Very high risk prostate case

[CodeRedDew]

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Hello all,

Just wanted to get thoughts regarding a unique case.

55 y/o male with non-secretory GS 5+4 prostate cancer following RP/LND 2-3 years ago and treated with adjuvant long-term ADT alone, who now presents with a local bladder recurrence s/p salvage cystectomy with multiple +margins. No gross disease on post-op MRI and Axumin just shows mild avidity in the operative bed but no mets.

What is the role for XRT in his case? Specifically, what would be your treatment volumes and to what dose would you treat?

Initial management at diagnosis was at an outside PP center and it’s unclear why he wasn’t at least referred to discuss adjuvant XRT following initial surgery. Although his post-op PSAs have remained undetectable given non-secretory histology (iPSA was ~2).


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[Palex80]

Questions:

1. What's in the place of the bladder? Neobladder? Ordinary bowel?

2. Did the recurrence arise during/shortly after long-term ADT? Would you classify this tumor as HSPC or CRPC?

 

[CodeRedDew]

Questions:

1. What's in the place of the bladder? Neobladder? Ordinary bowel?

2. Did the recurrence arise during/shortly after long-term ADT? Would you classify this tumor as HSPC or CRPC?

1) Ordinary bowel (ileal conduit)

2) About ~10 months or so following cessation of ADT (presented with AKI). And I would say HSPC - MedOnc restarted ADT a couple months prior to cystectomy.


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[RickyScott]

1) Ordinary bowel (ileal conduit)

2) About ~10 months or so following cessation of ADT (presented with AKI). And I would say HSPC - MedOnc restarted ADT a couple months prior to cystectomy.


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Would certainly radiate to tolerance and consider taxane.

 

[CodeRedDew]

Would certainly radiate to tolerance and consider taxane.

what would your volumes consist of? Do you contour it like a post-op bladder case?


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[RickyScott]

I would. Try to guesstimate where postitive margin would be, and boost bed inferior to top of femoral heads to as high as possible. Would think that preop scan could possibly help for boost.

I know there is some data on radiosensitizing doses of taxanes for intact prostate as had pt on such a trial many years ago. May not be a bad idea to consider.

 

[mavrik13]

Can you convince a surgeon to put in a sling to move small bowel out of the way for RT? Perhaps a bit extreme, but this case is a bit extreme and probably deserves consideration... Absorbable Mesh Sling Prevents Radiation-Induced Bowel Injury During "Sandwich" Chemoradiation for Rectal Cancer

 

[Palex80]

The problem is going to be the ileal conduit.

You would prefer to put something like 66 (+) Gy in those positive margin areas but the ileal conduit (and its constraints) are going to ruin your dose distribution. I am not sure if widely accepted constraints for ileal conduit exist, but I wouldn't like to go above 54 Gy point dose.

 

[seper]

Ileal conduit is as radiosensitive as any small bowel, so I'd keep the total dose < 60 Gy.
A unique case, never seen anything like that.

 

[DoctwoB]

The ileal conduit should be a significant distance away from the prostatic fossa. If your positive margins were in the region of the bladder neck and trigone it will likely just be ordinary bowel filling that space that you need to worry about.

Interesting case. Did he progress while on his adjuvant ADT or afterwards? If during then I’d call him non metastatic crpc and give ADT plus docetaxel or Apilutamide, favoring the former if good PS.

 

[CodeRedDew]

The ileal conduit should be a significant distance away from the prostatic fossa. If your positive margins were in the region of the bladder neck and trigone it will likely just be ordinary bowel filling that space that you need to worry about.

Interesting case. Did he progress while on his adjuvant ADT or afterwards? If during then I’d call him non metastatic crpc and give ADT plus docetaxel or Apilutamide, favoring the former if good PS.

He progressed ~10 months following ADT, which was restarted a couple of months prior to cystectomy.


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