Fortunately there are very good diagnostic tools available today to locate the site and extent of recurrent disease. Finding the prostate cancer cells is the first step in planning an effective “salvage” treatment.
The advanced staging studies we conduct to determine local, regional and distant metastases include:
- Multimodality TRUS imaging (grey scale and especially color flow Doppler ultrasound)
- Dynamic (functional) contrast enhanced MRI (DCE-MRI)
- 18F-FDG fluoride PET/CT
- Combidex®/Sinerem MRI (when available)
- 11C-choline PET/CT
- CTC (Circulating Tumor Cell) blood test
- New Ferriheme analysis
It is important to understand at this point that treating a recurrence is much more challenging than initially treating most prostate cancers. There is a new set of critical circumstances to consider. Primary of these is the condition of the prostate bed or the prostate gland (if first treatment was anything other than surgery). Surgery (either radical or robotic) leaves a void in the pelvic area that rapidly becomes occupied by the bladder and/or rectum, making radiation tricky so as not to permanently damage these organs in the process of killing the remaining cancer cells. In addition, the surgical process will have left the area badly devascularized (decreased blood flow), therefore - the "target zone" will be lacking in appropriate oxygenation to activate the highest killing response of radiation. Higher doses, only achieved by "true" DART, typically accompanied by hormonal therapy, are necessary to salvage a cure.
If the recurrent patient had primary radiation, then he has already received a significant dose of radiation which makes additional radiation especially dangerous. To ensure safety, these men will need the higher doses available only through the sophistication of treatment delivery programs encompassing all the available tools (especially found with DART). To maximize the potential of radiation for recurrent patients, we often prescribe hormonal therapy - which creates a positive synergy with radiation resulting in mathematically boosting the effects (1+1 = 3 or 4 or 5, for instance).