SBRT prostate after prior EBRT?

[thesauce]

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Has anyone done SBRT after prior EBRT or brachy? I found 2 relatively recent studies and it seems to be equally-effective and better tolerated than some other modalities out there. Thoughts?

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

Reirradiation for isolated local recurrence of prostate cancer: Mono-institutional series of 64 patients treated with salvage stereotactic body radiotherapy (SBRT) - PubMed

Salvage SBRT reirradiation for the locally recurrent PCa offer a satisfactory tumor control and excellent toxicity profile, if BED ≥130 Gy is administered.

pubmed.ncbi.nlm.nih.gov

 

[Gfunk6]

I do it all the time. I use Dr. Fuller's protocol published in PRO.

High-dose-rate stereotactic body radiation therapy for postradiation therapy locally recurrent prostatic carcinoma: Preliminary prostate-specific antigen response, disease-free survival, and toxicity assessment - PubMed

Two-year disease-free survival is encouraging, and the prostate-specific antigen response kinetic appears comparable with that seen in de novo patients treated with SBRT, albeit still a preliminary finding. Grade ≥2 genitourinary toxicity was occasionally seen with no obvious predictive factor...

pubmed.ncbi.nlm.nih.gov

 

[ramsesthenice]

Has anyone done SBRT after prior EBRT or brachy? I found 2 relatively recent studies and it seems to be equally-effective and better tolerated than some other modalities out there. Thoughts?

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

Reirradiation for isolated local recurrence of prostate cancer: Mono-institutional series of 64 patients treated with salvage stereotactic body radiotherapy (SBRT) - PubMed

Salvage SBRT reirradiation for the locally recurrent PCa offer a satisfactory tumor control and excellent toxicity profile, if BED ≥130 Gy is administered.

pubmed.ncbi.nlm.nih.gov

Unless they have had prior LDR brachy, I typically prefer HDR for in-gland salvage. There is a pretty good literature for it. I have yet to see a major complication or even severe LUTs. The literature on salvage SBRT is mixed but I know folks (apparently GFunk is one of them) who do it and it seems to go ok as well.

 

[tomhobbes]

Yes, our practice does. I personally have not done it for in-gland recurrences less than 4 years after previous EBRT. I do try to get a perirectal spacer in before re-RT, but optimal spacer placement is not as high as in the RT-naive setting given fibrosis/scarring in that space. It does take a fair amount more dissection and gentle manipulation to create the pocket. We've used 35-36.25/5fx.

 

[OTN]

I've done it after HDR which was done more than 10 years ago. It was scary to do, but the patient has done well.

 

[BobbyHeenan]

I haven't done this.

Excuse my ignorance.

Do you all do just focal radiation based upon biopsy location/MRI (and now PSMA or axumin)? LIke gross disease plus (small) margin?

Of note, on quick glance at the Fuller paper they only included patients with G1 toxicity at XRT round 1 only. So clearly you need to be selective.

 

[Gfunk6]

I treat whole gland but dose escalate to gross disease

 

[BobbyHeenan]

I treat whole gland but dose escalate to gross disease

I think that's what I would probably do too in my theoretical world.

But a congruent saturation biopsy, MRI, and now with PSMA pet would be really tempting to just treat a hot area.

 

[thecarbonionangle]

HDR or SBRT 6x6 with spaceOAR.

 

[ramsesthenice]

I think that's what I would probably do too in my theoretical world.

But a congruent saturation biopsy, MRI, and now with PSMA pet would be really tempting to just treat a hot area.

I see where you are coming from but the counter argument is you only get one shot at this. I’ve re-treated the whole gland with HDR 30/3 (albeit in folks with good baseline urinary function) a few times without any notable toxicity. In the definitive setting, hemi-gland BT failed miserably even with pretty thorough work up. Until I see good data otherwise, I feel like if you are going to do it, do it right.

 

[GI_RadOnc]

36.25 / 5 fractions; checking every day that no hot spot in urethra (max dose 38.8) as well as the prostate/rectal boundary is appropriate. Some patients have had fluciclovine PET, only a few with PSMA-PET due to availability where we are. We may have done between 5 and 10 cases thus far. Since we have MR guidance, we have been using that. Not enough for a series yet.

 

[ramsesthenice]

On a slightly different but related note, I have also used 45/30 BID as an aggressive palliation dose for folks with symptomatic in gland recurrences after full dose in guys who also have Mets and been extremely happy with it. First guy I did it in was close to needing a suprapubic cath. Told him I might make things better or worse and ended up getting him 2.5 years of complete resolution of his LUTS. Oddly enough, it helped with his castrate resistance too. I eventually ended up treating his PA nodes with a modest dose and he’s still doing great on ADT (though PSA is starting to rise slowly again even on ADT…but still, happy to buy a couple more years). No toxicity issues. I’ve also used this dose a couple times for secondary rectal cancers after bladder or prostate RT in medically inoperable folks a few times. Not enough for a series but something that has served me well.

 

[Neuronix]

36.25 / 5 fractions; checking every day that no hot spot in urethra (max dose 38.8) as well as the prostate/rectal boundary is appropriate. Some patients have had fluciclovine PET, only a few with PSMA-PET due to availability where we are. We may have done between 5 and 10 cases thus far. Since we have MR guidance, we have been using that. Not enough for a series yet.

Putting spacer in?

 

[GI_RadOnc]

Putting spacer in?

I have not put in SPACE-OAR in my couple of patients; not sure about my colleagues'.

 

[medgator]

Putting spacer in?

Not sure if prior radiation affects denonvilliers fascia? Edit: just checked it seems to be a relative contraindication

 

[Gfunk6]

Not sure if prior radiation affects denonvilliers fascia? Edit: just checked it seems to be a relative contraindication

I just put in a SpaceOAR on a patient with locally recurrent prostate cancer s/p IMRT (78 Gy) delivered about 7 years ago. Axumin PET confirmed local recurrence without regional or metastatic disease.

Both the prostate and denonvilliers fascia were notably fibrotic based on the tactile feel with the needles. However, the fascia in particular appeared normal (like fat) on TRUS.

 

[Neuronix]

Doot. Yes, super fibrotic in recurrent setting hard to inject. I asked the question not realizing I was in a recurrent thread. Lol

 

[cancer_doc]

Putting spacer in?

Yes, definitely try to place SpaceOAR. I have performed a few and I will usually encounter some fibrosis of the Denonvilliers Fascia. Most will open up with hydrodissection to allow adequate placement of the gel, but some are totally stuck. It those situations, I may decide to go partial prostate vs whole gland, depending on disease location/size and pt's baseline GI/urinary status. Salvage brachy, HIFU, Cryo can be considered if you have the expertise locally...

 

[Ray D. Ayshun]

Reviving old thread but mostly appropriate as it fits the general idea of RT after RT. Seeing a guy s/p HDR brachy 10 yrs ago for LR prostate. Now with BCR and PSMA PET avid nodule in the back of 1 lobe pending biopsy. Wondering about options from EBRT perspective, etc. One rec to me was repeat HDR. From an EBRT perspective SBRT seems feasible, but mod hypo or conventional perhaps safer. I would think biggest risk is urethral tox as opposed to rectal. Moderate dose to prostate and boost nodule/spare urethra etc. other local ablative options with Urology?

 

[RickyScott]

Had similar case and treated conventionally just the psma/mri lesion w/margin margin and adt. Pt should also be biopsied.

 

[Ray D. Ayshun]

Looks like similar to the OP case in that the progression is at the base of and into the SV. I suspect I could safely SBRT the spot plus margin while entirely missing urethra and minimally dosing the rectum. I can't find much precedent for nodule only SBRT in lit, though frequently for nodule only HDR. Doing things kind of in reverse, but wondering if there's a go-to paper. Other option is nodule only re-HDR.

 

[OTN]

I've done SBRT before in the setting of prior EBRT. There's decent data. Agree with biopsy first.

 

[Ray D. Ayshun]

I've done SBRT before in the setting of prior EBRT. There's decent data. Agree with biopsy first.

Whole prostate or nodule plus margin? My case is in the context of prior HDR. Perhaps no diff on some level, but just looking for a pub re both of these things: treatment of lesion plus margin only, and EBRT after HDR.

 

[OTN]

Whole prostate or nodule plus margin? My case is in the context of prior HDR. Perhaps no diff on some level, but just looking for a pub re both of these things: treatment of lesion plus margin only, and EBRT after HDR.

Nodule plus margin

 

[Gfunk6]

Nodule plus margin

I agree. Given the heterogeneity of HDR, you can really mess up the urethra if you add an SBRT dose on top of that. I haven't had this problem with LDR however.

In this case, I would probably treat nodule + margin.

 

[evilbooyaa]

Reviving old thread but mostly appropriate as it fits the general idea of RT after RT. Seeing a guy s/p HDR brachy 10 yrs ago for LR prostate. Now with BCR and PSMA PET avid nodule in the back of 1 lobe pending biopsy. Wondering about options from EBRT perspective, etc. One rec to me was repeat HDR. From an EBRT perspective SBRT seems feasible, but mod hypo or conventional perhaps safer. I would think biggest risk is urethral tox as opposed to rectal. Moderate dose to prostate and boost nodule/spare urethra etc. other local ablative options with Urology?

I would get an MRI as well. Full sextant biopsy as well as ROI biopsy. If ONLY site of pCA is the PET avid area, I would be open to nodule + margin. However, full prostate biopsy necessary to ensure you don't need to treat the entire prostate. If anything beyond the PSMA PET avid nodule pops up as pCA, re-treat entirety of gland (can consider FLAME-style boost to PET avid lesion as feasible)

I only re-treat with SBRT because that's where the bulk of atleast conempotrayr data stands. Need to monitor for both rectal and urethral toxicity but there aren't really any well validated dose constraints for toxicity. Most folks seem to do OK though.

A non-RT alternative would be if its limited to the prostate would be to consider cryo per MASTER meta-analysis, some places are also offering HIFU although MASTER was not very positive on toxicity from that.

 

[Palex80]

So, what dose of SBRT would you all give?

 

[maxwellradonc]

Salvage prostatectomy to me seems reasonable if pts are young etc

 

[evilbooyaa]

Salvage prostatectomy to me seems reasonable if pts are young etc

Wrong per MASTER Meta-anslysis.

So, what dose of SBRT would you all give?

36.25Gy to PTV, 40Gy to CTV. Same 'constraints' as initial plan but treating all the quite conservative soft constraints on an initial 5fx SBRT plan like hard constraints, especially for rectum and bladder. Generally recommend a Barrigel in this space especially if nodule is posteriorly located. Don't love SpaceOAR in previously irradiated tissue.

 

[medgator]

A non-RT alternative would be if its limited to the prostate would be to consider cryo per MASTER meta-analysis, some places are also offering HIFU although MASTER was not very positive on toxicity from that.

Only real bonafide use for cryo..... RT Salvage

 

[ramsesthenice]

I’ve been doing this for the better part of 5 years with SBRT or HDR and in my experience, nodule plus margin isn’t enough and I only do it for people with significant obstructive symptoms. I had too many subsequent in gland failures. I get (or got) PYL, MRI, and sat biopsy for everyone. It’s no different than the upfront setting…there is often more than you can see. I treat whole prostate to 37.5 and decrease BR001 constraints by 20% keeping full coverage to the module and coverage of the whole gland to at least 85%. Plans come out hot but if you manage the urethral dose, it goes fine.

One exception are the LDR patients with failures in the base with no seeds in the base. It’s not great mystery why those failed and I tend to be more focused.

 

[Ray D. Ayshun]

I’ve been doing this for the better part of 5 years with SBRT or HDR and in my experience, nodule plus margin isn’t enough and I only do it for people with significant obstructive symptoms. I had too many subsequent in gland failures. I get (or got) PYL, MRI, and sat biopsy for everyone. It’s no different than the upfront setting…there is often more than you can see. I treat whole prostate to 37.5 and decrease BR001 constraints by 20% keeping full coverage to the module and coverage of the whole gland to at least 85%. Plans come out hot but if you manage the urethral dose, it goes fine.

One exception are the LDR patients with failures in the base with no seeds in the base. It’s not great mystery why those failed and I tend to be more focused.

Fwiw, I'd argue the case I'm seeing is similar to the last example. It's a failure vs new primary in base of SV, which was likely underdosed vs missed during primary HDR. Is this more of a focused situation for you. It's def not an in-field failure. At margins vs outside.

 

[ramsesthenice]

Fwiw, I'd argue the case I'm seeing is similar to the last example. It's a failure vs new primary in base of SV, which was likely underdosed vs missed during primary HDR. Is this more of a focused situation for you. It's def not an in-field failure. At margins vs outside.

I agree. That sounds like exactly the situation I described as well and keeping it focused makes sense. I’ve only had 1 in gland failure I know of after HDR and it was exactly where you described. I did focal SBRT about a year ago and so far, so good.

I was speaking more generally. Most of the referrals I get are square in the PZ and should definitely have been treated previously.

 

[evilbooyaa]

I’ve been doing this for the better part of 5 years with SBRT or HDR and in my experience, nodule plus margin isn’t enough and I only do it for people with significant obstructive symptoms. I had too many subsequent in gland failures. I get (or got) PYL, MRI, and sat biopsy for everyone. It’s no different than the upfront setting…there is often more than you can see. I treat whole prostate to 37.5 and decrease BR001 constraints by 20% keeping full coverage to the module and coverage of the whole gland to at least 85%. Plans come out hot but if you manage the urethral dose, it goes fine.

One exception are the LDR patients with failures in the base with no seeds in the base. It’s not great mystery why those failed and I tend to be more focused.

I do agree in that what would probably be 'better' in terms of bPFS is re-irradiation of whole gland and I wouldn't knock anyone who does not offer/recommend focal re-RT w/ SBRT or HDR. I consider the focal vs whole gland salvage part of SDM, in appropriately selected candidates (focal lesion on PET that lines up with MR that lines up with sat bx) that we truly don't know the 'best' answer between focal re-treatment vs whole gland, but if CRYO and HIFU are focal treatments and work 'just as well' then I think it's reasonable to offer focal SBRT/HDR to a motivated patient.

 

[DoctwoB]

In may area we will often do salvage brachy. I think both focal (in the right candidate, MRI, biopsy, and PSMA all concordant) and whole gland are both reasonable.

Definitely a high risk patient population. Expect to see more salvage hifu data and think there may be a legit use case here. While I have seen some patients fly through their salvage, many others post salvage re-irradiation and salvage brachy have pretty debilitating LUTS and one case of nasty/refractory bleeding that may be heading to a urinary diversion.

On the other hand I have been quite happy with the cancer control outcomes. Expect we will see more of this as PSMA makes us better at detecting recurrences + gives us more confidence that we are not missing distant recurrences.

 

[ramsesthenice]

In may area we will often do salvage brachy. I think both focal (in the right candidate, MRI, biopsy, and PSMA all concordant) and whole gland are both reasonable.

Definitely a high risk patient population. Expect to see more salvage hifu data and think there may be a legit use case here. While I have seen some patients fly through their salvage, many others post salvage re-irradiation and salvage brachy have pretty debilitating LUTS and one case of nasty/refractory bleeding that may be heading to a urinary diversion.

On the other hand I have been quite happy with the cancer control outcomes. Expect we will see more of this as PSMA makes us better at detecting recurrences + gives us more confidence that we are not missing distant recurrences.

HIFU, Cryo, IRE…probably all are useful. We are selecting for patients with a preponderance for local but non-metastatic biology. For people with peripheral lesions and significant pre-salvage LUTS, my preference is for uro to consider one of their focal options.

I haven’t seen any crazy toxicities yet. Doesn’t mean it’s tox free, but it’s also not noticeably different from treatment naive patients which dogma always told us it would be. But, I’m pretty choosy who I will radiate vs send out for other options since it’s a luxury I have with a great group in house who have experience with cryo and IRE.

 

[evilbooyaa]

HIFU, Cryo, IRE…probably all are useful. We are selecting for patients with a preponderance for local but non-metastatic biology. For people with peripheral lesions and significant pre-salvage LUTS, my preference is for uro to consider one of their focal options.

I haven’t seen any crazy toxicities yet. Doesn’t mean it’s tox free, but it’s also not noticeably different from treatment naive patients which dogma always told us it would be. But, I’m pretty choosy who I will radiate vs send out for other options since it’s a luxury I have with a great group in house who have experience with cryo and IRE.

The hard part is I generally recommend Cryo because MASTER suggested high tox from HIFU. But, I don't know enough about HIFU to know if HIFU now is the same as HIFU from when those patients were treated.

IRE for prostate cancer seems wild.... but again, a technique I am not intimately familiar with besides surgeons do it without evidence.

 

[ramsesthenice]

The hard part is I generally recommend Cryo because MASTER suggested high tox from HIFU. But, I don't know enough about HIFU to know if HIFU now is the same as HIFU from when those patients were treated.

IRE for prostate cancer seems wild.... but again, a technique I am not intimately familiar with besides surgeons do it without evidence.

Our guys don’t do HIFU, so I don’t have first hand experience.

I’m a full on IRE believer based on our experiences in borderline pancreatic cancers. I was a skeptic when our high volume Whipple guy brought it in but I’m a believer now. Our standard is conventional fractionation followed by resection +\- IRE to the vasculature and local control after R1+ resection is the rule, not the exception.

 

[emt409]

I treat whole gland but dose escalate to gross disease

Same. 30/5 to gland w/ SIB to PSMA guided gross tumor.

 

[DoctwoB]

Our guys don’t do HIFU, so I don’t have first hand experience.

I’m a full on IRE believer based on our experiences in borderline pancreatic cancers. I was a skeptic when our high volume Whipple guy brought it in but I’m a believer now. Our standard is conventional fractionation followed by resection +\- IRE to the vasculature and local control after R1+ resection is the rule, not the exception.

Prostate IRE data is quite limited and thus far relatively not compelling. All prostate focal therapy has the limitation of out of field failure rates, but IRE seems to have in-field failure rates in the 15-20% rate, which is unacceptably high in my view

https://jamanetwork.com/journals/jamasurgery/fullarticle/2800978

Which is a shame, since as a skillset it is extremely translatable for folks to do brachy or transperineal biopsy

This is why, if going focal, HIFU is the current winner imo, since with the "double-tap" approach in field failure rates ar in the ~6-7% range.

 

[ramsesthenice]

Prostate IRE data is quite limited and thus far relatively not compelling. All prostate focal therapy has the limitation of out of field failure rates, but IRE seems to have in-field failure rates in the 15-20% rate, which is unacceptably high in my view

https://jamanetwork.com/journals/jamasurgery/fullarticle/2800978

Which is a shame, since as a skillset it is extremely translatable for folks to do brachy or transperineal biopsy

This is why, if going focal, HIFU is the current winner imo, since with the "double-tap" approach in field failure rates ar in the ~6-7% range.

On top of that, they have already failed RT once. If it was EBRT, salvage Brachy makes sense given it probably has a higher BED. But repeating what failed before (ie, EBRT after EBRT or Brachy after Brachy) if you have other options is generally not my preference. Granted, I have the luxury of having urologists who do a fair bit of salvage focal therapies, so I can be a little choosier than many.

All that said, I wouldn’t fault anyone for doing repeat therapies under most circumstances (and I do it myself sometimes). The most tangible goal of salvage therapy most of the time is to avoid ADT. If the first round bought them 10+ years, salvage therapy will probably buy another 5-10 years and that’s probably enough most of the time.

 

[evilbooyaa]

On top of that, they have already failed RT once. If it was EBRT, salvage Brachy makes sense given it probably has a higher BED. But repeating what failed before (ie, EBRT after EBRT or Brachy after Brachy) if you have other options is generally not my preference. Granted, I have the luxury of having urologists who do a fair bit of salvage focal therapies, so I can be a little choosier than many.

All that said, I wouldn’t fault anyone for doing repeat therapies under most circumstances (and I do it myself sometimes). The most tangible goal of salvage therapy most of the time is to avoid ADT. If the first round bought them 10+ years, salvage therapy will probably buy another 5-10 years and that’s probably enough most of the time.

I see the draw of this and generally like re-SBRT in patients who did not get SBRT the first go around.... but I wouldn't send somebody to Urological salvage procedures (which require Foley generally?) just because of it.

 

[DoctwoB]

I see the draw of this and generally like re-SBRT in patients who did not get SBRT the first go around.... but I wouldn't send somebody to Urological salvage procedures (which require Foley generally?) just because of it.

It's anecdotal, but I would also look at response to initial therapy. A patient with a great PSA response to their initial treatment and then recurring 4 years later is very different from the guy whose PSA barely budged after their initial treatment. In the latter I would be hesitant to offer radiation based salvage options.

 

[ramsesthenice]

It's anecdotal, but I would also look at response to initial therapy. A patient with a great PSA response to their initial treatment and then recurring 4 years later is very different from the guy whose PSA barely budged after their initial treatment. In the latter I would be hesitant to offer radiation based salvage options.

100%

I see the draw of this and generally like re-SBRT in patients who did not get SBRT the first go around.... but I wouldn't send somebody to Urological salvage procedures (which require Foley generally?) just because of it.

I hope this goes without saying, but I don’t send anyone for anything. I express my reasoning why something else might be worth considering and refer them to hear what it’s all about. They get to choose. But how strongly I feel about it goes to DoctwoBs point. If they made it 5+ years after standard(ish) EBRT or Brachy, I like SBRT. If they had SBRT or EBRT and have reasonable urinary QoL, I like HDR. But the ones only make it 2-4 years (or less), I don’t feel as gung-ho about radiating. All this to say, my thinking is nuanced. Which, duh, we don’t know the right answer(s) yet.

 

[Haybrant]

I see where you are coming from but the counter argument is you only get one shot at this. I’ve re-treated the whole gland with HDR 30/3 (albeit in folks with good baseline urinary function) a few times without any notable toxicity. In the definitive setting, hemi-gland BT failed miserably even with pretty thorough work up. Until I see good data otherwise, I feel like if you are going to do it, do it right.

find the 'you only get one shot' arugments to be the things that get you into the biggest trouble. You only had 1 chance the first time too. the recurrence isnt some super RT sensitive entitiy. Also, you dont have to do it all, so dont get too caught up in you only get one shot (do not miss a chance to blow) - that will lead you into deep dark places.

 

[evilbooyaa]

It's anecdotal, but I would also look at response to initial therapy. A patient with a great PSA response to their initial treatment and then recurring 4 years later is very different from the guy whose PSA barely budged after their initial treatment. In the latter I would be hesitant to offer radiation based salvage options.

Sure, that is reasonable. If PSA doesn't budge at all after prostate RT, then I wouldn't really offering more radiation. All these folks that I've ever seen/heard of are when the PSA becomes low and then slowly starts climbing back up. Haven't really seen a prostate patient not have an at least initial dip in prostate.

I hope this goes without saying, but I don’t send anyone for anything. I express my reasoning why something else might be worth considering and refer them to hear what it’s all about. They get to choose. But how strongly I feel about it goes to DoctwoBs point. If they made it 5+ years after standard(ish) EBRT or Brachy, I like SBRT. If they had SBRT or EBRT and have reasonable urinary QoL, I like HDR. But the ones only make it 2-4 years (or less), I don’t feel as gung-ho about radiating. All this to say, my thinking is nuanced. Which, duh, we don’t know the right answer(s) yet.

What I mean when I say 'send for' is 'I recommend that you choose a non-RT option because I don't '. All patients see Urology to discuss salvage options regardless of whether I think re-SBRT is worth it or not.

Whether someone 2 years or 4 years or 6 or 8 or 10 years post-RT time frame to recurrence is..... mostly immaterial to me. Sure, I want the PSA to initially drop, but I don't know that lasting 2 years vs lasting 5 years without biochemical recurrence is predictive of response to salvage therapy....

Generally the ones with early recurrence are recurring in metastatic ways rather than local only salvage anyways...