Prostate NCCN Guideline Changes (Risk Stratification)

[thesauce]

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In my case the patient has gg5 dz with PSA > 100 but no nodal or bone dz and gross disease in the seminal vesicle and low lying bowel abutting the SV. No amount of bladder filling will move the bowel away. I don’t know what else to do at this point and am thinking 2 fractions of sbrt with extremely tight margins peeling off bowel is my best options vs. going to 80 gy with god knows what kind of daily match. Thoughts?

If you’re worried about the daily match, then even more of a reason not to deliver high doses per day.

I’d leave off the SBRT boost and just standard frac. Works great.

 

[deleted1180461]

If you’re worried about the daily match, then even more of a reason not to deliver high doses per day.

I’d leave off the SBRT boost and just standard frac. Works great.

I’ve thought about it both ways. I can personally check the match and verify everything is absolutely perfect 2 times. At the same time high doses per fraction increase the risk of late toxicity. You can’t put seeds is the SV anyway. I tried flipping prone. It’s just a nightmare of a case. I can’t get a definitive dose with with conventional margins and no steep fall off. The alternative I guess is to stop the dose to the SV at 60 gy kniwing it probably wasn’t a curable case to begin with.

 

[ramsesthenice]

I wouldn't dose escalate here. I doubt it does anything regarding the natural history of GG5/PSA 100 disease based off of the prospective data. The early progression with GG5 patients happens independent of dose escalation. You might save a few later biochemical failures, but not sure how relevant that is for this patient?

My general feeling about dose escalation is that it may actually benefit the unfavorable intermediate or GG4 patient the most. Still good prognosis and lower risk of distant dissemination. You expect your benefit 5 years down the road.

I wouldn't dose escalate here. I doubt it does anything regarding the natural history of GG5/PSA 100 disease based off of the prospective data. The early progression with GG5 patients happens independent of dose escalation. You might save a few later biochemical failures, but not sure how relevant that is for this patient?

My general feeling about dose escalation is that it may actually benefit the unfavorable intermediate or GG4 patient the most. Still good prognosis and lower risk of distant dissemination. You expect your benefit 5 years down the road.

I’m with communitydoc on this one. I would probably just do 55/20 with ADT. I give it for bladder all the time with no severe bowel tox. If you really wanted to go higher, did you try a prone set up? It doesn’t for ever, or even most cases, but I’ve had some luck from time to time repositioning small bowel enough to get away with it.

 

[gvsudew]

I’ve thought about it both ways. I can personally check the match and verify everything is absolutely perfect 2 times. At the same time high doses per fraction increase the risk of late toxicity. You can’t put seeds is the SV anyway. I tried flipping prone. It’s just a nightmare of a case. I can’t get a definitive dose with with conventional margins and no steep fall off. The alternative I guess is to stop the dose to the SV at 60 gy kniwing it probably wasn’t a curable case to begin with.

HDR could be an option. But sbrt boost with bowel prep to maximize reproduciblity reasonable.

 

[deleted1180461]

I’m with communitydoc on this one. I would probably just do 55/20 with ADT. I give it for bladder all the time with no severe bowel tox. If you really wanted to go higher, did you try a prone set up? It doesn’t for ever, or even most cases, but I’ve had some luck from time to time repositioning small bowel enough to get away with it.

I tried prone and it made no difference. I like the idea of 55/20 but I’m close to finishing up 5040/28 to the pelvis. I guess I could just go to the typical conventional frac bladder dose of 64. Thanks