SPACEOAR complications

[TheWallnerus]

There is a reason I converted to HDR. It’s more work for me (at least as a mono therapy) but the needles never go quite where you want and the seeds then have some migration.

I can tell you from experience if you are doing combo Brachy/EBRT with a spacer do the Brachy first if you really think you need it. Imaging is fine but the anterior displacement of the prostate if you get good spacer placement will bring the pubic arch into play for all but the smallest of prostates. You end up with worse prostate coverage far more often than significantly better rectal dose.

And surprise to no one, you loose out on procedural charges if you try to do the spacer and Brachy on the same day.

I agree with the above. If you are doing Brachy (boost or mono) I really don’t see a role for spacer. Rectal tox should be low unless you manage to put a seed in the rectal wall which, well, dose happen sometimes with LDR.

Pubic arch interference after shoving the prostate toward the pubic arch; makes perfect sense, but had never occurred to me. Thanks for sharing that.

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[ramsesthenice]

I offer all my favorable intermediate risk patients AS. I steer most of the younger folks away from it do the small but non-zero risk of progression to Mets (1-10% depending on the series you look at) and very high rates of conversion to radical therapy (~50-60% at 5 years). I also get edgy with higher volumes of disease, even if it’s a 1-2 cores of GG2 in a background of 8/12 cores with GG1 (though that’s technically unfavorable IR per NCCN, which tbh I disagree with)

Incidentally I think this is the one area where focal therapy be beneficial. If you have low volume Gleason 7 disease and you can reduce their risk of progression to therapy from 60% to 20% with minimal ADRs that’s a potential benefit.

I think NCCN is unclear on risk grouping based on volume of disease. There is no consideration of % cores positive for low risk. Someone can have 10/12 cores positive for GGG1 disease and anything, even AS, is ok. But now if the same person has a single core of GGG2 disease, they go all the way to unfavorable disease and need ADT if they opt for RT (and are no longer a Brachy only candidate)? Give me a break. I personally don’t count the GGG1 cores and neither do our urologists. It wouldn’t make sense.

 

[ramsesthenice]

Pubic arch interference after shoving the prostate toward the pubic arch; makes perfect sense, but had never occurred to me. Thanks for sharing that.

It’s not always a problem but it’s made a couple cases way more difficult than they needed to be for me.

 

[DoctwoB]

I think NCCN is unclear on risk grouping based on volume of disease. There is no consideration of % cores positive for low risk. Someone can have 10/12 cores positive for GGG1 disease and anything, even AS, is ok. But now if the same person has a single core of GGG2 disease, they go all the way to unfavorable disease and need ADT if they opt for RT (and are no longer a Brachy only candidate)? Give me a break. I personally don’t count the GGG1 cores and neither do our urologists. It wouldn’t make sense.

Agreed. Same thing applies for the nomograms we use for counseling patients, where it only has you enter the highest grade group and number of cores, thus not differentiating between the guy with 10/12 cores GG2 and the guy with one core GG2 and 9 GG1.

That being said, there is real data that the volume of disease, even GG1 is a predictor of pT3 disease, etc. So lately I’ve printed off both nomograms for these patients. One with the “assumption” that all is GG2, one with the “assumption” that all is GG1, and tell them their real probabilities lie somewhere in the middle.

 

[thesauce]

I think NCCN is unclear on risk grouping based on volume of disease. There is no consideration of % cores positive for low risk. Someone can have 10/12 cores positive for GGG1 disease and anything, even AS, is ok. But now if the same person has a single core of GGG2 disease, they go all the way to unfavorable disease and need ADT if they opt for RT (and are no longer a Brachy only candidate)? Give me a break. I personally don’t count the GGG1 cores and neither do our urologists. It wouldn’t make sense.

I don’t think that’s how they come up with risk categories. I believe they look at past trials and find specific factors that make someone at a higher risk than the risk group below them. These specific factors are what shakes out and they don’t always make sense. I don’t think it’s a judgment call so to speak.