Salvage radiation for prostate CA with Oligomet?

[RadOnc007]

I have a 65 y/o male who had pretreatment PSA of 25 , GS 8, and negative imaging on workup. He had a prostatectomy 6 months later and was found to T3a disease and GS 9. His lowest PSA was 2 ng/mL. Axumin PET shows uptake in L4 vertebral body but there are no lytic changes seen on non-contrast CT. The SPECT bone scan shows uptake in L3 pedicle but nothing in L4 vertebral body. Imaging is discordant and waiting to get the images to review since they were done at 2 separate locations.

If he does indeed have a 1-2 lesions on the L3 or L4, is there data to support salvage radiation therapy and ablation with SBRT to oligomet? Thanks in advance!

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[Mandelin Rain]

PSA of "2", you mean.

Ablate the mets, leave the pelvis alone.


Just to add, waiting 6 months to operate with a high-risk prostate cancer seems like poor form (in addition to operating at all).

 

[Palex80]

I'd perform an MRI.

You occasionally see lesions there that you will miss on CT, I've seen it often in myeloma.

If verified by MRI, I'd ablate the metastatic disease in L3/L4. You won't cure this patient, you will simply buy him some time until ADT has to start.
I wouldn't treat the pelvis now.

If MRI comes back negative, I'd wait and measure PSA (+/- rescan at 3 months according to what the PSA does by then).

 

[evilbooyaa]

Without evidence for gross disease in the fossa I would not treat the fossa. Ablate the oligomet, treat the fossa if there is visible gross disease or you have biopsy confirmation.

 

[metview]

For treatment of oligomets there is data: STOMP and ORIOLE trials. It will extend your pt's time off of ADT.

 

[Chartreuse Wombat]

For treatment of oligomets there is data: STOMP and ORIOLE trials. It will extend your pt's time off of ADT.

Radiation is better than no treatment..yay radiation!!!

 

[RadOnc007]

Thanks for everyone's feedback. Greatly appreciate it.

 

[xrthopeful]

Radiation is better than no treatment..yay radiation!!!

I know this is tongue in cheek, but for many men, delaying the quality of life decline with permanent ADT would be a win, especially when the time and side effect cost is low.

 

[RickyScott]

I know this is tongue in cheek, but for many men, delaying the quality of life decline with permanent ADT would be a win, especially when the time and side effect cost is low.

Why is it tongue in cheek? It is absolutely true here and I see it in similar situations
In lung ca allowing pts to stay on tki instead of going to chemo

 

[xrthopeful]

Why is it tongue in cheek? It is absolutely true here and I see it in similar situations
In lung ca allowing pts to stay on tki instead of going to chemo

I didn't mean my point was tongue in cheek, I believe in what I said.

I meant that C. Wombat's post was tongue in cheek. or at least I hope it was. RT to delay systemic therapy or keep them on a systemic therapy they are tolerating and is otherwise working are reasonable strategies IMO. I think many of us are getting more and more consults like this, which is a good thing.

 

[ramsesthenice]

How to approach salvage therapy in the setting of new generation PET-CTs is a challenge that you will get no agreement on. This case is definitely a grey zone case. This is the patient who failed/progressed immediately. How likely are they to really be oligometastatic? Without the PET-CT standard of care would be salvage treatment to the fossa and regional nodes. Just because you can see something that may be a met on the PET-CT does that mean that it really is ok to do less than the current standard of care? How sensitive is PET for detecting minimal residual disease in the fossa in the immediate post-op setting?

Don't get me wrong, you could easily argue that there is nothing wrong with treating the PET-Avid disease only and then checking for biochemical response. If the PSA goes to zero then you could feel good about not treating the fossa. If it doesn't, you have not burned any bridges and you can still treat the fossa.

But what about ADT? Should you omit it now? Or should you give focal therapy and 2 years of ADT like you would patients with non-metastatic high risk disease and hope for better long-term control?

My point is this is quickly devolving into the wild-wild west and we really need well-thought out trials to answer these questions. Not huge RCTs that take 20 years to accrue but at least prospective feasibility studies.

My bias is to use a risk based assessment. If they have PSA < 5, DT > 12 months, interval from surgery to recurrence > 18 months, and only 1-2 lesions total then I am more inclined to consider focal therapy alone. In patients with multiple high-risk features I don't think the control with SBRT alone is going to pan out all that well. In that instance I am more inclined to consider standard therapy with boost to gross disease. But I am keenly aware I could be very wrong.