966490099.jpeg
 
SneakyBooger said:
Just ran across this MAUDE database entry on 2/1/22 submitted by Boston Scientific regarding fistulas in salvage HDR and thought it would be a good addition to this thread. I searched for the publication as mentioned below but was unable to locate it. Perhaps it isn't published yet? Who knows...

"BOSTON SCIENTIFIC CORPORATION BECAME AWARE OF AN EVENT THROUGH THE ARTICLE "REVIEW OF RECTO-URETHRAL FISTULAE FOLLOWING FOCAL SALVAGE HIGH DOSE RATE BRACHYTHERAPY" WRITTEN BY DOCTOR ROBERTO ALONZI . IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT SPACEOAR DEVICE WAS USED IN 7 SPACEOAR PLACEMENT PROCEDURES PERFORMED ON UNKNOWN DATES. THE SPACEOAR DEVICE WAS INSERTED PRIOR TO SALVAGE BRACHYTHERAPY IN ALL SEVEN PATIENTS. THE PATIENTS EACH DEVELOPED A FISTULA 4-7 MONTHS AFTER SALVAGE HIGH DOSE RATE (HDR) BRACHYTHERAPY. IN 2 OF THE PATIENT'S THERE WAS EVIDENCE OF RECTAL WALL COMPROMISE. IN 3 OF THE PATIENT'S THE SPACEOAR GEL WAS DIFFICULT TO VISUALIZE AND DISPERSED THROUGHOUT THE PERI PROSTATIC, PERI RECTAL TISSUE. THE PLACEMENT OF THE SPACEOAR GEL WAS DEEMED THE CAUSE OF THE FISTULAE. THE PATIENT RECEIVED A COLOSTOMY AND BILATERAL NEPHROSTOMY AS TREATMENT. BOSTON SCIENTIFIC HAS BEEN UNABLE TO OBTAIN ADDITIONAL INFORMATION TO DATE, DESPITE GOOD FAITH EFFORTS. Manufacturer Narrative: AGE AT TIME OF EVENT: PATIENT 1: (B)(6) YEARS, PATIENT 2: (B)(6) YEARS, PATIENT 3: (B)(6) YEARS, PATIENT 4: (B)(6) YEARS, PATIENT 5: (B)(6) YEARS, PATIENT 6: (B)(6) YEARS, PATIENT 7: (B)(6) YEARS. THE EXACT DATE OF THE EVENT IS UNKNOWN."
Click to expand...

I personally do not offer spaceOAR in a previously irradiated pelvis.

This affirms my current practice, and therefore I will take this unpublished data as gospel going forward.

I will print out this SDN post and tape it to my wall as a defense of my current practice.
 
I've done a fair amount of prostate brachy for patients that come to me after local recurrence after external beam (>20 where PSMA/other imaging showed prostate only disease, biopsy positive.). They do well if their pre-existing urinary symptoms are not bad.

Send to someone with experience doing HDR/LDR salvage.

I usually recommend ADT as well but some decline that piece.
 
WanderingRad3 said:
Send to someone with experience doing HDR/LDR salvage.
Click to expand...

I don't know him, but Dr. Alonzi appears to be experienced.

Dr Roberto Alonzi, Clinical Oncologist | GenesisCare UK

Dr Alonzi is a Medical Research Council Clinician Scientist with a special interest in prostate cancer. Contact us today to find out more about our personalised service and cutting edge treatments.
www.genesiscare.com www.genesiscare.com

(Seems the Chinese govt is taking over radiation oncology throughout the world)
 
WanderingRad3 said:
I've done a fair amount of prostate brachy for patients that come to me after local recurrence after external beam (>20 where PSMA/other imaging showed prostate only disease, biopsy positive.). They do well if their pre-existing urinary symptoms are not bad.

Send to someone with experience doing HDR/LDR salvage.

I usually recommend ADT as well but some decline that piece.
Click to expand...

Nothing wrong with LDR/HDR brachy for salvage. I've offered it myself. But I'm not doing SpaceOAR in an irradiated pelvis.
 
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