Phillip Koo: Hi. My name is Phillip Koo, and welcome back to our exclusive coverage of the 13th International Uro-Oncology Conference here in beautiful Sao Paulo, Brazil. We're very fortunate to have with us today Dr. Robson Ferrigno, who is the medical director of Radiation Oncology of the Portuguese Beneficência Hospital of Säo Paulo. Welcome.

Robson Ferrigno: Thank you very much, Phil. Very good talk to you.

Phillip Koo: Great. So, you're giving a very interesting talk later today about the salvage treatment after radiation failure and the concept of re-irradiation, can you give us some of the highlights of that lecture?

Robson Ferrigno: Oh, yes. This is a very, very challenging problem, the radio recurrence. So you have a recurrence after treatment is radiation. So trying to do re-irradiation, you have some merit about complications. So based on the literature, you can use [inaudible 00:00:50] therapy like brachy therapy. And now it's increasing procedure, SBRT that's very high concentrated radiation through external beam for delivery from LINAC. So this technology is increasing. So the results is pretty good because the disease control is the same from radical prostatectomy with a bit lower genitourinary complications. So I think it's a reasonable option to offer to the patients with this condition.

Phillip Koo: Any sort of pitfalls? You talked about some of the genitourinary complications. What should physicians out there be on the lookout for?

Robson Ferrigno: Yes. The main problem is incontinence that is caused by a radical prostatectomy. Re-radiation don't cause incontinence, urinary incontinence. So it's interesting for this point. Gastrointestinal toxicity, no procedure cause this problem, so you don't have to worry about it. But genitourinary toxicity it's a very good object, so there must be hesitation about it. So re-radiation based on the trials published or mainly retrospective series don't show a very high genitourinary toxicity. If you insert some radioactive seeds or external beam delivered for this patient. So you can think about it.

Phillip Koo: So before you start the salvage treatment, are you routinely getting a prostate MRI or a PSMA PET in those scenarios before you treat?

Robson Ferrigno: PET PSMA, plus all these for all patients, to make sure that you have disease only in a prostate bed or a prosthetic gland so that you make sure you don't have disease outside the prostate. You don't do re-radiation for salvage treatment with disease outside the prostate. So nowadays PET PSMA for all patients.

Phillip Koo: So the PSMA is more about looking for metastatic disease. If the PSMA localizes to the prostate itself, do you give a boost in those areas that might have more activity?

Robson Ferrigno: Yes. If possible, if it is a very good identified lesions and just one side of the prostate, for example, you can make a boost not only with brachy, but also with SBRT. Start with the problem, because nowadays the treatment programs can make a fusion from the image from the CT user for treatment planning with the PET PSMA. So you can deliver very high concentrated dose in that area, you have an uptake from the contrast.

Phillip Koo: It's a very interesting concept because PSMA PET, I think we focus so much on the detection of metastatic disease, but I think we're learning more about its ability to characterize primary disease and recurrent disease in the prostate bed. And I think over the next few years, we'll probably see more data come out about the utility and value of a PSMA PET in that scenario. So I think it's great that you guys are pushing that and hopefully you'll have data to present in the future.

Robson Ferrigno: But sometimes very frequently you must check the uptake from PET with PSMA. I have a received patient with PET PSMA positive in the bone, consider metastatic disease puts low PSMA. I ask for biopsy in not just inflammatory disease, not re-recurring so that you must be careful beside indicate SBRT radiation. Make sure that's really disease. Surely if the uptake is on prostate bed, you don't have no doubt, but it's in bone and in no other place, you should check if it is a real metastatic disease.

Phillip Koo: Agreed. I think that's a great point, confirming some of the findings on PET. Because we do know there are false positives out there. So if we transition a little to the concept of mets directed therapy and oligo metastatic disease. In that radiation failure setting, if you get a PSMA PET and you see some oligo metastatic disease, how do you approach those patients with radiation?

Robson Ferrigno: It's an individual evaluation. SBRT for early metastatic disease is very useful. If you want to offer a hormonal therapy holiday for the patient due to some toxicity. So metastatic is up to from three to five sites. So metastatic you can use severity to treat those points and you postpone the systemic therapy for these patients. A particular patient who has a very high toxicity from hormonal therapy. So you are doing SBRT from the local of recurrences and you are postponing the reintroduction of hormonal therapy. So you have a true [inaudible 00:05:26] that show that it's possible, and you can even increase the overall survival. But all patients, you must evaluate, individualize it, to indicate this type of treatment. And I think it's very useful for this situation.

Phillip Koo: I think that's great discussing with patients and helping come to that decision together.

Robson Ferrigno: All is in a multidisciplinary board decision, because yes, SBRT, you must be reminded that nowaday, you have a very safe tools to deliver radiation. So the toxicity is very, very, very low. And it has a few application. One to five application with no symptoms for the patients. So it's a good option to offer for these patients.

Phillip Koo: Great. So we're going to switch gears a little and one thing I've learned during this trip to Brazil is that access to radiation oncology services in LINACs is very limited in Brazil and all Latin America. And clearly that will hurt patient care because all patients cannot be provided the same options, especially because we know cancer is so multidisciplinary. What are your thoughts on that? And how do we get past that? How do we increase access to ride on services?

Robson Ferrigno: Well, it's a very good question and it reflects our reality, not only Brazil, but also in all Latin America. So you have a very limited access to radiation therapy treatments here in Brazil. So you have approaches from the government. That is underway to introduce 100 more LINACs in Brazil. The first was 80 and now is 100 LINAC. You installed half of them, 50 LINAC, this tries to minimize, to decrease this problem. I think in the future, in two or three years, not solve totally this problem, but it's small, lower, and you are improving this access. So is still a very good problem.

Another problem is the access to the high technology, because it is very difficult the reimbursement for this techniques in Brazil. So it's another very, very big challenge.

Phillip Koo: So it's really about working with the government, as they are a large pair to increase access and support these technologies.

Robson Ferrigno: Yes, because in Brazil, you have some works from the government and for the public assistance and also private assistance. From the both sides, the radiation oncology services are increasing in number. So you are buying even more and more LINACs from the last years. So I think the access from the private and the public services are increasing. I think I hope and enact this three or four days you'll be much better than now.

Phillip Koo: Great. Well, wonderful. Thank you so much for joining us. And we appreciate the wonderful work that you guys are doing here. And we look forward to learning more when we come back to this meeting.

Robson Ferrigno: Okay. Thank you very much.