Is Radiation Therapy Wise with Gleason 9 and Metastasis in Lymph Nodes

Hello everyone,

I have been to several specialists and have done a lot of research on whether localized radiation and hormone treatment statistically can help slow down the prostate cancer I have. Everyone recommends hormone treatments, but the specialists I have seen to date are evenly split on the net benefits of localized radiation due to the metastasis in the pelvic lymph nodes.

The post operation pathology report showed Gleason nine prostate cancer, 95% involved, cancer in both seminal vesicles, extensive perineural invasion and two metastasis lymph nodes out of four glands tested.

Being a statistics sort of guy. I hate to go through the localized radiation treatments if the statistics for advanced cancer of this nature fail to show a real benefit. If any of you have some insight, feel free to pass it along, even if it is nothing more than what you would do in my shoes.

Thanks,

Excellent Question. Bone an CT are clean except some 'thickening of tissue around lower bladder' which the doctors think may be due to post operation swelling.

Thanks for asking.

Bob, I would be interested to know your post surgical PSA. DH had similar numbers, however, his post-surgical G9 was a shocker. He had the localized salvage radiation along with ADT with curative intent. All docs agreed that radiation and ADT would possibly get all remaining PCa. We are now in the wait and see phase. My understanding (and I'm no expert) is that if the cancer is locally advanced, RT presents a possible cure.

RandyJoe,

Again, excellent question. Post-of PSA was .2 three months after operation. Am scheduled to take another PSA this January.

Thanks for asking.

Bob,

There are no really good studies to help with your decision, and what we have is equivocal. You are quite right that adjuvant radiation carries the risk of significant side effects.

Adjuvant or salvage RT to the pelvic LNs when cancerous nodes have been identified was the subject of a retrospective studies published last year by Abdollah et al. that showed a benefit to salvage RT, and two by and Rusthoven et al. and by Kaplan et al. that showed no benefit.

In the Abdollah study, they found that men with two or fewer positive nodes, identified by extended lymph node dissection (ePLND), had better prostate cancer survival. This study was retrospective and subject to selection bias (the ones who received aRT got it because they had better chance of survival with it). Also, the LNs were identified by ePLND, a procedure more popular in Europe and at Mayo, whereas you only had 4 LNs removed.

Impact of Adjuvant Radiotherapy on Survival of Patients With Node-Positive Prostate Cancer

The Rusthoven study was a data analysis. They saw no difference in 10-year PC survival between those LN-positive men who had RP and those who had RP+salvage RT.

The Impact of Definitive Local Therapy for Lymph Node-Positive Prostate Cancer: A Population-Based Study

The Kaplan study study was also a data analysis. They also found no benefit to adjuvant RT in LN positive men:

Patterns of care and outcomes of radiotherapy for lymph node positivity after radical prostatectomy

What is needed is a randomized clinical trial to sort this out. There's one in the works (RTOG 0534) but it won't have results until 2021.

FWIW, what I would do is wait to get a PSA in January (they usually like to wait 3 months before giving adjuvant radiation anyway.) Then:

(1) If it's undetectable or under 0.03 ng/ml on an ultrasensitive test, continue to wait.

(2) If it's between 0.03-0.2 ng/ml consider adjuvant RT

(3) If it's ≥0.2 ng/ml but < 2.0 ng/ml, try to get in on one of these clinical trials that may be able to detect distant mets that bone scans, NaF18 or C11 Choline or Acetate PET scans can't detect:
/clinicaltrials.gov/ct2/show/NCT02190279
/clinicaltrials.gov/ct2/show/NCT02523924
/clinicaltrials.gov/ct2/show/NCT01666808
/clinicaltrials.gov/ct2/show/NCT02624518

- Allen

Bob

Sorry that you need these questions answered. However, there are answers available. As most often the case, Allen has presented accurate information for your consideration. I finished SRT in May. I have had two psa tests, both <.006. I can not run a 4 min. mile. Unfortunately, I could not run that before the SRT. So far no side effects!

At the time of my surgery my urologist insisted that I have salvage radiation even before I had any evidence of metastasis but was denied on two occasions by my provider. As of January 2015 there was evidence of iliac lymph involvement and then the PSA took off like a California wildfire out of control. In three months my PSA shot up from 3.9 to 24 and CT scans showed that there was now bilateral lymph node involvement along the iliac chain. Consequently, if it were me having to make this decision, I probably would choose radiation.

Post Edited (Almost a 10) : 12/9/2015 8:01:03 AM (GMT-7)

My stats are very close to yours. G9, SV+, lymph node involvement, ...etc

I was told that the only way for a cure as HT won't cure it, was for me to try RT.

That's what I was told.

Empathy for your dilemma is all I can offer. Tall Allen, as usual, has provided as much guidance as you'll find from a lay person. His links and understanding are without peer here.

My treatment plan was based on MRI staging, and it showed some local advancement. We ended up doing about a 6mm margin around the prostate, 4mm at the rectal wall. Also, due to a nearly 40% chance of involvement of the lymph nodes, we zapped them too (to 50.4 Gy). There was a 7mm margin around the lymph node chains. Primary RT with neoadjuvant ADT2, with curative intent. So far, so good, undetectable PSA though still under the all-too-burdensome control of hormone therapy.

All the best on your decisions. It's hard, and I'm a stats guy too, but there just aren't solid studies to guide the choices. One big problem is that there just aren't a lot of us very high risk types, so the studies lump us in with a variety of other cases all considered "high risk" though in opinion quite different (PSA>20, any T3/4, any G>7). But, to really find folks with "very high risk" cases in the details of the available studies can be pretty difficult.