How do you manage a seminal vesicle recurrence after prostate brachytherapy?

Finding more of these in the PSMA era.

Have managed a few patients with SBRT +/- ADT adjusting dose based on overlapping OAR if needed.

We have run into this issue with several patients at Beaumont (now Corewell) over the years and have had excellent results with salvage HDR brachytherapy.

General Logic of Our Approach to Management

My standard approach to these cases is to obtain imaging workup with both MRI and PSMA to clarify all areas that are likely involved with disease and get pathologic confirmation with a repeat prostate/SV biopsy.

Once we have pathologic confirmation of recurrent disease and no evidence of extra-prostatic/extra-SV spread, we will offer salvage HDR brachytherapy. We standardly use 800 cGy BID in 4 fractions over 2 days in a single implant. So the patient is admitted to the hospital overnight.

We generally prefer multi-fraction over single-fraction do...

HDR brachytherapy.

Get an MRI, confirm the SV recurrence with biopsy, and make sure no metastatic disease (PSMA scan).

I don't think there is any clear or strong evidence to guide this, other than the obvious: ADT is a reasonable approach that will certainly reduce progression risk and may improve survival. If the patient is healthy and motivated to undergo local therapy, I am open to discussion of options, which include SBRT, repeat brachy, or surgical resection.

It must be emphasized that side effect risk is much higher than with the first treatment, and standard considerations are relevant, including the health of the patient, goals of care, baseline function, and no suspicion of regional/distant spread on PSMA PET. I would also order an mpMRI to evaluate both the seminal vesicles and the prostate. If there is cancer in the prostate, I wouldn't treat onl...

I've used multifraction HDR (13.5 Gy x 2) with 4-5 catheters with good success for these presentations. If possible fuse PSMA PET and/or MP MRI to HDR treatment planning CT to ensure appropriate coverage of recurrent area, being mindful of urethral, bladder/bladder neck, and rectal OAR, and any overlap with seeds if at all possible.

Agree with Dr. @Dr. First Last about r/o locoregional or distant mets.