Post Prostatectomy Radia/on. Bill McLaughlin MD University of Michigan

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1 Post Prostatectomy Radia/on Bill McLaughlin MD University of Michigan

2 No disclosures COI

3 Important Disclosure I am the most pro-surgery radia/on oncologist in the universe Example: If a 45 year old man has Gleason 3+4 disease and it appears prostate confined I strongly advise surgery I have talked more people into surgery than out I maintain an advocacy stance to avoid the despicable medicine barker rou/ne we put pa/ents through

4 Advocacy Our job is to help the individual pa/ent define the best path to CURE with QUALITY OF LIFE mpmri is invaluable in securing these ends The /me to discuss post op radia/on is pre op Neutrality is cri/cal to this approach

5 Cure and QOL Classical Configura/on Cure is of no concern Cure is of infinite value 0 0 QOL is of infinite value QOL is of no concern

6 Disrup/on of the Old Order

7 n=1 Cure IS quality of life: Why do we have to stop the hormones ayer 2 years lets just keep going I don t mind being aggressive with radia/on but I refuse to take Lupron Just get rid of it hit me with your best shot I don t really care about erec/ons but I don t think I could live with incon/nence Its not worth it to me to go through all this. In the end I put myself in God s hands. I don t have any symptoms at all from this

8 MRI Tumor informa/on ECE, Seminal Vesicle, Bladder neck We can have a predy good idea who will need post op Func/onal anatomy Sphincter length >1cm = low risk of incon/nence Nerve in bundle configura/on = phenomenal erec/on preserva/on Bone clearance, prostate size, median lobe

9 Aggressive Rx Equivalence Prostate only Surgery Radio - surgery Prostate Plus

10 bladder seminal vesicle bone prostate rectum external sphincter Penile bulb Prostate side view: Note labels on right. Prostate is not enlarged and does not extend into the bladder. Urethra opening from the bladder is open (yellow arrow). Sphincter is normal length and there is no bony restriction note space between the bone and prostate (purple arrows)

11 Bread slice view note labels on the right. The right side of the gland panle is normal prostate with clear PZ and TZ. On the left side (red) not the dark area that extends into the TZ and from front to back. This is tumor

12 Bread slice view with contrast the area of concern on the left side of the panel is clearly seen, with a suggestion of extension beyond the gland (arrow). This is not definitive, but is suggestive whenever I see that I recommend hormones

13 Bread slice another level. Note the tumor on the left side of the panel (red) and possible extension beyond the capsule

14 Summary Excellent anatomy for seeds or surgery Gland size OK, no bone restric/on = OK for seed implant Sphincter normal, nerves in normal posi/on = OK for surgery Tumor is visible and there is some sugges/on of extension through the capsule, but no extension to the seminal vesicle or nodes capsule penetra/on is s/ll highly curable but I favor hormones if radia/on chosen they can shrink the tumor rapidly and improve the implant dose coverage By anatomy a good surgical candidate but you would likely need radia/on ayer due to the capsule penetra/on

15 A Cri/cal Dis/nc/on Advocacy If you believe surgery is best and can t sleep at night without surgical removal, then trust your gut. Medicine Barker / Hack If you are really serious about curing this you must do surgery. No mader what anyone says radical removal is and always will be a best treatment for prostate cancer

16 Legi/mate Concerns / Barriers to Adjuvent and Salvage The study that demonstrated an OS benefit was flawed Many will be treated unnecessarily If I can t cure it with surgery it is incurable The stream of pa/ent care and recovery precludes referral for adjuvent and early salvage Radia/on toxicity concern

17 Study Flaw SWOG was a simultaneous adjuvent and salvage protocol On both arms there were undetectable and detectable PSA pa/ents It does not prove adjuvent is beder The OBS arm was not specified and many had delayed salvage treatment This explains the OS advantage not seen the other trials

18 In Spite of Flaws bned advantage (in all randomized trials) Biochemical failure is consequen/al in healthy young men with high grade recurrence DMFS advantage PCSM advantage Long term toxicity very limited, or was it? The most important outcome: Completely upends the theory that local control is unimportant in high risk Simultaneous local and distant does not occur in most Men die of metastasis from residual local cancer

19 Unnecessary Treatment SWOG obs arm <.2 = undetectable 73% developed biochemical failure at 10 years To address the risk 100 pa/ents would be treated to adempt to cure 73 CURRENT only 15% treated To avoid overtreatment of the 23% we are now undertrea/ng 85%

20 Not cured with Surgery = not curable Coming to a peer reviewed journal 94% 90% % Mets Free 79% 66% 61% 25-30% Year 5 Year10

21 The Missing Adjuvent Gap coming to an insurance provider 94% 90% % Mets Free 79% 66% 61% 25-30% The missing adjuvent gap Year 5 Year10

22 The Adjuvent Gap Too smart for your own good In a world of evidence based medicine reimbursement for therapy 30 points off the mark will not be allowed Too smart for your pa/ent s good

23 Lost in the Stream of Care Delay Adjuvent Box They are just recovering. They just need to recover now. The last thing they need right now is radia/on. This guy did not want radia/on and will be devastated if I tell him he needs it. Delay Salvage Box Their PSA is low. We can watch that for now and consider salvage later. They are just geung back on their feet. Salvage results are very good

24 Concerns about radia/on There were and are major flaws in post op radia/on A standard pelvis field set up to bony anatomy rou/nely treated the en/re GUD and the en/re penile bulb and bulbar urethra MRI planning can dras/cally reduce unnecessary dose and can mi/gate concern about toxicity There is no complica/on like death

25 XRT Planning - Apex MRI APEX GUD CT CONTOUR BONE

26 Radia/on Technique Given how poor our technique has been historically, we are actually lucky the toxicity was as limited as it was

27 Legi/mate Concerns / Barriers to Adjuvent and Salvage The study that demonstrated an OS benefit was flawed Many will be treated unnecessarily If I can t cure it with surgery it is incurable The stream of pa/ent care and recovery precludes referral for adjuvent and early salvage Radia/on toxicity concern

28 Post Op Radia/on Thompson Editorial We must inform our pa/ents that immediate post opera/ve radia/on can improve survival / cure/ With available super sensi/ve PSA tes/ng a case can be made for close monitoring, with radia/on administra/on at the first sign of eleva/on

29 Who needs Adjuvent? Or Near Adjuvent? Gleason Grade 5 (Gleason Score 9,10 or ter/ary GG5) with almost any adverse path need immediate post surgery beam Those with an US PSA of 0.03 (not 0.2) with any adverse path need radia/on (near -adjuvent) Important technical improvements in Post Prostatectomy Radia/on mi/gate concerns about toxicity There is no complica/on like death

30 Advocacy