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How risky is pelvic lymph node radiation after failed SRT?

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Posted 1/23/2014 8:37 PM (GMT 0)
My last PSA went up a little and has me looking at my options if it turns out to be BCR. My RO did not recommend whole pelvic radiation with SRT. He said I could always come back and target the pelvic lymph nodes later if necessary. Has anyone had any experience with pelvic node radiation after SRT failed?

My other choices include using Avodart and early vs. late ADT. I'm leaning toward early ADT3 if I can find a physician in the Pensacola Area.

Carlos

Post Edited (Carlos) : 1/23/2014 3:22:18 PM (GMT-7)

Posted 1/23/2014 8:50 PM (GMT 0)
Never heard of anyone have whole pelvic radiation after SRT failure, most RO's would not do that, as the risk for serious radiation damage would be high, in the same area that had been previously radiated. Doesn't mean they couldn't do some targeted spot radiation for bone mets, etc.

david
Posted 1/23/2014 8:59 PM (GMT 0)
Purg, There was no intent to radiate areas previously targeted. He simply planned to target lymph node areas that were excluded in the original plan.

Carlos
Posted 1/23/2014 9:16 PM (GMT 0)
Carlos, I don't know if you saw my report on the recent trip to LA. I went out there to have 2 nodes radiated that had recently shown to be growing and were possibly the cause of my rising PSA.

When we did a C11 Acetate scan there were two or three more that raised their ugly heads. At that point the doc said that targeted radiation was off the table. The area would have been too wide and "could" venture into the area that had already been radiated.

The biggest concern was the amount of toxicity delivered by the targeted radiation. While he did say that radiation was a possible option, it would have to be done at low dose and over an extended time. The bigger concern was the possibility of life altering QoL side effects.

As much as I have been reluctant to start HT, at this point it offers the best chance of slowing down the growth with the least chance of "long term" side effects.

Of course each case is different as we all know. I have no idea where your nodes are located, but it is something I would suggest you look at very closely if there is the slightest chance that the side effects could change the way you want to live.

FWIW,

Sonny
Posted 1/23/2014 9:27 PM (GMT 0)
Sonny, Yes I saw your report and found it very informative. I'm really not inclined to try any more radiation at this time. I have a good quality of life and don't want to ruin it. My PCP said I was in good health could easily make it into my 90's. I may be able to stay alive long enough for my PCa to become a problem.

Carlos
Posted 1/24/2014 1:27 AM (GMT 0)
Sorry, Carlos, misunderstood what you wrote then. With today's more accurate targeted radiation, it would be possible to pin point radiation to other areas close to the original target. I would want to have a really top notch RO at hand to attempt it though. And since you are concerned about QOL, not wanting to jump into any more radiation at this time might be your best decision, as the risk for damage is always on the table.

David
Posted 1/24/2014 4:21 AM (GMT 0)
Carlos,

There are two possibilities:

(1) isolated lymph node treatment on cancerous nodes identified by PET scans or USPIO MRI. If there are 5 or fewer in total, called oligometastatic disease, such treatment can sometimes be curative. These are picked off using SBRT. This is what Sonny was hoping for, but he had too many mets and they were not contained in the pelvic area.

(2) treatment of the entire pelvic lymph node area, which may also be curative. The latest thing is to irradiate the area with SBRT, which is highly precise and may not incur the same degree of bowel effects as other forms of radiation. You may be interested in the following study from UFlorence. They treated LN mets from a variety of cancers but had particularly good results with PC. "An excellent local control rate (90.9%) was obtained in patients affected by abdominal lymph node metastases of prostatic origin."

Clinical outcome of stereotactic body radiotherapy for abdominal lymph node metastases

Some have treated the regional pelvic lymph nodes with as much as 54 Gy of IMRT with no deleterious effects (typically treated with about 45 Gy).

Quality of Life Outcomes in Patients With Prostate Cancer Treated With Nodal Irradiation

SBRT affords the opportunity to increase the biologically effective dose to the LN region without escalating the toxic effects of higher dose. My friend will be treated with 25 Gy (5 doses of 5 Gy) at UCLA next week. Sunnybrook is doing a similar study.

- Allen
Posted 1/24/2014 4:57 PM (GMT 0)
TA, thanks for the info and the links. I meet with my onco this afternoon to talk about my options and will mention SBRT. I guess the real problem is the inability to detect mets that may be out of the pelvic lymph node area unless the PSA is very high. Again, thanks for the info.

Carlos
Posted 1/25/2014 9:55 AM (GMT 0)
Carlos, if you are asymptomatic and having a great time, at your age I can’t see the point in risking your present QoL. The radiation already absorbed by your local tissues places you at high risk for collateral damage even with spot RT. ADT may be a better alternative to hold the bandit if such becomes necessary. For the moment the PSA is still very low for whatever treatment you might choose.

Radiation is done with predefined targets otherwise it becomes a sort of “guessing” treatment with low chances of success. Your IMRT (68.4 Gy) has covered the fossa, nerve bundles, bladder neck and rectum. At the area only the iliac could be safe to be radiated and for that you would have to find an RO highly experienced in rads over rads. Apart from that, to find targets you would have to locate them with sophisticated PET/MRI testing whose contrast agent requires PSA levels above 1.5.

I would recommend you to obtain second opinions before advancing with any RT.
Posted 1/25/2014 3:58 PM (GMT 0)
Pardon my ignorant question. If the radiated area is now necrotic tissue, then how can re-radiating this area, or actually targeting an area quite close to it, be dangerous. The tissue is dead, thus cannot be further damaged. I am sure there is an obvious answer. Someone please provide it.
Posted 1/25/2014 5:36 PM (GMT 0)
Baptista, Thanks for your comments. I met with my onco yesterday and we covered most of my options. The plan at this time is simply to test my PSA for a couple of 3 month cycles to get a better feel for what is going on. If my PSA is increasing and the PSADT warrants it, I will probably start ADT. If PSA reaches the point that it might be detectable with an MRI we will consider SBRT. The MRI at the facility I'm using is linked to their Trilogy linac and would make targeting a few lymph nodes with SBRT fairly safe. The problem with a healthy life style is that I may live long enough for the PCa to become a problem. At least I can mess up the statistics.

Tarhoosier, I can't come close to answering your question.

Carlos
Posted 1/25/2014 6:35 PM (GMT 0)
tarhoosier,
RT does not kill most healthy tissue; most will self-repair within a couple of hours. Necrosis of the actual tumor will occur because cancerous cells lack cellular repair and apoptosis mechanisms that healthy tissue has. The acute (initial) side effects are mostly irritative. The late term damage of healthy tissue is caused by secondary effects due to inflammation and fibrosis.

Because modern IGRT/IMRT techniques are so precise, the radiation absorbed by nearby organs falls off rapidly with distance. On top of that, with SBRT, the total dose is only half the IMRT dose, so exposure of healthy tissue is even further minimized.

Treatment of the pelvic lymph nodes after initial prostate treatment has low rates of late term side effects. One worries about the effect on the bowels especially, but as you can see in the following study, "Maximum late gastrointestinal toxicities were Grade 1 [lowest grade] for 4.9% of the pts, no patient experienced acute >Grade 1 gastrointestinal symptoms."

GI and GU Toxicity in the Pelvic Nodal Treatment of High-Risk Prostate Cancer

- Allen
Posted 1/25/2014 6:46 PM (GMT 0)
Carlos,

ADT will interfere with LN met detection. Optimal detection via C11 PET scans requires PSA to be above 2, so you'll want to have it done before you start on ADT.

- Allen
Posted 1/25/2014 6:48 PM (GMT 0)
Carlos,

I had one enlarged lymph node that was targeted during my SRT, but not afterward. The RO allocated a portion of each day's treatment to directly target the lymph node throughout most of the treatments. But they stopped targeting the lymph node about 10 or 12 sessions before the end of my SRT, because the RO had calculated that was the maximum dose that could be targeted at that area without risking damage to nearby organs. But that was just a single lymph node, I'm sure it would be more complicated and potentially more risky if there were several that needed to be radiated.

Jim
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